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30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
471
Table 30.1 Different denitions of anastomotic leak based on diagnostic test and timing of leak
References
Ambrosetti
etal. [71]
Biondo
etal. [72]
Bokey etal.
[73]
Bouillot
etal. [74]
Burke etal.
[75]
Cornwell
etal. [76]
De Wever
etal. [77]
Debus etal.
[78]
Deen and
Smart [79]
Dehni etal.
[80]
Docherty
etal. [81]
Fingerhut
etal. [82]
Fingerhut
etal. [83]
Hallbook
etal. [84]
Study
Operation
CR Cohort 199 5 (3) No WS
CR Cohort 63 3 (5) No Unspecied
C/CR Cohort 1846 79 (4) Ye s WS contrast,
C Cohort 50 1 (2) No Unspecied
CR RCT 186 7 (4) Ye s WS contrast Routinely
C Cohort 56 3 (5) Ye s Surgical
CR Cohort 16 5 (31) No Endoscopy and
CR Cohort 77 6 (8) No Barium contrast When
C Cohort 53 2 (4) Ye s Unspecied
CR Cohort 258 31 (12) Yes WS contrast,
CR RCT 652 38 (6) Yes WS contrast,
CR RCT 159 10 (6) Yes WS contrast,
CR RCT 113 17 (15) Yes WS contrast,
CR RCT 97 9 (9) Ye s Digital and
design
Sample
size
No. of
leaks Denition Test
contrast
contrast
abdominal
reoperation
radiography
re-exploration,
CT, or WS
contrast
unspecied
radiological test
radiography
imaging, or
reoperation
reoperation
sinography
sinography,
reoperation
endoscopic
examination,
contrast,
reoperation, CT
closure
Timing
Routinely
on day 9–11
When
suspected
When
suspected
Unclear
on day 7in
rst half of
study, then
changed to
when leak
suspected
Variable
3–4months
suspected
When
suspected
Routine
contrast
study
8–10weeks
before
stoma
Routine on
day 4–14
Routine
contrast
study on day
7
Routine
contrast
study on day
7
Routine
contrast
study before
stoma
closure
(continued)
472
Table 30.1 (continued)
References
Hansen
etal. [85]
Hida etal.
[86]
Iversen
etal. [87]
Junger etal.
[88]
Karanjia
etal. [89]
Kessler
etal. [90]
Kockerling
etal. [91]
Kracht
etal. [92]
Mann etal.
[93]
Merad etal.
[94]
Merad etal.
[95]
Miller etal.
[96, 97]
Moore etal.
[98]
Norris etal.
[99]
Pakkastie
etal. [100]
Petersen
etal. [101]
Redmond
etal. [102]
Sagar etal.
[103]
Operation
CR Cohort 615 9 (1) Ye s Unspecied
CR RCT 43 2 (5) No WS contrast Routinely at
CR Cohort 161 17 (11) No WS contrast When
CR Cohort 219 38 (17) Yes WS contrast When
CR MRCT 621 88 (14) Ye s Unspecied
CR MRCT 949 46 (5) No Unspecied Unspecied
C MRCT 440 31 (7) Ye s WS contrast,
CR Cohort 370 11 (3) Yes WS contrast When
CR RCT 705 53 (8) Yes WS contrast,
CR RCT 494 32 (6) Yes WS contrast,
CR Cohort 103 6 (6) Ye s WS contrast Routine
CR Cohort 300 34 (11) No Unspecied
L Cohort 156 6 (4) No Unspecied
CR RCT 38 15 (39) Ye s WS contrast Routine
CR Cohort 467 41 (9) Yes WS contrast When
CR Cohort 111 13 (12) Yes WS contrast Routine
CR RCT 100 12 (12) Yes WS contrast Routine
Study
design
Sample
size
V. O. Shaer and E. C. McLemore
No. of
leaks Denition Test
radiography
Yes LPS
concentration
radiological
tests, methylene
blue test
reoperation
reoperation
reoperation
radiological
examination,
reoperation
(clinically
signicant)
imaging or
reoperation
Timing
When
suspected
2months
suspected
LPS level
assessed
daily
suspected
When
suspected
Routine
contrast on
day 8–10
suspected
Routine
contrast on
day 8
Routine
contrast on
day 7
contrast on
day 10
Routine
before
stoma
closure
When
suspected
contrast on
day 7–10
suspected
contrast on
day 10–12
contrast on
day 5–7
30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
Table 30.1 (continued)
Study
References
Santos etal.
