Skip to main content
SpringerLink
Log in

Anastomotic Failure in Colorectal Surgery: Where Are We at?

  • Review Article
  • Published:
Indian Journal of Surgery Aims and scope Submit manuscript

Abstract

Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases the costs and demands on health services. There is inevitable interplay between patient physiology and technical factors that predispose a patient to AL. Obesity, preoperative total proteins, male gender, ongoing anticoagulant treatment, intraoperative complication and number of hospital beds have been identified as independent risk factors. This has led to an online risk calculator for AL. Non-steroidal anti-inflammatory drugs and neoadjuvant chemoradiotherapy have also been implicated, but no significant evidence has yet been found to support causation. In addition, technical factors such as type of anastomosis, mechanical bowel preparation, drains, omentoplasty and faecal diversion have failed to show significant differences in AL rates. Early diagnosis and intervention in AL is essential in reducing the rates of morbidity and mortality. Clinical assessment has high sensitivity but low specificity and should be used in combination with imaging techniques to get a diagnosis. C-reactive protein is also a useful marker. The management will depend on the grade of AL and the clinical state of the patient. Management options include conservative measures such as antibiotics and/or percutaneous drainage to more invasion procedures such as open drainage and/or Hartmann’s procedure. In conclusion, ALs will forever pose challenges to the surgeon in diagnosis and management. It is often the yardstick by which each surgeon is measured and is the source of significant morbidity to patients and health care services worldwide. As a result, a low threshold for investigation and intervention is mandatory to ensure better outcomes and lower overall mortality and morbidity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Travers, B., Enquiry into the Process of Nature in Repairing Injuries of the Intestine. London: Longman, Rees, Orme, Brown, and Green, 1812

  2. Lembert A (1826) Memoire sur l’enteroraphie avec la description d’un procede nouveau pour pratiquer cette operation chirurgicale. Rep Gen Anat Physiol Path 2:100

    Google Scholar 

  3. Murphy J (1892) Cholecysto-intestinal, gastrointestinal, enterointestinal anastomosis and approximation without sutures. Med Rec 42:665–676

    Google Scholar 

  4. Dietz U, Debus E-S (2005) Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery. World J Surg 29(3):396–401

    Article  PubMed  Google Scholar 

  5. Bruce J, Krukowski ZH, al-Khairy G, Russell EM, Park KGM (2001) Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 88(9):1157–1168

    Article  PubMed  CAS  Google Scholar 

  6. Adams K, Papagrigoriadis S (2013) Little consensus in either definition or diagnosis of a lower gastro-intestinal anastomotic leak amongst colorectal surgeons. Int J Color Dis 28(7):967–971

    Article  CAS  Google Scholar 

  7. Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147(3):339–351

    Article  PubMed  Google Scholar 

  8. Buchs NC, Gervaz P, Secic M, Bucher P, Mugnier-Konrad B, Morel P (2008) Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int J Color Dis 23(3):265–270

    Article  Google Scholar 

  9. Damen N, Spilsbury K, Levitt M, Makin G, Salama P, Tan P, Penter C, Platell C (2014) Anastomotic leaks in colorectal surgery. ANZ J Surg 84(10):763–768

    Article  PubMed  Google Scholar 

  10. Platell C, Barwood N, Dorfmann G, Makin G (2007) The incidence of anastomotic leaks in patients undergoing colorectal surgery. Color Dis 9(1):71–79

    Article  CAS  Google Scholar 

  11. Phillips BR, Harris LJ, Maxwell PJ, Isenberg GA, Goldstein SD (2010) Anastomotic leak rate after low anterior resection for rectal cancer after chemoradiation therapy. Am Surg 76(8):869–871

    PubMed  Google Scholar 

  12. Pronio A, di Filippo A, Narilli P, Mancini B, Caporilli D, Piroli S, Vestri A, Montesani C (2007) Anastomotic dehiscence in colorectal surgery. Analysis of 1290 patients. Chir Ital 59(5):599–609

    PubMed  Google Scholar 

  13. Krarup PM, Jorgensen LN, Andreasen AH, Harling H (2012) A nationwide study on anastomotic leakage after colonic cancer surgery. Color Dis 14(10):e661–e667

    Article  Google Scholar 

  14. Park JS, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257(4):665–671

    Article  PubMed  Google Scholar 

  15. Lipska MA, Bissett IP, Parry BR, Merrie AE (2006) Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg 76(7):579–585

    Article  PubMed  Google Scholar 

  16. Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T (2014) Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 101(4):424–32; discussion 432

    Article  PubMed  CAS  Google Scholar 

  17. Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M (1998) Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 85(3):355–358

    Article  PubMed  CAS  Google Scholar 

  18. Aytac E, Lavery IC, Kalady MF, Kiran RP (2013) Impact of obesity on operation performed, complications, and long-term outcomes in terms of restoration of intestinal continuity for patients with mid and low rectal cancer. Dis Colon Rectum 56(6):689–697

