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18 The Failed Anastomosis
293
Proximal diversion has improved mortality (15 % vs. 37 %)
compared to anastomotic takedown and end colostomy
(Hartmann’s) [
132 ]. Patients with proximal diversion are
more likely to have their stomas reversed (100 % vs. 57 %)
and with decreased morbidity (17.6 % vs. 71 % ) compared
to Hartmann’s [
132 ]. Proximal diversion can improve anas-
tomotic healing and allow for the use of other interventions
needed to repair the anastomosis [
133 , 134 ]. Local drainage
alone without diversion risks prolonged pelvic sepsis
causing fi brosis of the neorectum resulting in very poor
function [ 135 ].
Diversion, Resection, and Revision
Key Concept : Unstable patients or those with low rectal
anastomoses have better early and future outcomes if the
anastomosis is left alone and only diversion and drainage is
performed .
During the laparotomy, high-volume lavage with warm
fl uid and drainage of the infected material is the basis for successful infectious source control. In addition the surgeon can
perform proximal diversion, anastomotic revision with or
without proximal diversion, or resection of the anastomosis
with Hartmann’s stump and end ostomy. Several factors are
against both you and the patient at this stage. Reoperations
for anastomotic leaks take place in a hostile abdomen in the
setting of a severe infl ammatory response to the infection and
usually encumbered by the dense adhesions of the postoperative period. Patients with septic shock are also not likely to
tolerate the long operation needed for any formal revision.
Additionally, the infl ammatory mass around the anastomotic
leak prevents any safe surgical dissection [ 91 ]. Many outside
factors also infl uence your options (i.e., age, shock, immune
status). Treatment of anastomotic leak accompanied by septic
shock may benefi t from a diverting colostomy or ileostomy,
such as in the case of trauma or diverticulitis, as these adequately control the source of contamination and infection
[ 115 , 132 , 136 ]. Diversion is particularly benefi cial in patients
with septic shock who might not tolerate a longer procedure
or those cases where the peri- anastomotic infl ammatory process does not permit a safe dissection of the anastomosis.
Resection of the low-lying rectal anastomosis and end
colostomy can negatively impact a patient’s ability to
undergo future ostomy closure [ 132 ]. The literature confi rms
that an end colostomy with a Hartmann pouch causes
increased morbidity and increases the permanent stoma rate
without actually providing any signifi cant benefi t over a
diverting ostomy [ 132 ]. Anastomotic revision under severe
infl ammatory conditions may adversely affect the blood supply at the anastomosis that could result in continued sepsis
from the ensuing bowel necrosis. For this reason many advocate the use of diversion alone [ 113 , 131 ].
In situations where there is necrosis or a greater than
50 % dehiscence of the anastomosis, a diverting ostomy
may be inadequate in controlling the source of infection.
Resection and reanastomosis with proximal diversion are
recommended, if technically feasible, in a stable patient.
However, if the blood supply still appears to be insuffi cient
following resection or in any circumstance where a reanastomosis would be inappropriate, an end ostomy should be
created. The exception to this is the circumstance where an
extremely low rectal anastomosis has been constructed with
proximal diversion. The addition of rectal lavage has been
shown to be effective even in cases with >50 % dehiscence
[
74 ]. It is benefi cial in the long term to preserve the anasto-
mosis, but ongoing pelvic contamination or chronic infection can likewise have devastating consequences for future
bowel function and quality of life [ 137 ]. In circumstances
where that is likely, another approach may be considered.
The Turnbull- Cutait pull-through of the left colon can eliminate the risk of poor blood supply or tension causing another
anastomotic leak (Fig. 18.5a–d ). This technique often
requires extensive mobilization of the left and transverse
colon to allow the bowel to be pulled though the short rectal
stump. The mucosa is stripped to the dentate line, and the
bowel is pulled through the anus to leave 7–10 cm hanging
from the anus. A 34-French mushroom catheter is placed in
the left colon to hang out of the anus and the bowel tied to
the catheter to prevent slippage. The catheter is placed to
closed drainage, and the externalized bowel is wrapped with
Betadine soaked Kerlix and kept moist with fresh
Betadine for 7 days. The patient returns to the OR on day 7
to amputate the external segment and suture the coloanal
anastomosis.
