The American Journal of Surgery (2011) 201, 623 627

North Pacic Surgical Association

Does sacrice of the inferior mesenteric artery or superior rectal artery affect anastomotic leak following sigmoidectomy for diverticulitis? a retrospective review
Ryan K. Lehmann, D.O.a, Lionel R. Brounts, M.D.a, Eric K. Johnson, M.D.b, Julie A. Rizzo, M.D.b, Scott R. Steele, M.D.a,*
a

Department of Surgery, Madigan Army Medical Center, 1708 Yakima Ave, Tacoma, WA 98405, USA; bDepartment of Surgery, Dwight David Eisenhower Army Medical Center, Fort Gordon, GA KEYWORDS:
Sigmoid colectomy; Diverticulitis; Anastomotic leak; Inferior mesenteric artery Abstract BACKGROUND: Anastomotic leak after sigmoidectomy for diverticular disease can have devastating consequences. Preservation or sacrice of the descending colon or rectal arterial supply may affect the anastomosis. The aim of this study was to evaluate whether preservation of the inferior mesenteric artery (IMA) or superior rectal artery (SRA) was associated with a decreased anastomotic leak rate. METHODS: A retrospective review of adult patients undergoing sigmoidectomies from 2 military tertiary care centers was performed, evaluating patient demographic and operative variables for their effects on anastomotic leak rate. RESULTS: A total of 130 patients were identied. The overall anastomotic leak rate was 5.4%. Laparoscopy was used in 41%, and stapled anastomoses were used in 91%. The IMA was sacriced in 29% and the SRA in 37%. There were no signicant differences in leak rates when the IMA or SRA was sacriced (0% and 3.7% with the IMA and SRA sacriced, 9.3% and 6.5% with the vessels preserved; P .140 and P .610, respectively). Laparoscopic technique (P .843), emergency surgery (P .29), and operative time (P .78) did not affect leak rate. Hand-sewn anastomoses were associated with a higher leak rate (33% vs 2%; odds ratio, 3.44; 95% condence interval, 1.514 7.817; P .001). CONCLUSIONS: IMA or SRA preservation or sacrice was not associated with an increased leak rate from colorectal anastomoses after sigmoidectomy for diverticular disease. Stapled anastomoses were associated with a lower leak rate than hand-sewn anastomoses. Published by Elsevier Inc.

This report represents the opinions of the authors only and does not represent the views of the US Department of Defense, the US Department of the Army, Dwight David Eisenhower Army Medical Center, or Madigan Army Medical Center. This report was presented at the North Pacic Surgical Association Meeting, November 12 to 14, 2010, Tacoma, Washington. * Corresponding author. Tel.: 253-968-2200; fax: 253-968-5337. E-mail address: harkersteele@mac.com Manuscript received October 28, 2010; revised manuscript January 13, 2011

Diverticular disease is a common process seen in more than one-third of the Western population aged 45 years1 and up to two-thirds aged 85 years. Although most patients remain asymptomatic, 10% to 20% will develop symptoms or complications.2 Surgical indications for resection in complex disease are well established, either in surgical emergencies or in patients whom eventual life-threatening complications are feared.3 Resection of the diseased segment of colon to margins free

0002-9610/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.amjsurg.2011.01.011

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Table 1 Variable Men Age (y) (mean SD) Prior pelvic surgery Chronic obstructive pulmonary disease Diabetes Hypertension Renal failure Atrial brillation Cardiac history* Patient demographics Value 50% 55 12 17% 13% 12% 27% 2% 5% 8%

The American Journal of Surgery, Vol 201, No 5, May 2011 Only the index operation for an individual patient was included. The electronic medical record for each case was queried for patient age, sex, preoperative medical comorbidities, history of pelvic surgery, emergent or elective nature of case, and preoperative laboratory values. Operative reports were evaluated for ndings and technique, including operative time, length of colon resected, laparoscopic or open approach, stapled or hand-sewn anastomosis, and preservation or sacrice of the IMA or SRA. All anastomoses underwent air-leak testing before leaving the operating room. These characteristics were used as independent variables in statistical analysis. The dependent variable used was the development of an anastomotic leak, found either during inpatient postoperative stay or at outpatient follow-up. Anastomotic leak was dened clinically either by intraoperative ndings at subsequent operation or radiographic analysis in suspected cases. Those cases requiring antibiotics or percutaneous drainage for pelvic abscess or phlegmon were included in the anastomotic leak group. Statistical analysis was performed using SPSS version 14.0 (SPSS, Inc, Chicago, IL). Chi-square tests were used to compare categorical variables between the 2 groups of patients: those who experienced anastomotic leaks and those who did not. Students t test was used to compare means of continuous variables between the 2 groups. In addition, all variables were subjected to logistic and linear regression analyses. Results of regression analyses are reported as odds ratio with 95% condence intervals. Differences with P values .05 were considered significant.