[104]
Slim etal.
[105]
Stewart
etal. [106]
Tagart
[107]
Thompson
etal. [108]
Watson
etal. [109]
Wheeler
and Gilbert
[110]
Used with permission of John Wiley and Sons from Bruce etal. [15]
Values in parentheses are percentages
C colonic resection, CR colorectal surgery, CT computed tomography, L laparotomy (for Crohn’s
disease), Lap laparoscopic, LPS lipopolysaccharide, MRCT multi-randomized clinical trial, RCT
randomized clinical trial, WS water soluble
Operation
CR RCT 149 11 (7) Yes Unspecied
Lap. CR Cohort 65 6 (9) Ye s WS contrast,
CR RCT 88 1 (1) Ye s Unspecied Unspecied
CR Cohort 220 79 (36) No Limited barium
CR Cohort 535 18 (3) No None Unspecied
C/CR Cohort 477 9 (2) No WS contrast When
CR Cohort 102 7 (7) No WS contrast Routine
design
Sample
size
No. of
leaks Denition Test
radiological
examination
reoperation for
peritonitis
contrast
Timing
When
suspected
When
suspected
Routine
contrast on
day 14
(not done
routinely)
suspected
contrast on
day 8
473
being able to be managed nonoperatively with antibiotics with or without radiologic drainage [17, 18]. The treatment ultimately hinges on the clinical picture and
stability of the patient.
Studies have also noted that there may be differences between early and late AL
[19] and that risk factors may be different [7]. A recent large cohort study found that
early leaks were associated with male gender, rectal cancer, higher BMI, laparoscopic surgery, emergency surgery, and lack of proximal fecal diversion. Late-onset
leaks were associated with male gender, ASA class greater than 3, Charlson
Comorbidity Index greater than 2, advanced tumor stage, and extensive additional
resection required [7].
Impact ofAnastomotic Leaks
Postoperative anastomotic leaks are associated with signicant morbidity, longer
lengths of hospital stay, and overall worse oncological outcomes [20–23]. Up to
68% of patients live with a permanent stoma following anastomotic leakage [24,
25]. A NSQIP study of over 13,000 patients undergoing colectomy and anastomosis
found that AL was associated with an increased 30-day mortality rate [6.8% vs
1.6% p<0.001] and longer lengths of hospital stay (13 vs 5days) and was 37 times
more likely to require reoperation [20]. A review of 13 studies with a total of 12,202
474
V. O. Shaer and E. C. McLemore
patients in rectal cancer found that patients with anastomotic leak had twice the
odds of local recurrence. A review of seven studies on outcomes of patients undergoing resection for rectal cancer found no signicant impact of AL on distant recurrence rates but did nd an increased risk of cancer-specic mortality [21].
AL also has detrimental effects on bowel function and quality of life (QOL) in
patient undergoing low rectal anastomoses for cancer. One year postoperatively,
patients who suffered from AL had worse physical and mental SF-36 scores, more
frequent daytime and nighttime bowel movements, and worse control of solid
stool as compared to patients without AL [26]. A study examining the effect of
pelvis sepsis on function following ileal pouch-anal anastomosis (IPAA) found
that patients with pelvic sepsis had worse function and QOL [27]. A different
study in over 800 patients who underwent restorative proctocolectomy found that
AL did not adversely affect long-term outcomes or QOL but did increase the risk
of pouch loss and ileostomy creation [28]. In addition to overall worse clinical
outcomes, AL is quite costly. A study evaluating gastrointestinal leak in the
NSQIP database found a mean cost of $16,085.39 vs $56,349.12in non-leak vs
leak patients [29]. Anastomotic leak has also been found to be the complication
with the largest impact on 30-day end-organ dysfunction and the third largest
impact on mortality after elective colorectal surgery. It also contributed the most
to reoperation and readmission [30].
Principles andQuality Benchmarks
Intraoperative Testing ofColorectal Anastomoses
Intraoperative air testing of intestinal anastomosis was introduced to mitigate potential adverse outcomes [31]. Most commonly, after the anastomosis is complete, the
pelvis is lled with sterile water or saline and the proximal bowel occluded. Air is
insufated through the anus through either a rigid, exible, or bulb irrigator. When
a rigid or exible endoscope is used, the anastomosis can be directly visualized for
integrity and hemostasis. If bubbles are noted, the anastomosis is not airtight. Some
surgeons go a step further and perform an additional betadine-tinged saline infusion
to look for extravasation [32]. Different methods for anastomotic leak testing are
described in Table30.2.
