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Causes and Prevention of Leak After Colorectal Surgery Anastomosis
Causes and Prevention of Leak After Colorectal Surgery Anastomosis
COLORECTAL SURGERY
BIELECKI K., GAJDA A.
DEPARTMENT OF GENERAL SURGERY, ORBOWSKI HOSPITAL, WARSAW, POLAND
The cause of the leakage may be multifactorial, including con nely performed barium enema on 5-7-th day after surgery [4].
tribution from faulty technique, ischemia of the intestine at the Our personal leak rate is 5.7% among 263 patients who under
suture line, excessive tension across anastomosis and mesente went colorectal resection and primary anastomosis.
ry, the presence of local sepsis, presence of obstruction distal to The consequences of anastomotic leak are peritonitis, fistula
the anastomosis. The old patient (>80 years), anaemic, malnou formation or abscess.
rished with several coexisting diseases, receiving high doses ste The principles of the good and reliable colorectal anastomo
roids, after chemio-radiotherapy is more prone to develop the sis are as follows: (Fig. 2)
anastomotic leakage. The presence of any of these risk factors 1. good exposure and access to large bowel (long enough inci
calls into question the safety of the planned anastomosis. sion)
Anastomotic leakage is the most significant complication after 2. adequate blood supply of anastomosed stumps
colorectal surgery especially after anterior resection and it is 3. prevent sepsis or gross faecal contamination
the major cause of postoperative mortality and morbidity. Defi 4. sutures or staplers should be properly placed assuring good
nition of clinically apparent anastomotic leakage is following: approximation of all layers of bowel wall (most important
fistula to the skin or vagina, fever above 38C or septicaemia is submucosa)
in patients with radiological or endoscopic leak, with presen 5. no tension of the anastomosis (always release the splenic
ce of intraperitoneal abscess or symptoms and signs of perito flexure in left colorectal surgery)
nitis in the presence of an anastomotic leakage [1]. (Fig. 1) 6. prevent distal obstruction
Its frequency is higher after anterior resection. In 60% of cases lea 7. the patient should be well nourished and large bowel should
kage heals under the conservative treatment. If re-laparotomy is be mechanically well prepared (no faecal contamination)
necessary the mortality related to this complication is very high. (Keighlyl993)[17].'
The leak incidence varies from 3.4% to 40% (the larger figures inc
lude subclinical radiological diagnoses) [5]. In the series published Good exposure includes: long incision, adequate bowel
after 1990 in the group of 1318 patients the rate of clinically detec mobilisation, appropriate illumination, correct positioning of
ted anastomotic leak was 4.7%, varying between 2.7 and 10.5%. assistants and retractors.
In an addition 5.7%-10.7% of patients had subclinical leaks dis Blood supply is essential for the healing of anastomosis. The
covered by routine postoperative radiological examination [2,3]. cut ends of bowel should bleed. To assess the adequate blood
Goligher in 1970 found radiological leak in 69% of patients supply of the bowel stump the routine measurement of tissue
with low colorectal anastomosis diagnosed by means of routi oxygen and laser Doppler flowmetry are currently being eva-
luated in many centres. To achieve a good blood supply some An alternative to manual techniques is the use of staplers. Stap
important operative precautions should be followed, namely: lers have allowed colonic or rectal closure and anastomosis is
adequate mobilisation, no tension on anastomosis, sutures performed more quickly than manually.
must not be placed too deep or too tight (extramucosal sutu There are three types of stapling instrument which are appli
res are the best in this aspect) used bowel clamps should be ed in colorectal surgery. These are linear staplers ( T A or R L ) ,
non-crushing and should be lightly applied without including the linear cutters ( G I A or P L C ) and the circular instrument
the mesentery since that may compromise the blood supply. ( E E A or l L S ) .
Whether stapled anastomosis is more tight and reliable than
Manual sutured anastomosis. conventional hand-sewn is open to debate. Reported leak rates
Since Czerny (1880) recommendation a two layer technique after stapled and hand-sewn anastomosis were 8% and 27%
of colorectal anastomosis was commonly used. The first lay respectively.
er was an inner through-and-through suture which was either Thirteen randomised, controlled trials showed a little or no dif
continuous or interrupted and the second layer (usually inter ferences between hand-sewn vs. stapled anastomoses in outco
rupted) was an outer serosomuscular Lambert stitch. me variables including mortality, technical problems, leak rates,
Halsted (1887) and Gambee (1951) showed that the submu- wound infections, strictures and cancer recurrences [8].
cosa was the strongest layer of the bowel wall and they sup Strictures and intraoperative technical problems were more
ported the single layer technique with moderate inversion. common with stapled than hand-sewn anastomosis. Thus both
Currently generally accepted view is that for colorectal ana techniques are effective, stapled technique is a little bit quic
stomosis the inversion techniques should be employed. ker but the choice may be based on the personal preference.
