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338 D. I. Chu and E. J. Dozois
Fig. 31.6 Tertiary or Bailout Maneuvers. a Resection of
colon to the proximal transverse colon and ligation of the
middle colic artery prepares for two maneuvers that allow
for a tension-free, low anastomosis. SMA superior mesenteric artery, IC ileocolic artery, RC right colic artery,
MC middle colic artery. b Deloyers procedure. Counter-
similar to IPAA reconstruction. Careful stepwise
scoring of the peritoneum on the mesentery can
provide additional length when the end ileostomy
is held under tension. There may also be circumstances when the fixed, cut edge of the mesentery
creates more tension than the mesentery of the
bowel 4–6 cm proximal to the cut edge, and construction of an end-loop ileostomy, rather than
an end ileostomy, makes the better tension-free
stoma. In the unusual circumstance that primary
maneuvers or the end-loop conversion fail to provide enough mesenteric length, then secondary
maneuvers, including ligation of vascular pedicles such as the ileocolic artery, can be performed
after ensuring adequate collateral circulation to
the distal bowel edge.
Bailout Maneuvers—It Just Does Not Reach
There will be very rare situations when the small
bowel or colon will not reach the distal bowel for
an anastomosis despite all the above primary and
clockwise rotation of the remaining right colon around the
axis of the SMA may allow for a tension-free low pelvic
anastomosis. c Retroileal reconstruction. Tunneling the
remaining right colon through the ileal mesentery may
allow for a tension-free low pelvic anastomosis. © Mayo
Clinic
secondary maneuvers. At this juncture, there are
a few remaining tertiary, or bailout, maneuvers
within the surgeon’s armamentarium.
In the rare situation when primary and secondary maneuvers fail to deliver enough colon length
for a low colorectal or coloanal reconstruction, a
technique called the Deloyers procedure involves
additional resection to the proximal transverse
colon and then counterclockwise rotation of the
remaining right colon, around the axis of the
SMA, to construct a tension-free anastomosis
(Fig. 31.6a, b) [22]. Besides requiring complete
mobilization of the right colon, this maneuver
also requires ligation of the middle colic artery,
but good clinical outcomes have been reported
[23]. Blood to the remaining colon flows from
the SMA through the right colic, ileocolic artery,
and marginal artery arcades. Alternatively, there
have also been case reports of orienting the remaining right colon behind the ileal mesentery to
construct a retroileal colorectal anastomosis after
left colectomy (Fig. 31.6c) [24, 25].
If the above maneuvers are not possible, a
completion colectomy to the terminal ileum
33931 Pearls for the Small Bowel and Colon That Will Not Reach
might be justified depending on the indication
for the operation. The terminal ileum can then be
used for a distal anastomosis (ileorectostomy or
IPAA). In every situation, if a safe anastomosis
is in serious doubt, the surgeon should consider
construction of a stoma to establish a dependable
gastrointestinal outlet.
Conclusions
Reestablishment of gastrointestinal continuity is
a technically challenging but rewarding part of
abdominal surgery. Undoubtedly, surgeons will
encounter situations when the bowel does not
easily reach for an anastomosis, but if these situations are approached in a deliberate fashion, the
techniques illustrated in this chapter can be used
to allow construction of a safe anastomosis or
stoma in almost all circumstances.
Key Points on How to Avoid the Complication
1. A detailed understanding of embryologic
planes and gastrointestinal vascular anatomy
is essential to be technically proficient in employing advanced anastomotic techniques.
2. If a patient has had prior bowel surgery, operative notes should be obtained to clearly define
the patient’s current anatomy and remaining
blood supply as it may impact intraoperative
decisions in advanced reconstruction options.
3. If the patient has had a previous bowel resection in which key vessels were ligated that
may be necessary for a second resection and
reconstruction, alternative strategies will have
to be considered. An angiogram in some circumstances may be necessary to clarify a patient’s gastrointestinal vascular anatomy.
4. During colorectal or coloanal anastomoses,
the proximal bowel end should easily reach
the distal end without any pulling or tension.
If a tension-free configuration is not achieved,
there is high risk for anastomotic complications and further mobilization needs to be performed.
5. During IPAA, use the inferior edge of the
pubis symphysis as a rough estimate of adequate length if the apex of the pouch can reach
it without tension.
Key Points on Diagnosing/ Managing the Complication
1. Intraoperative techniques to assess blood supply, such as mesenteric trans- illumination and
handheld Doppler probes, can facilitate decision making regarding safe vascular ligation
and adequate perfusion to an anastomosis.
2. Primary maneuvers to provide additional
bowel length should be employed first and include mobilizing embryonic planes and dividing peri-organ “ligaments” or attachments.
3. Secondary maneuvers include directed ligation of vascular pedicles that restrict the mobility of the corresponding proximal bowel.
Often, these vascular ligations are already part
of the oncologic resection.
