Clin Colon Rectal Surg 2021; 34(06): 391-399
DOI: 10.1055/s-0041-1735270
Review Article

Diagnosis of Anastomotic Leak

Paul T. Hernandez
1   Division of Colorectal Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
,
Raj M. Paspulati
2   Department of Radiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
,
Skandan Shanmugan
3   Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
› Author Affiliations

Abstract

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.



Publication History

Article published online:
23 November 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Dietz UA, Debus E-S. Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery. World J Surg 2005; 29 (03) 396-401
  • 2 Hardy KJ. Bowel surgery: some 18th and 19th century experience. Aust N Z J Surg 1988; 58 (04) 335-338
  • 3 Lindgren R, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P. What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial. Dis Colon Rectum 2011; 54 (01) 41-47
  • 4 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 (05) 890-899
  • 5 Nordholm-Carstensen A, Rolff HC, Krarup P-M. Differential impact of anastomotic leak in patients with stage IV colonic or rectal cancer: a nationwide cohort study. Dis Colon Rectum 2017; 60 (05) 497-507
  • 6 Gessler B, Eriksson O, Angenete E. Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis 2017; 32 (04) 549-556
  • 7 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; 102 (05) 462-479
  • 8 Zheng H, Wu Z, Wu Y. et al. Laparoscopic surgery may decrease the risk of clinical anastomotic leakage and a nomogram to predict anastomotic leakage after anterior resection for rectal cancer. Int J Colorectal Dis 2019; 34 (02) 319-328
  • 9 Zhang W, Lou Z, Liu Q. et al. Multicenter analysis of risk factors for anastomotic leakage after middle and low rectal cancer resection without diverting stoma: a retrospective study of 319 consecutive patients. Int J Colorectal Dis 2017; 32 (10) 1431-1437
  • 10 Vignali A, Fazio VW, Lavery IC. et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg 1997; 185 (02) 105-113
  • 11 Pakkastie TE, Luukkonen PE, Järvinen HJ. Anastomotic leakage after anterior resection of the rectum. Eur J Surg 1994; 160 (05) 293-297 , discussion 299–300
  • 12 Hamabe A, Ito M, Nishigori H, Nishizawa Y, Sasaki T. Preventive effect of diverting stoma on anastomotic leakage after laparoscopic low anterior resection with double stapling technique reconstruction applied based on risk stratification. Asian J Endosc Surg 2018; 11 (03) 220-226
  • 13 Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007; 9 (01) 71-79
  • 14 Kayano H, Okuda J, Tanaka K, Kondo K, Tanigawa N. Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer. Surg Endosc 2011; 25 (09) 2972-2979
  • 15 Park JS, Choi GS, Kim SH. et al. Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 2013; 257 (04) 665-671
  • 16 Kim SH, Park IJ, Joh YG, Hahn KY. Laparoscopic resection of rectal cancer: a comparison of surgical and oncologic outcomes between extraperitoneal and intraperitoneal disease locations. Dis Colon Rectum 2008; 51 (06) 844-851
  • 17 Qu H, Liu Y, Bi DS. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc 2015; 29 (12) 3608-3617
  • 18 Midura EF, Hanseman D, Davis BR. et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 2015; 58 (03) 333-338
  • 19 Tanaka K, Okuda J, Yamamoto S. et al. Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial. Surg Today 2017; 47 (10) 1215-1222
  • 20 Tsuruta A, Tashiro J, Ishii T. et al. Prediction of anastomotic leakage after laparoscopic low anterior resection in male rectal cancer by pelvic measurement in magnetic resonance imaging. Surg Laparosc Endosc Percutan Tech 2017; 27 (01) 54-59
  • 21 Zur Hausen G, Gröne J, Kaufmann D. et al. Influence of pelvic volume on surgical outcome after low anterior resection for rectal cancer. Int J Colorectal Dis 2017; 32 (08) 1125-1135
  • 22 Nikolian VC, Kamdar NS, Regenbogen SE. et al. Anastomotic leak after colorectal resection: a population-based study of risk factors and hospital variation. Surgery 2017; 161 (06) 1619-1627