Suture Repair
Key Concept : Do not give in to the allure of performing a
simple suture repair .
Since many anastomotic dehiscences are small, it seems
logical that they would be amenable to simple suture repair.
Unfortunately sutures can decrease the blood supply to
nearby tissues in an area of dehiscence that may already
have a questionable blood supply, thus potentially making
matters worse. Some surgeons are advocates of suture
repair in minor defects (1 cm or less); however, there is limited evidence to support this recommendation. In fact, at
least one study has questioned whether suture repair should
be an option at all [ 112 ]. This study found that patients with
a positive leak test during an elective colorectal resection
had a much higher incidence of postoperative leaks with
suture repair compared to revision [ 113 ]. If you do decide
to perform a suture repair, you should consider performing
a proximal diversion. In fact, with any positive leak test, the
decision tree should almost always include a diverting
stoma [
138 ].
294
N. Smallwood et al.
Fig. 18.5 Turnbull-Cutait pull-through. ( a ) The end of the colon is
grasped from below and pulled through the anal verge. ( b ) Excess
length is pulled through to the desired level and wrapped in dressing.
Management Unique to the Crohn’s Patient
Key Concept : Crohn ’ s patients with an ileocolic anastomotic
leak behave differently and require different treatment than
those with a colocolic anastomosis .
Anastomotic leaks can have a severe impact on the longterm outcome in patients with Crohn’s disease. Only one
study specifi cally focuses on the management of ileocolic
and colocolic anastomotic leaks. The only apparent difference in Crohn’s patients was seen in ileocolic leaks [ 139 ]. It
was readily apparent in this study that resection with end
ileostomy had far superior results in mortality (0 % vs.
21 %) and disease recurrence (0 % vs. 57 %) compared to
methods which attempted to preserve or revise the
( c ) After time, the excess length is resected. ( d ) Final hand-sewn colo-
anal anastomosis. (Reprinted with permission. © Cleveland Clinic
Foundation, Cleveland, OH)
anastomosis. Colo- colonic anastomotic-related complications were treated with methods of anastomotic preservation
or takedown with end ostomies. Anastomotic-preserving
methods included combined antibiotics, percutaneous drainage, and laparoscopic lavage or laparotomy with suturing of
the leak site or resection and revision with or without proximal diversion. There was no difference in mortality, enterocutaneous fi stula, or disease recurrence. Colo-colonic
anastomotic leaks appeared to be a more localized process,
with a much higher rate of spontaneous healing of enterocutaneous fi stula. These results should be given consideration
when faced with ileocolic anastomotic complications and
warrant further studies. Most often, though, a conservative
approach to managing the leak should be considered.
18 The Failed Anastomosis
295
Establishment of drainage by percutaneous placement of
pigtail catheters allows the sepsis to be treated and bowel
rest to be applied in an attempt to close the leak without
operating. This approach can successfully manage up to
two-thirds of abscesses and fi stulas [
140 ].
Management After the Acute Setting
Key Concept : You are not fi nished treating a leak until after
ostomy closure . Treating the area of dehiscence early on may
allow for higher rates of ostomy closure and improved functional outcomes .
After the successful management of an anastomotic
leak, the focus should shift to planning for the eventual restoration of intestinal continuity. This is an issue of equal
importance, especially to the patient, and is best addressed
early. Anastomotic defects, whether they are simple fi stulas
or large sinuses, can often spontaneously heal on their own
if the patient is diverted [ 124 , 130 ]. Unfortunately, not all
defects will heal completely. Some will require additional
months of diversion before they completely heal. The cavity around the leak must be completely healed before
ostomy closure in order to prevent recurrent pelvic sepsis
[ 134 ]. During this “healing period,” chronic infl ammation,
and even low-grade infection, is allowed to persist while
the defect undergoes secondary healing. The resulting
fi brosis and scar formation can lead to persistent larger
sinuses or ultimately to stenotic areas [ 141 ]. New methods
of treating the local area of disrupted anastomosis may
speed healing and reduce contamination to improve functional outcome.