Dunn and other authors stated that everted anastomosis should Hashemi showed, that side-to-side stapled anastomosis is asso
not be performed in patients with abdominal infections, after ciated with lower incidence of recurrence in Crohn's disease
radiotherapy, with inflammatory bowel diseases [6]. These requiring reoperation (2%) at 46 months with comparison to
are risk factors for anastomotic leakage especially after stap the end-to-end hand-sewn anastomosis (43%) [28].
ling technique employed. However longer follow-up is required to evaluate this techni
Kusunoki showed no significant differences in anastomotic que in randomised prospective study.
dehiscence (5-7%) or recurrence of Crohn's disease between Docherty and co-workers in randomised, controlled trial eva
the stapling and hand-sewn procedures [7]. luated 732 patients who had had any form of elective or emer
These results indicate that stapling technique producing an gency colorectal resection or reconstruction. In patients having
everted anastomosis is a safe procedure for Crohn's disease. suturing or stapling of anastomoses was equally effective. In
Still exists controversy about the need for a one or two layer patients who had colorectal anastomoses, incidence of radio
anastomosis. Theoretically the two layer anastomosis produ logical leak were lower when staplers were used [29].
ces more ischemia, the tissue necrosis and more narrowing of
the bowel lumen than one layer technique. Factors influencing anastomotic healing.
Currently for low colorectal extraperitoneal anastomosis one The morbidity and mortality related to anastomotic breakdown
layer manual anastomosis is recommended. A two layer ana in colorectum is considerable. Fielding (1980) in his study
stomosis is performed in more proximal colon whenever it is showed, that among 1466 patients who underwent large bowel
reasonable to do so. In many centres most surgeons opt to use anastomosis there were 191 patients with an anastomotic leak
the circular staplers. with 22% of hospital mortality compared with 7.1% of 1275
To perform a two layer anastomosis the absorbable material is used patients without a leak [9].
for inner layer and non-absorbable material for an outer layer. Anastomotic leak can only be prevented if the causes are
A single layer anastomosis is accomplished using a non-absor understood. Many factors may play a pathological causative
bable material usually monofilament, which causes less tis role, including: (Fig. 3)
sue reaction. N e w developed long-resorbable materials, like 1. poor surgical technique
vicryl, P D S , maxon, are recommended for one layer colorec 2. wrong intraoperative judgement
tal anastomosis. The size or gauge of the suture material is 3. local complications (sepsis, bowel preparation, drains, role
usually 00 or 000 for adult intestinal anastomosis and the need of omentum and peritoneum, anaesthetic drugs, protective
le is of the round type. stoma)
There are numerous variations in technique to perform ana 4. systemic complications (nutritional status, blood loss)
stomosis. Most common are: end-to-end anastomosis (doub 5. surgeon-related factors, which are of the most important
le layer, single layer full thickness, single layer extramucosal) causes of an anastomotic leakage.
end-to-side anastomosis, side-to-side anastomosis.
End-to-side anastomosis many surgeons prefer to perform fol Local sepsis
lowing right hemicolectomy or after low rectal anterior resec The presence of local sepsis (e.g. perforated diverticulitis,
tion. Most essential is to secure the mesenteric and antimesen- a perforated colorectal cancer, colorectal trauma, faecal con
teric corners by using the Connell stitches. Personally, I prefer tamination during colorectal surgery) causes the reduction in
to anastomose short distal rectal stump to side of proximal colon collagen at the colonic anastomosis. This may result in hig
employing end-to-side technique (so called Baker technique). her anastomotic dehiscence rate.
Fig. 5 Fig. 6
We are concerned about the integrity of an anastomosis, about epithelium). Hananel and Gordon in their experimental study
anastomotic blood supply, particularly in elderly patients and the demonstrated the 5-fluorouracil and leucovorin introduced in
se with severe atherosclerosis or cardio-respiratory insufficiency. several regimens have no effect on the colonic anastomosis hea
It is important from the practical point of view to assess the ling process [23]. Surgery, at least in experimental animals, can
anastomotic integrity by using intraoperative air test (cycle be performed safely during and shortly after chemotherapy.
tire puncture manoeuvre).