  • 23 Eriksen TF, Lassen CB, Gögenur I. Treatment with corticosteroids and the risk of anastomotic leakage following lower gastrointestinal surgery: a literature survey. Colorectal Dis 2014; 16 (05) O154-O160
  • 24 Slieker JC, Komen N, Mannaerts GH. et al. Long-term and perioperative corticosteroids in anastomotic leakage: a prospective study of 259 left-sided colorectal anastomoses. Arch Surg 2012; 147 (05) 447-452
  • 25 Zeeh J, Inglin R, Baumann G. et al. Mycophenolate mofetil impairs healing of left-sided colon anastomoses. Transplantation 2001; 71 (10) 1429-1435
  • 26 Petri JB, Schurk S, Gebauer S, Haustein UF. Cyclosporine A delays wound healing and apoptosis and suppresses activin beta-A expression in rats. Eur J Dermatol 1998; 8 (02) 104-113
  • 27 Schäffer MR, Fuchs N, Proksch B, Bongartz M, Beiter T, Becker HD. Tacrolimus impairs wound healing: a possible role of decreased nitric oxide synthesis. Transplantation 1998; 65 (06) 813-818
  • 28 van der Vliet JA, Willems MCM, de Man BM, Lomme RMLM, Hendriks T. Everolimus interferes with healing of experimental intestinal anastomoses. Transplantation 2006; 82 (11) 1477-1483
  • 29 D'Haens G, Baert F, van Assche G. et al; Belgian Inflammatory Bowel Disease Research Group, North-Holland Gut Club. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn's disease: an open randomised trial. Lancet 2008; 371 (9613): 660-667
  • 30 Khanna R, Bressler B, Levesque BG. et al; REACT Study Investigators. Early combined immunosuppression for the management of Crohn's disease (REACT): a cluster randomised controlled trial. Lancet 2015; 386 (10006): 1825-1834
  • 31 Yamamoto T, Spinelli A, Suzuki Y. et al. Risk factors for complications after ileocolonic resection for Crohn's disease with a major focus on the impact of preoperative immunosuppressive and biologic therapy: a retrospective international multicentre study. United European Gastroenterol J 2016; 4 (06) 784-793
  • 32 Huang W, Tang Y, Nong L, Sun Y. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: A meta-analysis of observational studies. J Crohn's Colitis 2015; 9 (03) 293-301
  • 33 Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000; 179 (04) 275-281
  • 34 Kiran RP, Remzi FH, Fazio VW. et al. Complications and functional results after ileoanal pouch formation in obese patients. J Gastrointest Surg 2008; 12 (04) 668-674
  • 35 Biondo S, Parés D, Kreisler E. et al. Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 2005; 48 (12) 2272-2280
  • 36 Bosset J-F, Collette L, Calais G. et al; EORTC Radiotherapy Group Trial 22921. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006; 355 (11) 1114-1123
  • 37 Sebag-Montefiore D, Stephens RJ, Steele R. et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 2009; 373 (9666): 811-820
  • 38 Qin Q, Ma T, Deng Y. et al. Impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection: post hoc analysis of a randomized controlled trial. Dis Colon Rectum 2016; 59 (10) 934-942
  • 39 Park JS, Huh JW, Park YA. et al. Risk factors of anastomotic leakage and long-term survival after colorectal surgery. Medicine (Baltimore) 2016; 95 (08) e2890
  • 40 Matthiessen P, Hallböök O, Andersson M, Rutegård J, Sjödahl R. Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 2004; 6 (06) 462-469
  • 41 Hu M-H, Huang R-K, Zhao R-S, Yang K-L, Wang H. Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis. Colorectal Dis 2017; 19 (01) 16-26
  • 42 Chang JS, Keum KC, Kim NK. et al. Preoperative chemoradiotherapy effects on anastomotic leakage after rectal cancer resection: a propensity score matching analysis. Ann Surg 2014; 259 (03) 516-521
  • 43 Qin C, Ren X, Xu K, Chen Z, He Y, Song X. Does preoperative radio(chemo)therapy increase anastomotic leakage in rectal cancer surgery? A meta-analysis of randomized controlled trials. Gastroenterol Res Pract 2014; 2014: 910956
  • 44 Park J-H, Kim D-H, Kim B-R, Kim Y-W. The American Society of Anesthesiologists score influences on postoperative complications and total hospital charges after laparoscopic colorectal cancer surgery. Medicine (Baltimore) 2018; 97 (18) e0653
  • 45 Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis 2017; 19 (03) 288-298