Endoscopic Vacuum-Assisted Closure (Endoluminal VAC) or Endo-Sponge™
Key Concept : This negative pressure system may be useful
for select low - lying anastomotic leaks ; however , it should be
applied within 6 weeks and will require several endoscopic
changes .
Modifi cation of the vacuum-assisted dressing to achieve
endoluminal and endocavitary suction has been useful in
closing low colorectal anastomotic leaks [
(Fig. 18.6 ). The actual manufactured device currently
available for use in treating gastrointestinal complications
is the Endo-Sponge™ (B Braun Melsungen AG,
Melsungen, Germany) [ 145 ], which has been available in
Europe for more than a decade (Fig. 18.6 ). As of 2012 the
FDA has approved it in the USA. Surgeons have adapted
the current Wound V.A.C™ (Lifecell, Bridgewater, NJ) for
use as an internal Wound V.A.C™ dressing. The amount of
negative pressure to use when adapting the Wound V.A.C™
141 – 144 ]
for anastomotic leaks is unknown. For the Endo-Sponge™
the negative pressure is set at a much lower negative pressure than the traditional Wound V.A.C™, but it appears
that even −125 mmHg is well tolerated [
ported advantage is the endoluminal VAC can drain intestinal contents before they are able to leak out into the
adjoining abscess cavity. On the contrary, percutaneous
drainage is unable to prevent this extravasation. Effective
drainage and removal of necrotic material reduces the bacterial burden facilitating an increase in granulation tissue
and a decrease in the size of the cavity [
minal VAC can at times even prevent the need for proximal
diversion [ 142 ]. However, the endoluminal VAC is more
effective at shrinking cavities if applied within 6 weeks
after the anastomotic leak [ 143 ]. This is likely attributable
to the increase in collagen deposition and scarring within
the adjoining cavity which takes place over time. Once
secondary healing occurs, the cavity is far less likely to
undergo any signifi cant cavity contraction [ 143 ]. Closure
of presacral sinuses, abscess cavities, and fi stulas occurs in
75–97 % of patients who began treatment within 6 weeks
compared to 38 % in patients who began treatment after
6 weeks. Total number of VAC changes (endoscopic sessions) needed for successful closure was a median of
11–13 over a median time period of 34–40 days [ 142 ,
143 ]. At times patients may have very small fi stula open-
ings that feed larger sinuses. Endoluminal VAC placement
into the abscess cavity is diffi cult or impossible through
small fi stula openings. For these small fi stulae orifi ces that
lead to larger sinuses, the endoluminal VAC can be applied
over the fi stula orifi ce within the rectum with or without
percutaneous drainage of the sinus. The other option would
be to expand the fi stula orifi ce to allow sponge placement.
Endoluminal VAC therapy is promising and seems to be
very useful in the early setting—allowing for both healing
and drainage, and even complete closure of anastomotic
fi stulas or sinuses. Even if the endoluminal VAC is unable
to completely close a defect, it will still have resolved any
infection and provided healthier tissue for use in other
methods of repair.
141 ]. One pur-
142 ]. The endolu-
Fibrin Glue
Key Concept : Fibrin glue is probably best used in the chronic
setting to close small fi stula openings before trying other
more invasive options — so long as there is limited purulent
material and a minimal amount of fecal or bacterial
contamination .