A study evaluating the selective or routine use of intraoperative endoscopy in
elective laparoscopic surgery showed a trend toward more overall anastomotic complications in the selective group vs routine use group [33]. Proponents of intraoperative leak testing estimate this may identify leaks in as many as 25% of anastomoses
[31, 34]. Some studies indicate a lower rate of clinically diagnosed anastomotic
leaks in the air leak-tested patients when compared to controls, and several studies
have shown value and efcacy with this practice [31, 35–38]. A recent study of 777
laparoscopic left-sided colon resections with primary anastomosis and no proximal
diversion demonstrated a lower anastomotic leak rate in intraoperatively air leaktested anastomoses [39]. Sasaki and colleagues reviewed 148 consecutive cases of
30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
Table 30.2 Methods of intraoperative testing in recent studies
Authors
Vignali
etal. [111]
Schmidt
etal. [112]
Ishihara
etal. [113]
Lanthaler
etal. [114]
Ricciardi
etal. [36]
Li etal. [33] 2009 Air insufation into the rectum using endoscope with anastomosis
Shamiyeh
etal. [115]
Ivanov
etal. [116]
Lieto
etal. [117]
Xiao
etal. [118]
Kamal
etal. [119]
Year
2000 Air insufation into the rectum with anastomosis under saline
2003 Air insufation into the rectum using endoscope with anastomosis
2008 Air insufation into the rectum with anastomosis under saline
2008 Air insufation into the rectum with anastomosis under saline
2009 Air insufation through a proctoscope or exible endoscope with the
2012 400cc air insufation into the rectum using a syringe with the
2011 Air insufation into the rectum using a sigmoidoscope with the
2011 Air insufation into the rectum using endoscope with anastomosis
2011 Air insufation into the rectum using a rectoscope with anastomosis
2015 Air insufation into the rectum using a sigmoidoscope with the
Method of testing
irrigation
under saline irrigation
irrigation
irrigation
anastomosis under irrigation of saline
under saline irrigation
anastomosis under saline irrigation
anastomosis under saline irrigation
under saline irrigation
under irrigation of saline
anastomosis under saline irrigation
475
left-sided anastomoses and found 7 to yield a positive intraoperative leak test; they
reconstructed the anastomosis and performed proximal diversion. They had no
anastomotic leaks in this cohort [40].
Management ofPositive Intraoperative Leak Test
If a positive air leak test is found, there are several options, including suture repair,
reanastomosis, diversion, or a combination of techniques. Kamal and colleagues
reviewed 415 consecutive cases of hand-assisted laparoscopic colorectal resection
and had 15 patients with a positive leak test. Fourteen underwent takedown and
reanastomosis with no proximal diversion with no subsequent clinical leak. Based
on this, they recommend formal takedown and reconstruction of the anastomosis
[38]. Davies and colleagues studied 33 patients with postoperative gastrogran
(water soluble) contrast enemas. In their cohort, six patients had positive air leaks
which were suture repaired only. Two of the six had radiographic leaks on postoperative day 8 (POD8), and one of the two also developed a clinical leak [41]. A
recent study looked at patients that had a positive air leak test and divided patients
into those receiving a suture repair alone vs suture repair with diversion or reconstruction of the anastomosis. This study of non-inferiority found 9% clinically signicant leak rate in the suture repair alone group vs 0% in the diverted or
reanastomosis group. The study was not able to conclude that suture repair alone
was non-inferior to diversion or reanastomosis after an intraoperative positive leak
476
V. O. Shaer and E. C. McLemore
+ intraoperative
leak test
Anastomosis
visible/accessible,
large defect
Resect anastomosis
and redo
Fig. 30.1 Proposed algorithm for positive intraoperative leak test
Anastomosis not easily
Large defect
Suture repair
and proximal
diversion
accessible
Small or not
visible defect
Proximal
diversion
test [25]. There is literature describing the management of postoperative leak by
proximal diversion alone without repair of anastomosis as safe and non-inferior to
resection [42–44]. Extrapolating these data, one might conclude that if because of
location of air leak, one is unable to suture repair it or reconstruct it, it may be safe
to proximally divert with a loop ileostomy (Fig.30.1). Proximal diversion, however,
does not eliminate the need for additional surgery, hospitalization, and the risk of
complications. Leahy and colleagues [19] studied the rate of anastomotic leak even
after diversion and found that 34 of 245 patients experienced anastomotic leak with
8 of those occurring after stoma closure. In this study, there was no difference in the
proportion of positive leaks intraoperatively in patients with and without subsequent
clinical leak.