*Prior myocardial infarction, atherosclerotic coronary artery disease, or heart failure.

of inammation proximally and to the splaying of the taenia coli distally for sigmoid disease decreases the possibility of recurrent diverticulitis.4 Multiple technical factors have been associated with an increased anastomotic leak rate after bowel resection, including tension at the anastomosis, contamination of the operative eld, intraoperative hypotension, need for blood transfusion, and other technical aws.5,6 When performing a sigmoidectomy for diverticulitis, ligation of the inferior mesenteric artery (IMA) or the superior rectal artery (SRA) can potentially diminish the blood supply to the rectum. Such decreased blood supply may also hinder healing of the anastomosis,7 as collateral ow from proximal vessels or the middle and inferior rectal arteries does not always compensate in a timely manner, especially in older patients with atherosclerosis.8,9 Preservation of the SRA or IMA may help prevent this risk in healing by preserving the natural proximal blood supply to the rectum to achieve a more viable anastomosis and avoid potential damage to low-lying autonomic nerves. By contrast, dissection and resection may be facilitated by resection of the IMA or SRA, especially in cases with a large perisigmoid inammatory component or phlegmon, and may be required to aid in a tension-free anastomosis. Therefore, we sought to evaluate whether preservation of the IMA or SRA was associated with a decreased leak rate from these anastomoses.

Results
From May 2002 to September 2009, 130 cases were found for inclusion in the study. The mean age was 55 years (range, 28 83 years). Fifty percent of patients were women. Case breakdown by institution was 47 and 83, without signicant differences between the 2 groups. Therefore, all were evaluated together. Patient characteristics are listed in Table 1. Operative ndings are listed in

Methods
After obtaining protocol approval from the institutional review boards of Madigan Army Medical Center and Dwight D. Eisenhower Army Medical Center, we sampled the operating room database system for all sigmoid colectomies performed from May 2002 to September 2009. Cases were excluded if the postoperative diagnosis was not diverticulitis or if a colorectal anastomosis was not performed. In addition, we excluded those cases in which proximal diversion of a primary anastomosis was performed.

Table 2

Operative factors (n 130) n (%) 17 113 53 70 7 38 48 118 9 (13) (87) (41) (54) (5) (29) (37) (91) (7)

Operative factor Emergent Elective Laparoscopic Open Laparoscopic converted to open IMA sacriced SRA sacriced Stapled anastomosis Hand-sewn anastomosis

R.K. Lehmann et al.

Table 3 ndings Variable

IMA sacrice and leak in diverticulitis

625 ticular have found numerous factors related to an increased risk for anastomotic failure, such as hypoalbuminemia, steroid use, blood transfusion and blood loss, longer operative time, and tension at the anastomosis.5,6,10 12 Other common practices, contrary to popular belief, have not been proven to protect against anastomotic leak, such as preoperative bowel preparation and choice of antibiotic.6,11 Technical factors such as splenic exure mobilization, proper dissection, and resection margins also ultimately play a major role in achieving a successful outcome, in terms of both anastomotic integrity and minimizing postoperative complications such as urogenital dysfunction.1316 The purpose of this study was to evaluate the effect of preservation or sacrice of the IMA or SRA on leak rates from colorectal anastomoses. Prior randomized and nonrandomized prospective studies have linked preservation of the SRA and IMA individually with improved anastomotic integrity.9,10,17 In a randomized prospective study of 163 patients, Tocchi et al10 found that preserving the IMA in diverticular cases was associated with a decreased radiologic and clinical leakage rate. The investigators dened a clinical leak as abdominal pain, distention, and leukocytosis after postoperative day 3, persistent fever and leukocytosis for 1 week, or feculent output from the surgical drain. A radiographic leak was dened as any nding other than regular and uniform caliber at the anastomosis. Likely because of these liberal denitions, the rates of leakage were high. Radiographic leaks were found in 7% of patients with the IMA preserved and 18.1% of patients with the IMA sacriced, while clinical leaks were found in 2.3% of patients with the IMA preserved and in 10.4% of patients with the IMA sacriced. Similarly, Bergamaschi et al17 reported their results from a small nonrandomized series of 30 patients with complete rectal prolapse. The SRA was preserved during laparoscopic sigmoid resection in all patients. Morbidity was very low, and the anastomotic leak rate was zero. This more reects the safety of preserving the SRA in sigmoid colectomy, rather than its superiority to sacrice of the SRA. The present study failed to demonstrate similar associations, as the leak rate for anastomoses with a sacriced IMA was lower than those with a preserved IMA, albeit not signicantly different. Although Tocchi et al10 included only elective cases, the current study showed no leaks in the emergency cases, likely secondary to excluding proximal diversions and Hartmanns procedures. As such, both studies reected predominantly elective cases. Additionally, both studies were multi-institutional, were performed at teaching hospitals that involved heavy resident participation, and provided mirror surgeon and patient populations. Surgical technique differed between the 2 studies; drains were not used in the current study but were used in every case in Tocchi et als study. The differences in results between these 2 studies could there-