Fibrin glue (combined thrombin and fi brinogen) or other
types of nonbiologic glues have been used during anastomosis creation and for leaks and fi stulas. Despite the early success showing an 85 % healing rate of anal fi stulae, recent
296
N. Smallwood et al.
Fig. 18.6 Adaptation of KCI’s proprietary V.A.C.® Therapy System for
use as a type of endoluminal VAC. Images A – D are a pictorial guide in
creating an endoluminal VAC. Step A : Cut the tubing close to the suction
application pad to provide adequate length without requiring extra tubing. The KCI
attached to a smaller diameter drain for smaller fi stulas. Cut the sponge
to the size of sinus or fi stula tract keeping in mind the amount of magni-
TM
tubing can be directly applied to the sponge or if needed
studies have failed to replicate these numbers. It also has
been shown that fi brin glues are less effective in treating
rectal complications compared to other areas like the esophagus. During the acute setting tissues have a signifi cant
amount of bacterial content and infl ammation [
146 ].
Currently, fi brin glue has a 25–33 % success rate as a single
agent for treating rectal anastomotic complications [ 146 ,
147 ]. It is diffi cult to discern from the literature the exact role
for fi brin glue. The two benefi ts in using fi brin glue are that
it is fairly quick and easy to apply and it will not prevent the
use of any other method if it fails. Fibrin glue is most useful
in a chronic setting, especially with the low-volume small
bowel fi stula that is due to an anastomotic leak at an ileocolic
staple line or strictureplasty. After removal of the percutaneous drain from the collapsed tract, the tract can be fi lled with
fi brin glue to fi nish the healing.
fi cation when viewed through the endoscope. Make sure the base is
broader to allow a securer attachment of the tubing. Step B : Cut a circu-
lar area out of the base of the sponge extending about half the length of
the sponge. Steps C , D : Secure the sponge with through and through
bites of sponge and tubing. Three different horizontal mattress stitches
using a Keith needle is a fairly easy and secure method. The remainder
of the procedure is similar to placing the Endo-Sponge™
Covered Stents
Key Concept : While the emerging use of covered stents may
dramatically change the way we treat certain leaks , for now
they are relegated to treating those patients with a severe or
complete disunion of their anastomosis , typically along with
a proximal diverting ostomy , or in patients that have both a
fi stula and an adjacent stenotic area .
Stents are beginning to be used in cases of malignant
colorectal obstructions, with a very limited amount of use in
colorectal anastomotic leaks. Much of what we know about
the use of stents for anastomotic complications comes from
treating esophageal anastomotic leaks. Covered stents, when
used to treat esophageal anastomotic leaks, have been able to
achieve complete resolution, in a minimally invasive fashion,
within days to weeks. Studies show that esophageal stents
18 The Failed Anastomosis
297
allow much earlier resumption of oral intake, signifi cant
shorter hospital stays, and an 87–94 % success rate [
148 ,
149 ]. The overall therapeutic principle behind stents is that
they are able to effectively “bridge the breach” [
150 ] and in
doing so provide a scaffold which allows for reapproximation of the two ends, mucosal regeneration, and prevention of
further drainage through the anastomotic defect and infectious complications.
Only a small number of studies, mainly composed of case
series, include colorectal anastomotic leaks (Fig.
18.7 ).
Studies show varying degrees of success in treating acute
leaks, sometimes with almost complete anastomotic disunion
as well as chronic fi stulas [ 150 , 151 ]. This is level IV evi-
dence, at best, but we can draw some general conclusions.
1. Additional procedures, like percutaneous drainage, are
very often still needed [ 150 , 151 ].
2. The use of covered stents to cover the opening in the
colorectal anastomosis may allow the fi stula to heal without a diverting ostomy in up to 80 % of patients [ 151 ].
3. There is a high incidence of rectal pain if the distal aspect
of the stent is within 5 cm of anal verge [ 152 ].
4. Migration is the #1 problem:
• Full-thickness sutures or clips can help prevent
migration.
• Biodegradable and fully covered stents are more likely
to migrate.
• Patients who have stenosis in addition to a leak are less
likely to have migration problems.
• Due to these migration issues, using the stent to avoid
proximal diversion could be technically challenging
and may expose the patient to further infectiousrelated complications if migration does occur.