Strategies toReduce Mechanical Contributions toLeaks
Splenic Flexure Release
Factors that inuence a successful outcome after colorectal anastomosis include a
tension-free anastomosis, intact macro- and microcirculation of the retained colon
and rectum, as well as appropriate perioperative abdominal and pelvic sepsis and
wound prophylaxis [45]. In the setting of any bowel anastomosis, achieving a
tension- free anastomosis is of utmost importance. Patient body habitus and anatomic variants in colonic redundancy and vascular anatomy contribute to the broad
range in the variable length that can be achieved after splenic exure mobilization
and inferior mesenteric vein ligation. In both the cadaveric and invivo laparoscopic
setting, the longest length achieved is when splenic exure mobilization is combined with high ligation of the inferior mesenteric vein [46, 47].
In a recent systematic review and meta-analysis on the safety and use of splenic
mobilization, splenic exure mobilization was associated with longer operative
time, especially when performing TME for rectal cancer [48]. In addition, splenic
exure mobilization was found to be associated with a higher leak rate in the studies
with both benign and malignant indications, as well as the subgroup which included
30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
477
only rectal cancer resections [48]. Rather than a cause and effect, splenic exure
mobilization is a surrogate marker for low colorectal or coloanal anastomosis.
Splenic exure mobilization to the level of the midbody of the pancreas combined
with high ligation of the inferior mesenteric vein (IMV) is typically required to
facilitate colonic conduit mobilization and reach into the pelvis to create an anastomosis within 4–5cm from the anal verge. Please refer to Chap. 4 on laparoscopic
splenic exure release for more technical details.
Colonic Conduit Ischemia
Intraoperative colonic ischemia in the retained descending colon (colonic conduit)
planed for use and restoration of bowel continuity with low pelvic colorectal or
coloanal anastomosis can occur for a variety of reasons during open or minimally
invasive colorectal surgery (Fig.30.2a, b). Venous congestion can result in colonic
conduit ischemia if the IMV is ligated inadvertently during high ligation of the
inferior mesenteric artery (IMA). Disruption of collateral arterial blood ow to the
retained descending colon conduit during mesocolic transection up to the level of
Fig. 30.2 (a, b) Left
colonic conduit ischemia
recognized following
stapled colorectal
anastomosis during
laparoscopic low anterior
resection. The discoloration
of the left colon does not
improve following multiple
maneuvers to reduce tension
on the anastomosis. (Both:
Courtesy of Patricia Sylla,
MD)
a
b
478
V. O. Shaer and E. C. McLemore
the colon can occur secondary to tension on the retained left colic, arc of Riolan, or
marginal artery of Drummond resulting in spasm and/or arterial thrombosis. Colonic
ischemia can also occur in patients with altered mesocolic vascular anatomy due to
embryologic developmental variations and/or prior rectosigmoid surgery. (See Fig.
4.3 in Chap. 4 in this volume.) There is also potential for ischemia during specimen
extraction completed either abdominally or transanally.
During mesocolic dissection and high ligation of the IMA for left-sided colon or
rectal cancer, two technical errors can be made. The rst is inadvertent ligation of the
inferior mesenteric vein during high ligation of the IMA, and the second is disruption
of collateral arterial blood ow during the mesenteric dissection. The IMV drains into
the splenic vein, and high ligation of the inferior mesenteric vein is typically performed
in cases in which low pelvic colorectal or coloanal anastomosis is required. A high ligation of the IMV is typically performed just to the left of the fourth portion of the duodenum at the level of the ligament of Treitz or duodenojejunal exure (Fig. 30.3).
However, the IMV can travel in close approximation to the IMA, and inadvertent ligation of the IMV during high ligation of the IMA can result in colonic ischemia due to
venous congestion. Patients with central obesity and/or increased mesocolic adiposity
are at risk for inadvertent ligation of the IMV during high ligation of the IMA as the
IMV may be obscured or difcult to identify due to increased mesocolic adiposity.
In cases in which a high ligation of the IMV is planned for reconstructive purposes, it may be prudent to perform a high ligation of the IMV as the rst step during the mesocolic dissection for distal sigmoid or rectal cancer. The IMV is typically
less challenging to identify at the level of the ligament of Treitz, even in patients
with increased mesocolic adiposity. After high ligation of the IMV, the mesocolic
dissection caudal to the IMA can proceed in a bloodless plane.