Preoperative laboratory values and intraoperative Mean SD 39.6 8.3 20.8 284.4 3,812.6 236 5.1 3.1 8.2 276.9 1,655.4 82

Hematocrit (%) Leukocyte count (109/L) Length of resection (cm) Estimated blood loss (mL) Fluid requirement (mL) Operative time (min)

Tables 2 and 3. Anastomotic leaks occurred in 5.4% of patients. There were no signicant correlations between preoperative patient factors or laboratory values and anastomotic leak. When operative techniques and ndings were subjected to analysis for correlation with anastomotic leak, only the performance of a hand-sewn anastomosis was found to be signicantly associated with leak. In patients who underwent hand-sewn anastomosis, 33% (3 of 9 patients) showed evidence of leaks postoperatively, while only 2% (3 of 118) of stapled anastomoses leaked (odds ratio, 3.441; 95% condence interval, 1.514 7.817; P .001). No other intraoperative factors were found to be associated with an increase in leak rate. Operative factors such as laparoscopic versus open technique (6% leak rate for each, P .843) and emergency versus elective surgery (0% vs 7% leak rate, P .291) did not affect leak rate. Mean operative time for cases resulting in anastomotic leaks was 269 minutes, compared with 234 minutes for cases that did not produce leaks (P .779). The preservation or sacrice of the IMA or SRA did not show a signicant difference in leak rate. The leak rates for preservation and sacrice of the IMA were 9.3% and 0%, respectively (95% condence interval, 0 ; P .140). When the SRA was preserved, the leak rate was 6.5%, compared with 3.7% when the vessel was taken (95% condence interval, .159 23.174; P .610). Injury to the lumbar sympathetic nerve plexus resulting in retrograde ejaculation occurred in 2 patients who underwent division of either the IMA or SRA (1%). This was transient in 1 patient and permanent in the other. Both injuries occurred during a laparoscopic approach.

Comments
The development of an anastomotic leak is a devastating outcome for the patient and surgeon alike. Therefore, much attention is placed on doing whatever is possible to reduce this occurrence. Proper anastomotic healing in the gastrointestinal tract depends on several factors. These factors are often related to operative technique and preoperative patient optimization.5,6,10 Prior studies examining colorectal anastomotic healing in par-

626 fore be due in part to the denitions of leak both clinically and radiographically. The higher leak rate based on the practice of drain use in Tocchi et als study potentially confers a lower leak rate in the current study.18 Perhaps a more conservative denition of anastomotic failure in the current study produced a lower leak rate. This could reduce the power enough to remove any statistical signicance between groups of patients. In addition, every anastomosis was evaluated using an airleak test before leaving the operating room in the present study. Although not commented on in the previous studies specically, failure to do so has been associated with higher postoperative anastomotic leak rates. The only technical factor associated with an increased risk for anastomotic leak was the performance of a handsewn anastomosis. Although some investigators have previously compared stapling and suturing, differences between the 2 techniques have been variable and more related to individual surgeon technique rather than method used.6,7 Other factors associated with an increased risk for anastomotic leak in previous studies include emergency surgery and longer operative time. These factors were not found to be signicantly associated with a higher leak rate in the present study. This could be due to the wide range of operative times and the relatively small number of primary anastomoses performed without diversion in emergency operations included in this study. Factors related to operative technique have been less consistent in prior studies. This may reect a delicate balance between obtaining a tension-free anastomosis through proper mobilization and maintaining adequate blood supply despite the need to ligate major vessels. Additionally, proper tension of the suture or staple line must be tight enough to avoid immediate leak but loose enough to avoid local ischemia and late breakdown.6,7 The ndings in the present study may reect this balance, with 2 training hospitals showing higher leak rates with hand-sewn anastomoses. One could assume that proper suture technique for colorectal anastomosis is more subject to technical variability, while stapling technique is more inherently standardized. Perhaps additional unreported factors, such as bowel edema or surgeon preference, led to the choice of performing hand-sewn anastomoses and could be related to the higher observed leak rate. The difference between stapled and hand-sewn anastomoses in the present study could also be unrelated to careful suture technique. The high leak rate in the relatively small number of hand-sewn anastomoses could represent a result of low power, because only 9%, or 12 patients, underwent hand-sewn anastomoses. In addition, the overall incidence of 7 patients of 130 in this study with anastomotic leaks is relatively low, though well within the realm of expected results for a series of almost 90% elective sigmoid resections.10,17,19 Although this study was limited somewhat by small numbers and its

The American Journal of Surgery, Vol 201, No 5, May 2011 retrospective nature, our data would suggest that sacrice or preservation of the IMA or SRA does not affect the anastomotic complication rate when one adheres to the standard tenets of bowel anastomosis (ie, tension free, minimal spillage, healthy bowel, good blood supply). Furthermore, proper mobilization of the bowel may require sacrice of the IMA or SRA to ensure other tenets such as a tension-free anastomosis are achievable.