Once anastomosis is performed the pelvic cavity is filled with Systemic factors
saline, intestinal clamp is applied proximal to the anastomosis The role of systemic factors in aetiology of anastomotic leak
and 50-100 ml of air is slowly and gently injected through the is not yet completely defined. Among systemic factors at least
anus. No bubbles means anastomotic tightness. In case when three of them do seem to play a significant role and they are:
bubbles appear an additional suture on the anastomotic line is 1. malnutrition (serum albumin level below 3.0 g/dl)
required [12]. In the group of patients to whom intraoperative 2. anaemia - Hb below 1 l g % and hematocrit below 33%
air test was performed in 23% of cases air leak was observed. 3. excessive blood loss and advanced malignancy.
This was an indication for additional stitches to secure anasto Excessive blood loss results in reduction of colonic blood flow
mosis. On 10-th postoperative day the radiological leak in 7.5% with subsequent tissue necrosis. B l o o d loss inevitably leads
of cases was showed and overall mortality in this group was 2%. to the need of transfusion, which in turn has been shown to
In the contrast, in group of patients to whom intraoperative air decrease the patientis immunocompetence.
test was not performed, postoperative radiological leak was
found in 23.5% of cases with 10% mortality [12]. (Fig. 7) Other risk factors
Averbach et co-workers published very interesting results of an
Anaesthetic drugs analysis of risk factors for anastomotic leak after double-stapled
Neostigmine which reverses the effect of the curare-type relaxants low colorectal resection. The incidence of anastomotic leak was
might evoke active contraction of the intestine after completion of directly related to extent of proximal colon resection [24].
the anastomosis and subsequently might result in its disruption. Standard colon resection for sigmoid colon-to-rectum anastomosis
Current evidence suggests, that neostigmine should be avoided was associated with 1 % leak rate compared with 29% leak after trans
during colorectal surgery even with combination with atropine. verse colon-to rectum anastomosis. Averbach presents also a risk fac
Halothane anaesthesia, however, abolished this neostigmine tors list of anastomotic leak after low anterior resection [Table 1].
adverse effect [17]. The most important factor for prevention of anastomosis brea
It is widely accepted that corticosteroids have a deleterious kdown is a good surgical technique that can improve with expe
effect on healing of skin wounds. Little is known about effect rience. The mobilisation of splenic flexure (with high ligation
of steroids on the healing of colonic anastomosis. of the inferior mesenteric vein) is essential to decrease the ten
Schrock et al. (1973) found that administration of corticoste sion across the anastomotic line and subsequently to prevent ana
roids did not increase significantly incidence of clinical ana stomotic dehiscence. In case of the narrow pelvis of small male
stomosis leakage (retrospective study) [21]. patients or in patients with a bulky tumour a triple stapling tech
From experimental study Furst et al. reported that steroids do nique (TST) is advocated in which a proximate linear stapler is
have an adverse effect on colonic anastomotic healing [22]. It used twice for transverse occlusion of the rectum. Staplers are
requires further clinical as well as experimental investigations. fired from both sides of the rectum. The centre of the rectum
Antineoplasmatic drugs can potentially adversely affect the hea with crossed staples is removed by a further procedure that is as
ling process of large bowel anastomosis via several mechanisms the same as the standard double stapling technique [25].
like impairment of the synthesis and maturation of collagen, Anterior resection for rectal cancer is associated with higher
retardation of production and function of the cellular mediators incidence of anastomotic leak. Total mesorectal excision ( T M E )
of the healing process (macrophages, fibroblasts, leukocytes, reduced the incidence of local recurrence of the tumour but inc-
L A R - functional outcome
median anastomotic height above anal verge -6 cm
present absent
neorectal" volume at distention, reduced 114 ml
pressure of 40 and 50 cm H 2 0
compliance at sensation of filling reduced ~ 4 ml/cm H 2 0
urge to defecate reduced ~3.5 ml/cm H 2 0
maximum tolerated volume reduced ~3ml/cm H 2 0
reased the rate of anastomotic dehiscence. Karanjia reported Determinationof lysozymecontent in the wound or in the eff-
11%of major anastomotic leaks associated with peritonitis and luent from pelvic drains might be useful in early diagnosis of
6.4%of asymptomatic leaks detected by contrast enema. anastomotic dehiscence.