  • 46 Rencuzogullari A, Benlice C, Valente M, Abbas MA, Remzi FH, Gorgun E. Predictors of anastomotic leak in elderly patients after colectomy: nomogram-based assessment from the American College of Surgeons National Surgical Quality Program procedure-targeted cohort. Dis Colon Rectum 2017; 60 (05) 527-536
  • 47 Tan WP, Talbott VA, Leong QQ, Isenberg GA, Goldstein SD. American Society of Anesthesiologists class and Charlson's comorbidity index as predictors of postoperative colorectal anastomotic leak: a single-institution experience. J Surg Res 2013; 184 (01) 115-119
  • 48 Shinji S, Ueda Y, Yamada T. et al. Male sex and history of ischemic heart disease are major risk factors for anastomotic leakage after laparoscopic anterior resection in patients with rectal cancer. BMC Gastroenterol 2018; 18 (01) 117
  • 49 Cong ZJ, Fu CG, Wang HT, Liu LJ, Zhang W, Wang H. Influencing factors of symptomatic anastomotic leakage after anterior resection of the rectum for cancer. World J Surg 2009; 33 (06) 1292-1297
  • 50 Volk A, Kersting S, Held HC, Saeger HD. Risk factors for morbidity and mortality after single-layer continuous suture for ileocolonic anastomosis. Int J Colorectal Dis 2011; 26 (03) 321-327
  • 51 Warschkow R, Steffen T, Thierbach J, Bruckner T, Lange J, Tarantino I. Risk factors for anastomotic leakage after rectal cancer resection and reconstruction with colorectostomy. A retrospective study with bootstrap analysis. Ann Surg Oncol 2011; 18 (10) 2772-2782
  • 52 Alberg AJ, Shopland DR, Cummings KM. The 2014 Surgeon General's report: commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and updating the evidence on the health consequences of cigarette smoking. Am J Epidemiol 2014; 179 (04) 403-412
  • 53 Baucom RB, Poulose BK, Herline AJ, Muldoon RL, Cone MM, Geiger TM. Smoking as dominant risk factor for anastomotic leak after left colon resection. Am J Surg 2015; 210 (01) 1-5
  • 54 Sørensen LT, Jørgensen T, Kirkeby LT, Skovdal J, Vennits B, Wille-Jørgensen P. Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999; 86 (07) 927-931
  • 55 Kwak HD, Kim SH, Kang DW, Baek SJ, Kwak JM, Kim J. Risk factors and oncologic outcomes of anastomosis leakage after laparoscopic right colectomy. Surg Laparosc Endosc Percutan Tech 2017; 27 (06) 440-444
  • 56 Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012; 255 (06) 1069-1079
  • 57 Sungurtekin H, Sungurtekin U, Balci C, Zencir M, Erdem E. The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr 2004; 23 (03) 227-232
  • 58 Schiesser M, Müller S, Kirchhoff P, Breitenstein S, Schäfer M, Clavien PA. Assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. Clin Nutr 2008; 27 (04) 565-570
  • 59 Mullen JL, Gertner MH, Buzby GP, Goodhart GL, Rosato EF. Implications of malnutrition in the surgical patient. Arch Surg 1979; 114 (02) 121-125
  • 60 Montomoli J, Erichsen R, Antonsen S, Nilsson T, Sørensen HT. Impact of preoperative serum albumin on 30-day mortality following surgery for colorectal cancer: a population-based cohort study. BMJ Open Gastroenterol 2015; 2 (01) e000047
  • 61 Suding P, Jensen E, Abramson MA, Itani K, Wilson SE. Definitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg 2008; 143 (09) 907-911 , discussion 911–912
  • 62 MD S, Chase S, Roopavathana S B, Nadarajan AR, Nayak S. Serum prealbumin, a novel indicator of risk of anastomotic leak in bowel anastomosis. International Surgery Journal 2018; 5: 1724
  • 63 Calin MD, Bălălău C, Popa F, Voiculescu S, Scăunaşu RV. Colic anastomotic leakage risk factors. J Med Life 2013; 6 (04) 420-423
  • 64 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014; 101 (04) 424-432 , discussion 432
  • 65 Choudhuri AH, Uppal R, Kumar M. Influence of non-surgical risk factors on anastomotic leakage after major gastrointestinal surgery: Audit from a tertiary care teaching institute. Int J Crit Illn Inj Sci 2013; 3 (04) 246-249
  • 66 Sakr A, Emile SH, Abdallah E, Thabet W, Khafagy W. Predictive factors for small intestinal and colonic anastomotic leak: a multivariate analysis. Indian J Surg 2017; 79 (06) 555-562
  • 67 Volanakis JE. Human C-reactive protein: expression, structure, and function. Mol Immunol 2001; 38 (2,3(: 189-197
