Advertisement

Anastomosis Viability Assessment in Colorectal Surgery

  • Mahmoud Abu Gazala
  • Steven D. WexnerEmail author
Chapter
  • 20 Downloads

Abstract

Anastomotic leak remains one of the most dreaded complications in colorectal surgery and is responsible for significant morbidity and mortality. While the risk for anastomotic leak is multifactorial and may not be totally eliminated, there has been much evidence that intraoperative fluorescence angiography is a safe and easy technique by which the incidence of anastomotic leaks can be reduced. We will review the risk factors for anastomotic leak, the technique of fluorescence angiography, and significant publications on this topic.

Keywords

Anastomotic leak Fluorescence imaging Fluorescence angiography Colon resection Proctectomy Colorectal anastomosis 

Supplementary material

Video 19.1

Evaluation of the bowel perfusion during sigmoid colectomy just prior to bowel transection. After we have decided on the location of the proximal site of division, an intravenous bolus of 3.5 mL of ICG is administered, and using a near-infrared (NIR) camera, the quality and distribution of florescence angiogram is evaluated. As can be seen in this video, there is a clear demarcation line between perfused and non-perfused bowel, allowing for a confident transection of bowel. (MP4 25665 kb)

Video 19.2

Following creation of a colorectal anastomosis during this laparoscopic sigmoid colectomy, another bolus of ICG is administered in order to evaluate the serosal surface of the anastomosis. The video clearly demonstrates perfect anastomotic perfusion. (MP4 15867 kb)

Video 19.3

Following colorectal anastomosis, a scope with NIR camera is inserted to the bowel lumen through the anus, and a third bolus of ICG is administered. This video demonstrates perfect anastomotic perfusion at the mucosal side of the anastomosis. (MP4 24814 kb)