All major leaks occurred at an anastomosis situated below Lysozyme is a component of local defence and is produced in
6 cm from anal verge. Defunctioning stoma reduces the inci- macrophages. In patients with impending anastomotic leak,
dence of major leak and protects against the development of lysozyme activity is significantlyincreased as early as the first
peritonitis. It has been considered it prudent to defunction the postoperative day in contrast to patients without any anasto-
low rectal anastomosis below 6 cm from anal verge, particu- motic complications [30].
larly after total mesorectal excision [27]. Total parental nutrition,broad spectrum antibiotics, treatment
With meticulous attention to the technical issues described of the septic shock and prompt surgery (depends on patient
below anastomotic complications can be kept to less than 5% status and diameter of fistula) are essential for the patient.
of the bowel resections. Disconnection of breakdown anastomosis followed by Hart-
man procedure is a treatment of the choice in anastomotic
Technique dehiscence bigger than 1 cm. (Fig. 9)
a) Conventional suturing- suture ,,~nterruptedor continuous, Long-termfunctional outcome after LAR may be impaired by
should take deeper muscularis and minimal mucosa, good anastomotic leakage [31]. In patients with leak as the results
approximation all layers of bowel wall; the floor of the pel- of pelvic sepsis, the fibrosis may develop with subsequent nar-
vis is not reconstituted but is vigorously imgated with sali- rowing of the distal bowel or stricture formation. (Fig. 10)
ne; no drains are advised "Neorectal" volume at distension pressures of 40 and 50 cm
b) Stapled anastomosis- various stapling technique can permit H20 and compliance at sensation of filling urgency maximum
a secure anastomosis. Following principles are essential for tolerated volume were significantlyreduced in patients with ana-
minimising complications related to the use of staplers: stomotic leak. The impaired anorectal function is measured by:
I. Use the largest calibre of stapler the anastomosis can 1. increased frequency of bowel movements
accommodate 2. increased urgency
11. After placing of the purse-string the excessivebulk of 3. increased incontinence score and
tissue should not appear around shaft 4. impaired evacuation.
111. The purse-string can be snagged up close to the shaft In addition anastomotic leak may increase the risk of loco-
IV. Reinforce the purse-string if one is concerned about regional neoplastic recurrence [32].
the possibility of a gap
V. Repair any identified defect Summary
VI. on-satisfactory anastomosis(e.g. incomplete dough- Several systemicand local factors play significantrole in aeti-
nuts) mandates a diverting colostomy or evidence of ology of anastomotic leak.
primary anastomosis.
Systemicfactors are: shock, sepsis, advancedage of patient (abo-
Most common factors leading to anastomotic leak are: disea- ve 75 y.), coagulopathy, steroids, advanced malignant disease,
se of the bowel itself, inadequate blood supply and diseases
that affect local blood flow particularly in distal stump, tensi- Table 1
on on the suture line, inaccurate suture placement, trauma and Risk Factors of Anastomotic Leak after Low Anterior Resection of
failure to obtain a watertight seal. the Rectum (Surgical Treatment Only)
The implementation of intraoperativeair testing or direct visu-
alisation of anastomosis by means of the sigmoidoscopecan ~emonstratedin randomised trials
reduce the leak rates from 14%("no test" group) to 4%("test" Low (below pentonea reflexion) vs. high anastomosis
group). implicated
The presence of drains is associated with an increased inci- inadequate blood supply; tension on suture line
dence of anastomotic leakage. Drains may adversely affect an Septic conditions or undrained pelvic collection
anastomotic healing. Selectively used protective colostomy Preoperative radiotherapy, chemotherapy, steroid therapy
Patients condition (concurrent disease), age
does not prevent the developmentof anastomoticleak but when Inadequate bowel cleaning or emergency or palliative surgery
it happens colostomy reduces the mortality and morbidity. Shock during surgery, coagulopathy
Low anterior resection, pre-existing sepsis (beforeoperation), Vitamin C, iron, zinc, methionine and cysteine deficiency (unbalanced
heavy faecal contamination during operation, perianastomo- collagen lysislsynthesis)
tic drainage, proximal diverting stoma, emergency operation, Implicated especially to double-stapledtechnique
cardio-respiratory insufficiency and less experienced surge- Mucosal tears caused by anvil or staple gun insertion
on: these are most essential risk factors for the incidence of Excessive upward traction of rectal stump during insertion or closing of
an instrument
an anastomotic leak. (Fig. 8) Forceful extraction of an instrument
The prompt diagnosis of anastomosis leak has a paramount Failwe of staples closure
value for the patient. Contrast enema with either uropolin or
gastrographine enables early diagnosis of anastomotic leak. Adapted from A.M. Averbach et al. Dis. Colon Rectum 1996,39,780