  • 68 Thompson D, Pepys MB, Wood SP. The physiological structure of human C-reactive protein and its complex with phosphocholine. Structure 1999; 7 (02) 169-177
  • 69 Kushner I, Antonelli MJ. What should we regard as an “elevated” C-reactive protein level?. Ann Intern Med 2015; 163 (04) 326
  • 70 Pepys MB, Hirschfield GM. C-reactive protein: a critical update. J Clin Invest 2003; 111 (12) 1805-1812
  • 71 Vijayan AL, Vanimaya, Ravindran S. et al. Procalcitonin: a promising diagnostic marker for sepsis and antibiotic therapy. J Intensive Care 2017; 5: 51
  • 72 Garcia-Granero A, Frasson M, Flor-Lorente B. et al. Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study. Dis Colon Rectum 2013; 56 (04) 475-483
  • 73 Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014; 101 (04) 339-346
  • 74 Giaccaglia V, Salvi PF, Antonelli MS. et al. Procalcitonin reveals early dehiscence in colorectal surgery: the PREDICS study. Ann Surg 2016; 263 (05) 967-972
  • 75 Tan WJ, Ng WQ, Sultana R. et al. Systematic review and meta-analysis of the use of serum procalcitonin levels to predict intra-abdominal infections after colorectal surgery. Int J Colorectal Dis 2018; 33 (02) 171-180
  • 76 Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13 (05) 426-435
  • 77 Facy O, Paquette B, Orry D. et al; IMACORS Study. Diagnostic accuracy of inflammatory markers as early predictors of infection after elective colorectal surgery: results from the IMACORS study. Ann Surg 2016; 263 (05) 961-966
  • 78 Zawadzki M, Czarnecki R, Rzaca M, Obuszko Z, Velchuru VR, Witkiewicz W. C-reactive protein and procalcitonin predict anastomotic leaks following colorectal cancer resections - a prospective study. Wideochir Inne Tech Malo Inwazyjne 2016; 10 (04) 567-573
  • 79 Adamina M, Warschkow R, Näf F. et al. Monitoring c-reactive protein after laparoscopic colorectal surgery excludes infectious complications and allows for safe and early discharge. Surg Endosc 2014; 28 (10) 2939-2948
  • 80 Giaccaglia V, Salvi PF, Cunsolo GV. et al. Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery. J Crit Care 2014; 29 (04) 528-532
  • 81 Kørner H, Nielsen HJ, Søreide JA, Nedrebø BS, Søreide K, Knapp JC. Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections. J Gastrointest Surg 2009; 13 (09) 1599-1606
  • 82 MacKay GJ, Molloy RG, O'Dwyer PJ. C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Colorectal Dis 2011; 13 (05) 583-587
  • 83 Platt JJ, Ramanathan ML, Crosbie RA. et al. C-reactive protein as a predictor of postoperative infective complications after curative resection in patients with colorectal cancer. Ann Surg Oncol 2012; 19 (13) 4168-4177
  • 84 Nicksa GA, Dring RV, Johnson KH, Sardella WV, Vignati PV, Cohen JL. Anastomotic leaks: what is the best diagnostic imaging study?. Dis Colon Rectum 2007; 50 (02) 197-203
  • 85 Samji KB, Kielar AZ, Connolly M. et al. Anastomotic leaks after small- and large-bowel surgery: diagnostic performance of ct and the importance of intraluminal contrast administration. AJR Am J Roentgenol 2018; 210 (06) 1259-1265
  • 86 Lim M, Akhtar S, Sasapu K. et al. Clinical and subclinical leaks after low colorectal anastomosis: a clinical and radiologic study. Dis Colon Rectum 2006; 49 (10) 1611-1619
  • 87 DuBrow RA, David CL, Curley SA. Anastomotic leaks after low anterior resection for rectal carcinoma: evaluation with CT and barium enema. AJR Am J Roentgenol 1995; 165 (03) 567-571
  • 88 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 (NY) 2017; 42 (02) 435-441
  • 89 Power N, Atri M, Ryan S, Haddad R, Smith A. CT assessment of anastomotic bowel leak. Clin Radiol 2007; 62 (01) 37-42
  • 90 Kaur P, Karandikar SS, Roy-Choudhury S. Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis. Clin Radiol 2014; 69 (01) 59-62
  • 91 Saif MW, Elfiky A, Salem RR. Gastrointestinal perforation due to bevacizumab in colorectal cancer. Ann Surg Oncol 2007; 14 (06) 1860-1869
  • 92 Heinzerling JH, Huerta S. Bowel perforation from bevacizumab for the treatment of metastatic colon cancer: incidence, etiology, and management. Curr Surg 2006; 63 (05) 334-337