References

  1. 1.
    McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg. 2015. 2015;102(5):462–79.CrossRefGoogle Scholar
  2. 2.
    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.CrossRefGoogle Scholar
  3. 3.
    Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg. 2014;18(6):1176–85.CrossRefGoogle Scholar
  4. 4.
    Caulfield H, Hyman NH. Anastomotic leak after low anterior resection: a spectrum of clinical entities. JAMA Surg. 2013;148(2):177–82.CrossRefGoogle Scholar
  5. 5.
    Ashburn JH, Stocchi L, Kiran RP, Dietz DW, Remzi FH. Consequences of anastomotic leak after restorative proctectomy for cancer: effect on long-term function and quality of life. Dis Colon Rectum. 2013;56(3):275–80.CrossRefGoogle Scholar
  6. 6.
    Marinatou A, Theodoropoulos GE, Karanika S, Karantanos T, Siakavellas S, Spyropoulos BG, Toutouzas K, Zografos G. Do anastomotic leaks impair postoperative health-related quality of life after rectal cancer surgery? A case-matched study. Dis Colon Rectum. 2014;57(2):158–66.CrossRefGoogle Scholar
  7. 7.
    Hallbook O, Sjodahl R. Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg. 1996;83(1):60–2.CrossRefGoogle Scholar
  8. 8.
    Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg. 2001;88(3):400–4.CrossRefGoogle Scholar
  9. 9.
    Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg. 2011;253(5):890–9.CrossRefGoogle Scholar
  10. 10.
    Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier SK. Anastomotic leaks after restorative resections for rectal cancer compromise cancer outcomes and survival. Dis Colon Rectum. 2016;59(3):236–44.CrossRefGoogle Scholar
  11. 11.
    Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg. 1998;85(3):355–8.CrossRefGoogle Scholar
  12. 12.
    Bertelsen CA, Andreasen AH, Jorgensen T, Harling H. Anastomotic leakage after anterior resection for rectal cancer: risk factors. Color Dis. 2010;12(1):37–43.CrossRefGoogle Scholar
  13. 13.
    Lipska MA, Bissett IP, Parry BR, Merrie AE. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg. 2006;76(7):579–85.CrossRefGoogle Scholar
  14. 14.
    Stone HB, Coleman CN, Anscher MS, McBride WH. Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol. 2003;4(9):529–36.CrossRefGoogle Scholar
  15. 15.
    Tibbs MK. Wound healing following radiation therapy: a review. Radiother Oncol. 1997;42(2):99–106.CrossRefGoogle Scholar
  16. 16.
    Enker WE, Merchant N, Cohen AM, et al. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg. 1999;230(4):544–52.CrossRefGoogle Scholar
  17. 17.
    Nisar PJ, Lavery IC, Kiran RP. Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer. J Gastrointest Surg. 2012;16(9):1750–7.CrossRefGoogle Scholar
  18. 18.
    Sharma A, Deeb AP, Rickles AS, Iannuzzi JC, Monson JR, Fleming FJ. Closure of defunctioning loop ileostomy is associated with considerable morbidity. Color Dis. 2013;15(4):458–62.CrossRefGoogle Scholar
  19. 19.
    Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after colorectal resection: what are the data? Arch Surg. 2009;144(5):407–11; discussion 411–2CrossRefGoogle Scholar
  20. 20.
    Ris F, Yeung T, Hompes R, Mortensen NJ. Enhanced reality and intraoperative imaging in colorectal surgery. Clin Colon Rectal Surg. 2015;28(3):158–64.CrossRefGoogle Scholar
  21. 21.
    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.CrossRefGoogle Scholar
  22. 22.
    Markus PM, Martell J, Leister I, Horstmann O, Brinker J, Becker H. Predicting postoperative morbidity by clinical assessment. Br J Surg. 2005;92:101–6.CrossRefGoogle Scholar
  23. 23.
    Boni L, David G, Mangano A, Dionigi G, Rausei S, Spampatti S, Cassinotti E, Fingerhut A. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29(7):2046–55.CrossRefGoogle Scholar
  24. 24.
    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.  https://doi.org/10.1007/s00464–016–5181–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Foppa C, Denoya PI, Tarta C, Bergamaschi R. Indocyanine green fluorescent dye during bowel surgery: are the blood supply “guessing days” over? Tech Coloproctol. 2014;18(8):753–8.CrossRefGoogle Scholar
  26. 26.
    Kudszus S, Roesel C, Schachtrupp A, Höer 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.CrossRefGoogle Scholar
  27. 27.
    Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, Lee SW, Senagore AJ, Phelan MJ, Stamos MJ. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg. 2015;220(1):82–92.CrossRefGoogle Scholar
  28. 28.
    Ris F, Liot E, Buchs NC, Kraus R, et al. Multicentre phase II trial of near-infrared imaging in elective colorectal surgery. Br J Surg. 2018;105(10):1359–67.CrossRefGoogle Scholar
  29. 29.
    Chude GG, Rayate NV, Patris V, Koshariya M, Jagad R, Kawamoto J, Lygidakis NJ. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology. 2008;55(86–87):1562–7.PubMedGoogle Scholar
  30. 30.
    Karliczek A, Benaron DA, Baas PC, Zeebregts CJ, Wiggers T, van Dam GM. Intraoperative assessment of microperfusion with visible light spectroscopy for prediction of anastomotic leakage in colorectal anastomoses. Color Dis. 2010;12(10):1018–25.CrossRefGoogle Scholar
  31. 31.
    Ashraf SQ, Burns EM, Jani A, Altman S, Young JD, Cunningham C, Faiz O, Mortensen NJ. The economic impact of anastomotic leakage after anterior resections in English NHS hospitals: are we adequately remunerating them? Color Dis. 2013;15(4):e190–8.CrossRefGoogle Scholar
  32. 32.
    Senagore A, Lane FR, Lee E, Wexner S, Dujovny N, Sklow B, Rider P, Bonello J. Bioabsorbable Staple Line Reinforcement Study Group. Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection: a randomized study. Dis Colon Rectum. 2014;57(3):324–30.CrossRefGoogle Scholar
  33. 33.
    Mongin C, Maggiori L, Agostini J, Ferron M, Panis Y. Does anastomotic leakage impair functional results and quality of life after laparoscopic sphincter-saving total mesorectal excision for rectal cancer? A case-matched study. Int J Color Dis. 2014;29(4):459–67.CrossRefGoogle Scholar
  34. 34.
    Leahy J, Schoetz D, Marcello P, Read T, Hall J, Roberts P, Ricciardi R. What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis? J Gastrointest Surg. 2014;18(10):1812–6.CrossRefGoogle Scholar
  35. 35.
    Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg. 2015;220(2):186–94.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Colorectal DepartmentCleveland Clinic FloridaWestonUSA
  2. 2.Department of Colorectal SurgeryDigestive Disease Center, Cleveland Clinic FloridaWestonUSA

Personalised recommendations