Conclusions
This retrospective database study showed no difference in anastomotic leak rates when comparing preservation or sacrice of the IMA or SRA. In addition, factors associated with higher leak rates that have been found in prior research, such as increased operative time, emergency surgery, and higher blood loss, were not signicant in the present study.

References
1. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. BMJ 1969;4:639 42. 2. Larson DM, Masters SS, Spiro HM. Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976;71: 734 7. 3. Roberts P, Abel M, Rosen L, et al. Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1995;38:12532. 4. Rodkey GV, Welch CE. Colonic diverticular disease with surgical treatment. A study of 338 cases. Surg Clin North Am 1974;54:65574. 5. Schrock TR, Deveney CW, Dunphy JE. Factor contributing to leakage of colonic anastomoses. Ann Surg 1973;177:513 8. 6. Thornton FJ, Barbul A. Healing in the gastrointestinal tract. Surg Clin North Am 1997;77:549 73. 7. Chung RS. Blood ow in colonic anastomoses. Effect of stapling and suturing. Ann Surg 1987;206:3359. 8. Foster ME, Lancaster JB, Leaper DJ. Leakage of low rectal anastomosis. An anatomic explanation? Dis Colon Rectum 1984;27:157 8. 9. Napolitano AM, Napolitano L, Costantini R, et al. Skeletization of the inferior mesenteric artery in colorectal surgery. Current considerations [article in Italian]. G Chir 1996;17:1859. 10. Tocchi A, Mazzoni G, Fornasari V, et al. Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease. Am J Surg 2001;182:1627. 11. Suding P, Jensen E, Abramson MA, et al. Denitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg 2008;143:90712. 12. Telem DA, Chin EH, Nguyen SQ, et al. Risk factors for anastomotic leak following colorectal surgery: a case-control study. Arch Surg 2010;145:371 6. 13. Forgione A, Leroy J, Cahill RA, et al. Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg 2009;249:218 24. 14. Liang JT, Lai HS, Lee PH, et al. Laparoscopic pelvic autonomic nerve-preserving surgery for sigmoid colon cancer. Ann Surg Oncol 2008;15:1609 16. 15. Gervaz P, Inan I, Perneger T, et al. A prospective, randomized, singleblind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010;252:3 8.

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IMA sacrice and leak in diverticulitis

627 ing underlying question is, Can changing surgical technique decrease the risk for anastomotic leak after sigmoid colectomy in diverticulitis? Their concern is reasonable. In oncologic resections with ligation of the IMA, the colorectal anastomotic leak was 7% to 8.3% (Boccola MA, et al. World J Surg 2011;35:186 195; Alici A, et al. Tech Coloproctol 2010;14:1 8). Yet, in an older study of diverticulitis, preserving the IMA decreased the clinical anastomotic leak rate from 10.4% to 2.3% (Tocchi A, et al. Am J Surg 2001;182:162167). In this study, the authors evaluated the primary operations of 130 patients with diverticulitis. They found an overall anastomotic leak rate of 5.4%. That compares favorably to the above rates. They found no differences in anastomotic leak rates between those with the IMA divided and those with the IMA preserved. When comparing cases with superior rectal artery sacrice versus preservation, they again did not nd a difference. This pilot study will require a larger, prospective study to verify its intriguing ndings.

16. Siddiqui MR, Sajid MS, Qureshi S, et al. Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis. Am J Surg 2010;200:144 61. 17. Bergamaschi R, Lovvik K, Marvik R. Preserving the superior rectal artery in laparoscopic sigmoid resection for complete rectal prolapse. Surg Laparosc Endosc Percutan Tech 2003;13:374 6. 18. Jesus EC, Karliczek A, Matos D, et al. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 2004; (4):CD002100. 19. Boccola MA, Lin J, Rozen WM, et al. Reducing anastomotic leakage in oncologic colorectal surgery: an evidence-based review. Anticancer Res 2010;30:6017.

Discussion
Kim Lu, M.D. (Portland, OR): In this retrospective review of two Army tertiary care centers experience with diverticulitis, Dr Lehmann et al asked the following question: Does preservation of the inferior mesenteric artery (IMA) or superior rectal artery affect anastomotic leak following sigmoidectomy for diverticulitis? The more intrigu-