This inframesocolic approach for splenic exure takedown can be utilized even in
cases in which a high ligation of the IMV is not required as a colonic conduit lengthening maneuver. Please refer to Chap. 4 on laparoscopic splenic exure release for more
Fig. 30.3 Dissection of
the inferior mesenteric vein
during laparoscopic left
colectomy. The tumor is
located in the mid-left
colon and was tattooed
preoperatively. (Courtesy
of Patricia Sylla, MD)
30 Intraoperative Air Leak, Colonic Ischemia, or Tension: How toSalvage theFailed…
479
details regarding this approach. The IMV can be identied at the level of the ligament
of Treitz but not divided. Inframesocolic dissection can be carried down to the level of
the IMA and then high ligation of the IMA performed after identication and separation from the IMV.Anatomic variations in blood supply should be kept under consideration during the mesocolic dissection in order to avoid inadvertent devascularization
of the colon conduit. The blood supply to the splenic exure can be distributed through
the superior mesenteric artery (SMA), the IMA, or both. The feeder vessels originating
from these arteries can be the left colic artery, left branch of the middle colic, an accessory middle colic artery, a combination of these arteries, or no direct feeder vessel [49].
Collateral arterial blood ow disruption after high ligation of the IMA during mesocolic dissection up to the level of the colon can be a cause of colonic ischemia.
Disruption of collateral arterial blood ow to the retained descending colon conduit
during mesocolic transection up to the level of the colon can occur secondary to tension
on the retained left colic, arc of Riolan, or marginal artery of Drummond resulting in
spasm and/or arterial thrombosis. (See Fig. 4.3 in Chap. 4 in this volume.)
There are several techniques that the surgeon can adopt to avoid arterial tension
and thrombosis during sigmoid and rectal resection. The rst is to identify the collateral arterial ow and avoid transecting the mesentery too proximally. Direct visualization of a proximal feeding vessel supplying the conduit may be possible. More
recently, uorescence angiography has been used to help in assessing intestinal perfusion. Intravenous injection of indocyanine green (ICG) dye followed by the use of
near-infrared light to assess bowel perfusion is safe and may decrease the risk anastomotic leaks by aiding the surgeons better identify ischemic segments (Figs.30.4a, b
and 30.5a, b) [50–52]. The second technique is to avoid tension on the mesentery
Fig. 30.4 (a, b) Perfusion
assessment of the bowel
during low anterior
resection using ICG
uorescence angiography.
(a) Demarcation of the
bowel is assessed
laparoscopically with
white light. (b) Following
ICG intravenous injection,
perfusion reassessment
using near-infrared light
conrms the level of
vascular demarcation.
(Both: Courtesy of Antonio
Caceydo, MD)
a
b
480
Fig. 30.5 (a, b) Perfusion
assessment during robotic
LAR using ICG
uorescence angiography.
(a) Vascular demarcation is
assessed with white light.
(b) Following ICG
intravenous injection,
perfusion is reassessed
using near-infrared light
and conrms the point of
vascular demarcation.
(Both: Courtesy of Daniel
Popowich, MD)
a
V. O. Shaer and E. C. McLemore
b
during mesocolic transection, either by performing the transection intracorporeally or
further mobilizing the colon and its mesentery in order to reduce the tension on the
vascular pedicles during extracorporeal extraction. When the mesentery performed
extracorporeally, undue tension may result in spasm and tearing of the left colic, arc
of Riolan, or marginal artery of Drummond leading to arterial colonic ischemia.
Special consideration should be made in cases in which transanal extraction of the
specimen and conduit is planned. Even if the mesocolic transection is performed intracorporeally prior to transanal specimen extraction, the weight of the specimen can
inadvertently pull on the proximal mesocolon and lead to spasm and/or arterial trauma
resulting in arterial colonic ischemia. Care should be taken to maintain hold of the
specimen after transanal extraction and not allow the weight of the specimen to pull on
the retained colonic conduit prior to distal bowel transection. The specimen should be
held at all times and not allowed to lay unsupported through the extraction site.
Options forAnastomotic Reconstruction
In the event of colonic conduit ischemia, the rst step is to discuss this nding with
your anesthesiology team. Vasopressors should be discontinued if the patient’s
hemodynamic status can be maintained with alternative agents, and normothermia
should be achieved. Intravenous uid warming devices as well as warm intraabdominal irrigation can facilitate increasing the patient’s body temperature if the
patient is hypothermic. In addition, temporary cessation of pneumoperitoneum and