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Minimizing Colorectal Anastomotic Leaks: Best Practices to Assess the Integrity and Perfusion of Left-Sided Anastomoses

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The SAGES Manual of Colorectal Surgery

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Abstract

Anastomotic leak is an uncommon but a serious complication of any gastrointestinal operation. This complication can result in significant perioperative morbidity and prolonged recovery. In addition, leaks can delay necessary systemic treatment for cancer patients or require reoperations with additional morbidity. Careful attention to anastomotic technique and evaluation of the anastomoses can reduce the risk of leak. Assessment of factors that affect anastomotic integrity includes evaluation of perfusion and tension. These factors can be evaluated, in part, through evaluation of the anastomotic mucosa via endoscopy. In addition to visual inspection, assessment of perfusion with fluorescent angiography is an area of active development that may reduce leak rates. Understanding the tools used to evaluate anastomoses is important for any surgeon operating on the gastrointestinal tract, and therefore proficiency in endoscopic evaluation must be mandated.

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References

  1. Cirocchi R, Trastulli S, Farinella E, Guarino S, Desiderio J, Boselli C, et al. Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy – systematic review and meta-analysis. Surg Oncol. 2013;22(1):1–13.

    Article  Google Scholar 

  2. Chadi SA, Fingerhut A, Berho M, DeMeester SR, Fleshman JW, Hyman NH, et al. Emerging trends in the etiology, prevention, and treatment of gastrointestinal anastomotic leakage. J Gastrointest Surg: Off J Soc Surg Alimentary Tract. 2016;20(12):2035–51.

    Article  Google Scholar 

  3. Fingerhut A, Hay JM, Elhadad A, Lacaine F, Flamant Y. Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research. Surgery. 1995;118(3):479–85.

    Article  CAS  Google Scholar 

  4. Fingerhut A, Elhadad A, Hay JM, Lacaine F, Flamant Y. Infraperitoneal colorectal anastomosis: hand-sewn versus circular staples. A controlled clinical trial. French Associations for Surgical Research. Surgery. 1994;116(3):484–90.

    CAS  PubMed  Google Scholar 

  5. Hyman NHOT, Cataldo P, Burns EH, Shackford SR. Anastomotic leaks after bowel resection: what does peer review teach us about the relationship to postoperative mortality? J Am Coll Surg. 2009;208(1):48–52.

    Article  Google Scholar 

  6. Fingerhut AHJ, Elhadad A, Lacaine F, Flamant Y. Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research. Surgery. 1995;118(3):479–85.

    Article  CAS  Google Scholar 

  7. Kamal T, Pai A, Velchuru VR, Zawadzki M, Park JJ, Marecik SJ, et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis: Off J Assoc Coloproctol Great Br Ireland. 2015;17(2):160–4.

    Article  CAS  Google Scholar 

  8. Sujatha-Bhaskar S, Jafari MD, Hanna M, Koh CY, Inaba CS, Mills SD, et al. An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses. Surg Endosc. 2018;32(4):1769–75.

    Article  Google Scholar 

  9. Chen CW, Chen MJ, Yeh YS, Tsai HL, Chang YT, Wang JY. Intraoperative anastomotic dye test significantly decreases incidence of anastomotic leaks in patients undergoing resection for rectal cancer. Tech Coloproctol. 2013;17(5):579–83.

    Article  Google Scholar 

  10. Alander JT, Kaartinen I, Laakso A, Patila T, Spillmann T, Tuchin VV, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012;2012:940585.

    Article  Google Scholar 

  11. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg. 2015;220(1):82–92 e1.

    Article  Google Scholar 

  12. Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Color Dis. 2009;24(5):569–76.

    Article  CAS  Google Scholar 

  13. Wu Z, van de Haar RC, Sparreboom CL, Boersema GS, Li Z, Ji J, et al. Is the intraoperative air leak test effective in the prevention of colorectal anastomotic leakage? A systematic review and meta-analysis. Int J Color Dis. 2016;31(8):1409–17.

    Article  Google Scholar 

  14. Yang SY, Han J, Han YD, Cho MS, Hur H, Lee KY, et al. Intraoperative colonoscopy for the assessment and prevention of anastomotic leakage in low anterior resection for rectal cancer. Int J Color Dis. 2017;32(5):709–14.

    Article  Google Scholar 

  15. Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2012;(2):CD003144.

    Google Scholar 

  16. Blanco-Colino R, Espin-Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol. 2018;22(1):15–23.

    Article  CAS  Google Scholar 

  17. Kudszus S, Roesel C, Schachtrupp A, Hoer JJ. Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbeck’s Arch Surg. 2010;395(8):1025–30.

    Article  Google Scholar 

  18. Ris F, Hompes R, Cunningham C, et al. Near‐infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc. 2014;28:2221–6.

    Article  Google Scholar 

  19. Boni L, Fingerhut A, Marzorati A, Rausei S, Dionigi G, Cassinotti E. Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study. Surg Endosc. 2017;31:1836–40.

    Article  Google Scholar 

  20. Protyniak B, Dinallo AM, Boyan WP Jr, Dressner RM, Arvanitis ML. Intraoperative indocyanine green fluorescence angiography: an objective evaluation of anastomotic perfusion in colorectal surgery. Am Surg. 2015;81:580–4.

    PubMed  Google Scholar 

  21. Foppa C, et al. Indocyanine green fluorescent dye during bowel surgery: are the blood supply “guessing days” over? Tech Coloproctol. 2014;18(8):753–8.

    Article  CAS  Google Scholar 

  22. Kawada K, et al. Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis. Surg Endoscopy. 2017;31(3):1061–9.

    Article  Google Scholar 

  23. Kim JC, Lee JL, Yoon YS, Alotaibi AM, Kim J. Utility of indocyanine‐green fluorescent imaging during robot‐assisted sphincter‐saving surgery on rectal cancer patients. Int J Med Robotics Comput Assist Surg. 2016;12:710–7.

    Article  Google Scholar 

  24. Kin C, Vo H, Welton L, Welton M. Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks. Dis Colon Rectum. 2015;58(6):582–7. https://doi.org/10.1097/DCR.0000000000000320.

    Article  PubMed  Google Scholar 

  25. Hellan M, Spinoglio G, Pigazzi A, Lagares-Garcia JA. The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc. 2014;28(5):1695–702. https://doi.org/10.1007/s00464-013-3377-6.

    Article  PubMed  Google Scholar 

  26. Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A. Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc. 2016;30(7):2736–42. https://doi.org/10.1007/s00464-015-4540-z.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors are indebted to Abhineet Uppal, MD, for his invaluable contributions to this chapter.

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Authors and Affiliations

  1. University of California, Irvine, Colon and Rectal Surgery, Orange, CA, USA

    Mehraneh D. Jafari & Alessio Pigazzi

Authors
  1. Mehraneh D. Jafari
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  2. Alessio Pigazzi
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Corresponding author

Correspondence to Alessio Pigazzi .

Editor information

Editors and Affiliations

  1. Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA

    Patricia Sylla

  2. Keck School of Medicine of USC, Los Angeles, CA, USA

    Andreas M. Kaiser

  3. Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA

    Daniel Popowich

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© 2020 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

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Jafari, M.D., Pigazzi, A. (2020). Minimizing Colorectal Anastomotic Leaks: Best Practices to Assess the Integrity and Perfusion of Left-Sided Anastomoses. In: Sylla, P., Kaiser, A., Popowich, D. (eds) The SAGES Manual of Colorectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-24812-3_29

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  • DOI: https://doi.org/10.1007/978-3-030-24812-3_29

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-24811-6

  • Online ISBN: 978-3-030-24812-3

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