    Article  PubMed  Google Scholar 

  19. Ionescu D, Tibrea C, Puia C (2013) Pre-operative hypoalbuminemia in colorectal cancer patients undergoing elective surgery—a major risk factor for postoperative outcome. Chirurgia (Bucur) 108(6):822–828

    CAS  Google Scholar 

  20. Yamamoto T, Allan RN, Keighley MR (2000) Risk factors for intra-abdominal sepsis after surgery in Crohn’s disease. Dis Colon Rectum 43(8):1141–1145

    Article  PubMed  CAS  Google Scholar 

  21. Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P (2007) Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn's disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum 50(3):331–336

    Article  PubMed  Google Scholar 

  22. Frasson M, Flor-Lorente B, Rodríguez JL (2015) Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg 262(2):321–330

    Article  PubMed  Google Scholar 

  23. Sammour T, Lewis M, Thomas ML, Lawrence MJ, Hunter A, Moore JW (2017) A simple web-based risk calculator (www. anastomoticleak. com) is superior to the surgeon’s estimate of anastomotic leak after colon cancer resection. Techniques Coloproctology 21(1):35–41

    Article  CAS  Google Scholar 

  24. Slieker JC, Komen N, Mannaerts GH, Karsten TM, Willemsen P, Murawska M, Jeekel J, Lange JF (2012) Long-term and perioperative corticosteroids in anastomotic leakage: a prospective study of 259 left-sided colorectal anastomoses. Arch Surg 147(5):447–452

    Article  PubMed  Google Scholar 

  25. Tay GS, Binion DG, Eastwood D, Otterson MF (2003) Multivariate analysis suggests improved perioperative outcome in Crohn's disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty. Surgery 134(4):565–572

    Article  PubMed  Google Scholar 

  26. Yang ZP, Hong L, Wu Q, Wu KC, Fan DM (2014) Preoperative infliximab use and postoperative complications in Crohn’s disease: a systematic review and meta-analysis. Int J Surg 12(3):224–230

    Article  PubMed  Google Scholar 

  27. Bhangu A, Singh P, Fitzgerald JEF, Slesser A, Tekkis P (2014) Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies. World J Surg 38:2247–2257

    Article  PubMed  Google Scholar 

  28. Marijnen CA et al (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20(3):817–825

    Article  PubMed  CAS  Google Scholar 

  29. Nisar PJ, Lavery IC, Kiran RP (2012) Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer. J Gastrointest Surg 16(9):1750–1757

    Article  PubMed  Google Scholar 

  30. Choy PY et al (2011) Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 9:CD004320

    Google Scholar 

  31. Shikata S, Yamagishi H, Taji Y, Shimada T, Noguchi Y (2006) Single- versus two-layer intestinal anastomosis: a meta-analysis of randomized controlled trials. BMC Surg 6(1):2

    Article  PubMed  PubMed Central  Google Scholar 

  32. Sajid MS, Siddiqui MR, Baig MK (2012) Single layer versus double layer suture anastomosis of the gastrointestinal tract. Cochrane Database Syst Rev 1:CD005477

    PubMed  Google Scholar 

  33. Koh PK, Tang CL, Eu KW, Samuel M, Chan E (2007) A systematic review of the function and complications of colonic pouches. Int J Color Dis 22(5):543–548

    Article  Google Scholar 

  34. Hallbook O et al (1996) Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 224(1):58–65

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  35. Cao F, Li J, Li F (2012) Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Color Dis 27(6):803–810

    Article  CAS  Google Scholar 

  36. Guenaga KF, Matos D, Wille-Jorgensen P (2011) Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 9:CD001544

    Google Scholar 

  37. Jesus EC et al (2004) Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 4:CD002100

    Google Scholar 

  38. Rondelli F, Bugiantella W, Vedovati MC, Balzarotti R, Avenia N, Mariani E, Agnelli G, Becattini C (2014) To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis. Color Dis 16(2):O35–O42

    Article  CAS  Google Scholar 

  39. Yeh CY, Changchien CR, Wang JY, Chen JS, Chen HH, Chiang JM, Tang R (2005) Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients. Ann Surg 241(1):9

    PubMed  PubMed Central  Google Scholar 

  40. Merad F, Hay JM, Fingerhut A, Flamant Y, Molkhou JM, Laborde Y (1998) Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations Surgical Res. Ann Surg 227(2):179

    CAS  Google Scholar 

  41. Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW (1990) Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg 77(10):1095–1097

    Article  PubMed  CAS  Google Scholar 

  42. Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ (2009) Anastomotic leak testing after colorectal resection: what are the data? Arch Surg 144(5):407–411

    Article  PubMed  Google Scholar 

  43. Ishihara S, Watanabe T, Nagawa H (2008) Intraoperative colonoscopy for stapled anastomosis in colorectal surgery. Surg Today 38(11):1063–1065

    Article  PubMed  Google Scholar 

  44. Shamiyeh A, Szabo K, Wayand WU, Zehetner J (2012) Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech 22(1):65–67