5. Partially covered stents migrate less, but allow for tissue
in-growth, and the eventual removal can at times be very
diffi cult.
Solution : Stent Within a Stent Technique
Some gastroenterologists prefer to place a fully covered stent within the previously placed stent a few days
before the stent will be removed. This will cause necrosis
and sloughing of the mucosal in-growth and easier
removal [ 153 ].
6. “Stent-guided regeneration and epithelialization” [ 150 ]—
This is an interesting concept where stents, in cases of
near-complete anastomotic disunion, act like scaffolds,
allowing for approximation of the two bowel ends and
reepithelialization.
Transanal Repair
Key Concept : Different methods of transanal repair have
been used in an attempt to close the unhealed fi stula or sinus
near the anal verge and allow for future ostomy closure .
Fig. 18.7 Covered stent use for a colorectal anastomotic leak
(Courtesy of Elisa Birnbaum, MD)
These include simple suturing , curettage , clips , marsupial-
ization , plugs ( for RVF ,) and mucosal advancement — all
with variable results and experience .
Transanal methods are technically more diffi cult to use
for leaks higher up in the rectum and are prone to fail in
patients who are not diverted. Simple suturing should only
be attempted for small defects in tissues with minimal
infl ammation, and even then it is prone to fail. Some chronic
small fi stula tracts may be allowed to heal by performing
local curettage to remove the epithelialized tract but more
often is used as an adjunct to other procedures such as fi stula
plugs and endomucosal fl aps [ 154 ]. Patients with chronic,
large presacral sinuses, associated with small openings, may
benefi t from expanding the small opening in a procedure
known as marsupialization where the rectal wall overlying
the abscess cavity is incised and abscess cavity laid open.
Marsupialization allows for better drainage and healing that
can result in complete resolution of the sinus in a few months
through reepithelialization. Marsupialization can be done
endoscopically using an Olympus Triple Lumen Needle
Knife [ 155 ], as well as with proctoscope or anoscope and the
laparoscopic electrocautery scissors. Currently, this author,
and others [ 156 ], uses a laparoscopic EndoGIA stapling
device placed through the anus with the thin anvil in the fi stula and the staple cartridge in the rectal lumen with good
results, but it is conceivable that radiofrequency tissue sealing devices could work just as well. Flap advancement techniques more often have been used to treat rectovaginal
fi stulas, but can also be applied to any anastomotic fi stula in
close proximity to the anal verge [
154 , 157 ]. Flap advance-
ment is akin to simple suturing but appears to have better
results because it involves excising the fi stula opening and
298
N. Smallwood et al.
Fig. 18.8 Endoscopic clip placement for an anastomotic leak
(Courtesy of Elisa Birnbaum, MD)
mobilizing the adjacent tissues, allowing for the approximation of healthy tissues without tension. Finally, there are limited reports of successful use of endoscopic clips to close the
opening (Fig. 18.8 ).
Redo Surgery
Key Concept : Reoperative surgery should not be undertaken
lightly , although it is sometimes the only way in which bowel
continuity can be restored after other methods have failed .
Redo surgery is an elective surgery to restore intestinal
continuity. It is associated with an approximately 20 % failure
rate due to intraoperative failures or postoperative complications that ultimately result in a permanent stoma [ 158 ].
Anastomotic leaks occur with at least equal frequency as the
initial operation; therefore, it is highly recommended to protect the new anastomosis with a diverting ostomy. This unfortunately will require an additional procedure, at a later date,
for ostomy closure. Mortality is typically low with the appropriate patient selection, while morbidity is still typically high
(32–55 %) [ 158 , 159 ]. Some patients, even after a successful
redo surgery, will have signifi cant functional issues, such as
increased frequency, incontinence, constipation, and diffi cult
evacuation, following ostomy closure. Ureteral stent placement is recommended in the previously operated pelvis [ 159 ].
