Abstract
Purpose
Interpretation of water-soluble contrast enema following laparoscopic low anterior resection can be very challenging for both radiologists and colorectal surgeons. Discriminating the radiological appearances secondary to anastomotic configuration from those caused by actual anastomotic dehiscence is a common problem and may be made worse with the advent of laparoscopic surgery. The aim of this study is to identify potential novel appearances of the water-soluble contrast enema (WSCE) images of rectal anastomosis following laparoscopic low anterior resection to radiologists and surgeons.
Methods
We enrolled 45 patients who underwent laparoscopic low anterior resection with proximal de-functioning loop ileostomy within a specialized colorectal unit. The water-soluble contrast enema reports were reviewed. Two blinded colorectal radiologists independently reviewed the images of patients suspected of anastomotic leak. All of these patients also underwent a flexible sigmoidoscopy to confirm or exclude anastomotic leak before reversal of loop ileostomy. Inter-observer concordance was calculated.
Results
Seven out of eighteen patients (38.9%) were found to have true anastomotic leaks on flexible sigmoidoscopy (15% overall leak rate). In the remaining eleven patients the image appearances were attributed to the appearance of the anastomotic ‘dog-ear effect’, created by the anastomotic configuration due to multiple firing of the intra-corporeal laparoscopic stapling device. Radiologist inter-observer concordance was 83%. Sensitivity was 100%, specificity 71%, positive-predictive value (38.9%) and negative-predictive value (100%).
Conclusions
The novel appearances of laparoscopic-stapled rectal anastomoses in WSCE can be mistaken for anastomotic leak. To avoid delay in reversal of ileostomy, a flexible sigmoidoscopy can be used to confirm or exclude a leak.
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Acknowledgments
Dr. Christopher Dennison, Consultant Radiologist, Queen Elizabeth Hosital Gateshead for the application of the water-soluble contrast enema technique.
Authors contribution
Mark Katory MD FRCS: Conception and design, acquisition of data, analysis and interpretation of data; and final approval. Ross McLean MRCS: Interpretation of data; and final approval. Khalid Osman PGCMEd FRCS: Conception and design, drafting the article and final approval. Mukhtar Ahmad, MMedSci, FRCS: Conception and design, acquisition of data, drafting the article and final approval. Tracey Hughes FRCR: Acquisition of data and revising it critically and final approval. Mike Newby FRCR: Acquisition of data and revising it critically and final approval. Christopher Dennison FRCR: Acquisition of data and revising it critically and final approval. Paul O’Loughlin FRCS: Analysis and interpretation of data; revising it critically and final approval.
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This study received no funding. There are no financial interests for any author in this manuscript.
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There are no disclosures for any of the authors involved in this study.
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The requirement for review by the Medical Ethics Committee or informed consent was waived because of the retrospective nature of this study with preexisting anonymized data.
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Katory, M., McLean, R., Osman, K. et al. The novel appearance of low rectal anastomosis on contrast enema following laparoscopic anterior resection: discriminating anastomotic leaks from “dog-ears” on water-soluble contrast enema and flexible sigmoidoscopy. Abdom Radiol 42, 435–441 (2017). https://doi.org/10.1007/s00261-016-0885-6
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DOI: https://doi.org/10.1007/s00261-016-0885-6