    Article  PubMed  Google Scholar 

  45. Montedori A et al (2010) Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev 5:CD006878

    Google Scholar 

  46. Huser N et al (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248(1):52–60

    Article  PubMed  Google Scholar 

  47. Nurkin S, Kakarla VR, Ruiz DE, Cance WG, Tiszenkel HI (2013) The role of faecal diversion in low rectal cancer: a review of 1791 patients having rectal resection with anastomosis for cancer, with and without a proximal stoma. Color Dis 15(6):e309–e316

    Article  CAS  Google Scholar 

  48. Damrauer SM, Bordeianou L, Berger D (2009) Contained anastomotic leaks after colorectal surgery: are we too slow to act? Arch Surg 144(4):333–338 discussion 338

    Article  PubMed  Google Scholar 

  49. Nesbakken A, Nygaard K, Lunde OC, Blücher J, Gjertsen O, Dullerud R (2005) Anastomotic leak following mesorectal excision for rectal cancer: true incidence and diagnostic challenges. Color Dis 7(6):576–581

    Article  CAS  Google Scholar 

  50. Sutton CD, Marshall LJ, Williams N, Berry DP, Thomas WM, Kelly MJ (2004) Colo-rectal anastomotic leakage often masquerades as a cardiac complication. Color Dis 6(1):21–22

    Article  CAS  Google Scholar 

  51. den Dulk M et al (2013) The DULK (Dutch leakage) and modified DULK score compared: actively seek the leak. Color Dis 15(9):e528–e533

    Google Scholar 

  52. Singh PP, Zeng ISL, Srinivasa S, Lemanu DP, Connolly AB, Hill AG (2014) Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 101:339–346

    Article  PubMed  CAS  Google Scholar 

  53. Goligher JC, Graham NG, De Dombal FT (1970) Anastomotic dehiscence after anterior resection of rectum and sigmoid. Br J Surg 57(2):109–118

    Article  PubMed  CAS  Google Scholar 

  54. Nicksa GA, Dring RV, Johnson KH, Sardella WV, Vignati PV, Cohen JL (2007) Anastomotic leaks: what is the best diagnostic imaging study? Dis Colon Rectum 50(2):197–203

    Article  PubMed  CAS  Google Scholar 

  55. Phitayakorn R, Delaney CP, Reynolds HL, Champagne BJ, Heriot AG, Neary P, Senagore AJ, International Anastomotic Leak Study Group (2008) Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J Surg 32(6):1147–1156

    Article  PubMed  CAS  Google Scholar 

  56. Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW (2008) Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 22(8):1818–1825

    Article  PubMed  Google Scholar 

  57. Biondo S, Parés D, Kreisler E, Ragué JM, Fraccalvieri D, Ruiz AG, Jaurrieta E (2005) Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 48(12):2272–2280

    Article  PubMed  Google Scholar 

  58. Branagan G, Finnis D (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 48(5):1021–1026

    Article  PubMed  Google Scholar 

  59. Ambrosetti P, Robert J, Mathey P, Rohner A (1994) Left-sided colon and colorectal anastomoses: doppler ultrasound as an aid to assess bowel vascularization. A prospective evaluation of 200 consecutive elective cases. Int J Color Dis 9(4):211–214

  60. Hirano Y, Omura K, Tatsuzawa Y, Shimizu J, Kawaura Y, Watanabe G (2006) Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications. World J Surg 30(3):457–461

    Article  PubMed  Google Scholar 

  61. Millan M, García-Granero E, Flor B, García-Botello S, Lledo S (2006) Early prediction of anastomotic leak in colorectal cancer surgery by intramucosal pH. Dis Colon Rectum 49(5):595–601

    Article  PubMed  Google Scholar 

  62. Fouda E, el Nakeeb A, Magdy A, Hammad EA, Othman G, Farid M (2011) Early detection of anastomotic leakage after elective low anterior resection. J Gastrointest Surg 15(1):137–144

    Article  PubMed  Google Scholar 

  63. Ravo B, Ger R (1985) Temporary colostomy—an outmoded procedure? A report on the intracolonic bypass. Dis Colon Rectum 28(12):904–907

    Article  PubMed  CAS  Google Scholar 

  64. Morks AN et al (2013) Thirty-seven patients treated with the C-seal: protection of stapled colorectal anastomoses with a biodegradable sheath. Int J Color Dis 28(10):1433–1438

    Article  Google Scholar 

  65. Xiao L, Zhang WB, Jiang PC, Bu XF, Yan Q, Li H, Zhang YJ, Yu F (2011) Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study. World J Surg 35(6):1367

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, The Royal Melbourne Hospital and Box Hospital, Melbourne, Victoria, Australia

    Vinna An & Raaj Chandra

  2. Department of Colorectal Surgery, Royal Adelaide Hospital, Adelaide, Australia

    Matthew Lawrence

Authors
  1. Vinna An
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Raaj Chandra
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matthew Lawrence
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Raaj Chandra.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

An, V., Chandra, R. & Lawrence, M. Anastomotic Failure in Colorectal Surgery: Where Are We at?. Indian J Surg 80, 163–170 (2018). https://doi.org/10.1007/s12262-018-1745-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12262-018-1745-0

Keywords

Search

Navigation