As a general rule of thumb, redo surgery is appropriate in
patients:
• When other methods have failed
• Who have a minimal risk of perioperative mortality
• Who are not currently undergoing chemotherapy or
radiation
• Nutritionally optimized
• Highly motivated for ostomy reversal
• Fully understand the risks involved and the possibility of
failure
Anastomotic Stenosis
Key Concept : Anastomotic stenosis may be as signifi cant as
leaks because of the impact on a patient ’ s quality of life ,
potential need for multiple revision attempts , and risk of permanent stoma .
Unfortunately for the colon and rectal surgeon, there are
multiple ways an anastomosis can fail, with stenosis being a
prominent one. It is a relatively common complication following colorectal surgery, reported in up to 20 % of patients
160 ]. Due to the wide variety of defi nitions used, the nor-
[
mally quoted incidence ranges from 3 to 30 % [
161 – 163 ].
Using a single defi nition for “stenosis” as the inability to
pass an 18- or 19 mm-diameter rigid rectoscope through an
observed narrowing regardless of symptoms resulted in an
incidence of 13–20 % [ 160 , 161 ]. This number is likely to
vary per surgeon and, in our own experience, does not seem
to be as common. Many patients will have a fi brous stricture
or web at the site of the anastomosis, sometimes appearing to
be totally occluding the lumen. These are almost always easily broken up digitally or with the passage of the rigid proctoscope, and ultimately do not recur. Regardless of its true
incidence, anastomotic stenosis is a challenge for the
surgeon.
Pathophysiology
Key Concept : Several risk factors , including stapling devices ,
correlate with higher stenosis rates , while an intact mucosa
may lead to lower rates of development .
Use of stapling devices, but not the size of stapler, is a risk
factor for stenosis [ 161 ]. Necrotic tissue within the staple line
and the small gap that is created between adjacent mucosa
leads to an increased infl ammatory response, collagen deposition, and secondary healing [ 101 ]. The signifi cance of hav-
ing an intact mucosa can further be derived from esophageal
endomucosal resections where signifi cant stenosis can occur
in 75–80 % of patients who undergo more than 75 % circumferential resections of the mucosa [ 164 ]. An iatrogenically
created mucosal defect in the esophagogastrostomy model in
a dog resulted in higher degrees of stenosis and more scarring
at the site of the anastomosis than those with an intact mucosa
164 ]. An intact mucosa and mucosa-to- mucosa apposition
[
appear to be important in preventing stenosis. Other identifi ed
risk factors include anastomotic leaks, pelvic sepsis, longterm diversion, and radiotherapy [ 163 , 165 ].
18 The Failed Anastomosis
299
Symptoms and Clinical Course
Key Concept : Symptoms of anastomotic stenosis include
bloating , constipation , and incomplete defecation . You
should realize that the severity of symptoms will often not
correlate with the degree of stenosis .
A clinical scoring system combines both the severity of
symptoms with the necessary therapeutic intervention [ 160 ,
161 ]. Severe cases of stenosis in diverted patients will not be
apparent until the patient undergoes hypaque enema evaluation for ostomy closure. Regardless of the absence of symptoms, the stenosis will need to be treated before ostomy
closure. In general, though, patients should only be treated if
they are symptomatic [ 160 ].
Treatment
Key Concept : Treatment for stenosis is accomplished
using fi nger dilation , endoscopic balloon dilation , or stent
placement .
Many stenoses will be amenable to fi nger fracture or
endoscopic dilation alone; however, repeat procedures are
commonly needed [ 161 ]. In some patients no method of
treatment will work other than surgical revision. Most treatments are more effective if performed within the fi rst few
months postoperatively and seem to be much more refractory if performed later [ 161 ]. Some patients, despite prob-
lematic symptoms, will wait months to years before seeking
help. Informing patients of the expected symptoms and
changes in bowel function will speed diagnosis and treatment [ 161 ].
Balloon Dilation
Endoscopic balloon dilation, whether performed under fl uoroscopy or through the scope, has up to a 90 % success rate
with minimal associated morbidity. Patients should realize
that multiple dilating procedures may be required before
symptom resolution. This may be related to inadequate initial balloon dilatation [ 162 ]. Kim et al. [ 162 ] used a balloon
dilation treatment algorithm that involved dilating a single
20 mm balloon followed by adding a second 10 mm balloon
if no pain or blood was seen on the catheter. The 10 mm balloon was then changed out to a 15 mm and fi nally a 20 mm
balloon as long as the patient did not experience pain or
blood is not seen on the catheter. This method resulted in an
86 % success rate at long-term follow-up; however, there
was no control group for comparison [ 162 ]. There is cur-
rently no consensus as to how many different dilation treatments are warranted before moving on to some other
modality. A general rule is that after three endoscopic dilations, any symptomatic recurrent stenosis should be treated
with a different method.
S t e n t s
Stents were fi rst used to treat cancer-related esophageal
obstructions. Obstructive colorectal cancers are now being
treated with soft expanding metal stents. The absolute effectiveness of this treatment modality is unknown at this time.
It has been shown to be effective in the cases where both
stenosis and a fi stula or sinus exist as previously discussed.
Successful stenting of anastomotic stricture has been
reported [ 166 ]. Migration and in-growth of tissue are likely
complications.
Complete Obstruction
There are other alternatives besides surgical revision that can
potentially treat the totally occluded anastomosis. In addition
to the circular stapled revision, which will be described later,
one other alternative remains. This method explained by
Curcio et al. [
access the proximal lumen from the distal lumen under both
endoscopic and fl uoroscopic control. Placement of a 0.025 in.
wire through the 18 gauge catheter allowed for progressive
balloon dilation of the area up to a 20 mm balloon with good
results. In circumstances where the ostomy proximal to the
obliterated anastomosis is available to introduce an endoscope, the light of the proximally placed endoscope can
guide recanalization using cautery or sharp dissection.
Resection of the central scar and complete dilation are then
possible.
167 ] uses a suprapapillary puncture catheter to
Surgical Revision
Surgical revision should be considered should other less invasive modalities fail. The operation will be diffi cult with blood
supply to the anastomosis tenuous, and similar to revision of
anastomotic leaks, should not be taken lightly. There are two
techniques that allow for surgical correction of the stenosis
without formal resection and revision. These are stricturoplasty and circular stapled revision without resection. The
stricturoplasty is similar to the Heineke-Mikulicz pyloroplasty on the anterior aspect of the anastomosis. The stapled
revision requires a longitudinal incision on the anterior border
of the proximal limb with insertion of the anvil, and under
direct vision, the pin of the circular stapler is deployed
through the stenotic or obstructed area and the anvil attached.
McKee and colleagues described this method [ 168 ] by using
a 29 mm circular stapler in a 51-year-old female. Success
with these two methods needs to be further explored.
However, they should remain in the surgeon’s armamentarium, especially in cases where the complete dissection of the
low rectal anastomoses is diffi cult. Anastomotic resection
and reconstruction is preferred if soft tissue is not available or
revision increases the likelihood of further complications due
to poor blood supply. A low rectal anastomosis is an extremely
diffi cult procedure in the reoperative pelvis and requires
patience and experience to achieve success.
300
Fig. 18.9 Algorithm to treat an
anastomotic stricture
N. Smallwood et al.
Anastomotic Stenosis Summary
The severity of the problem with anastomotic stenosis in relation to its incidence is extremely variable. Since staplers appear
future preventive measures will need to address the design of
stapled anastomoses. There is no consensus that outlines management or treatment of stenosis. A treatment algorithm is presented in Fig. 18.9 . Finally, anastomotic stenosis or recurrence
of stenosis months to years after successful treatment may be
due to cancer recurrence. It is therefore important to take biopsies upon the fi rst identifi cation of stenosis along with additional biopsies and/or imaging in cases of recurrent stenosis
that follows a prolonged asymptomatic period.
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