4. Tertiary mobilization techniques should only
be considered in those rare circumstances
when primary and secondary maneuvers fail.
5. Externalizing the bowel as a stoma is better than leaving a high-risk anastomosis that
could lead to significant intra-abdominal sepsis and death.
References
1. Kingham TP, Pachter HL. Colonic anastomotic leak:
risk factors, diagnosis, and treatment. J Am Coll Surg.
2009;208(2):269–78.
Trencheva K, et al. Identifying important predictors
2.
for anastomotic leak after colon and rectal
tion: prospective study on 616 patients. Ann Surg.
2013;257(1):108–13.
3. Morse BC, et al. Determination of independent predictive factors for anastomotic leak: analysis of 682
intestinal anastomoses. Am J Surg. 2013.
Slieker JC, et al. Systematic review
4.
nique of colorectal anastomosis. JAMA Surg.
2013;148(2):190–201.
Sherwinter DA, Gallagher J, Donkar
5.
transanal near infrared imaging of colorectal anastomotic perfusion: a feasibility study. Colorectal Dis.
2013;15(1):91–6.
T. Intra-operative
resec-
of the tech-
340 D. I. Chu and E. J. Dozois
6. Scott-Conner CEH. Chassin’s operative strategy in
colon and rectal surgery. Vol.
er; 2006. p. 283.
7. Fischer JE. Fischer’s mastery
Philadelphia: Wolters Kluwer; 2012.
8. Beck DE, American Society
Surgeons. The ASCRS manual of colon and rectal surgery. Vol.
p.
1046.
9. Brennan DJ, et al. Routine mobilization
flexure is not necessary during anterior resection for
rectal cancer. Dis Colon Rectum. 2007;50(3):302–7.
Discussion 307.
10. Araujo SE, et al. Assessing the extent of colon
lengthening due to splenic flexure mobilization
techniques: a cadaver study. Arq Gastroenterol.
2012;49(3):219–22.
11.
Bonnet S, et al. High tie versus low tie
gation of the inferior mesenteric artery in colorectal
cancer surgery: impact on the gain in colon length
and implications on the feasibility of anastomoses.
Dis Colon Rectum. 2012;55(5):515–21.
12.
Smith L, Friend
rior mesenteric artery. The critical factor in the
pouch pull-through procedure. Dis Colon Rectum.
1984;27(11):741–4.
13.
Baig MK, et al. Lengthening of small bowel mes
entery: stepladder incision technique. Am J Surg.
2006;191(5):715–7.
14.
Levine LA. Stepladder incision technique for
lengthening of bowel mesentery
Pt 1):351–2.
15.
Uraiqat AA, CM Byrne, Phillips
length in ileal-anal pouch reconstruction: a review.
Colorectal Dis. 2007;9(7):657–61.
16.
Cherqui D, et al. Inferior reach of ileal reser-
in ileoanal anastomosis. Experimental ana-
voir
xxvi. New Y
WG, Medwell SJ. The supe-
xv. New
York: Spring-
of surgery. 6th ed.
of Colon and Rectal
ork: Springer; 2009.
of the splenic
vascular li-
. J Urol. 1992;148(2
RK. Gaining
tomic and angiographic study. Dis Colon Rectum.
1987;30(5):365–71.
17.
Martel P, et al. Mesenteric lengthening in ileoanal
pouch anastomosis for ulcerative
division of the superior mesenteric pedicle a safe
procedure? Dis Colon Rectum. 1998;41(7):862–6.
Discussion 866–7.
18.
Burnstein MJ, et al. T
ening in ileal reservoir-anal anastomosis. Dis Colon
Rectum. 1987;30(11):863–6.
19.
Martel P, et al. Comparative anatomical
vision of the ileocolic pedicle or the superior mesenteric pedicle for mesenteric lengthening. Br J Surg.
2002;89(6):775–8.
20.
Araki T, et al. The ef
lengthening techniques and the use of a covering
stoma after ileoanal pouch surgery. Dis Colon Rectum. 2006;49(5):621–8.
21.
Goes RN, et al. Lengthening of the mesentery
the marginal vascular arcade of the right colon as the
blood supply to the ileal pouch. Dis Colon Rectum.
1995;38(8):893–5.
22.
Chalmers RT, Bartolo DC.
colon mobilization for colo-rectal anastomosis. J R
Coll Surg Edinb. 1998;43(4):274–5.
23.
Manceau G, et al. Right colon
-
sis (Deloyers procedure) as a salvage technique for
low colorectal or coloanal anastomosis: postoperative and long-term outcomes. Dis Colon Rectum.
2012;55(3):363–8.
24.
Rombeau JL, Collins JP,
colectomy with retroileal colorectal anastomosis.
Arch Surgery. 1978;113(8):1004–5.
25. Hogan NM, Joyce MR. Retroileal colorectal anastomosis: an old technique, still relevant. Tech Coloproctol. 2012.
echnique of mesenteric length-
fect on morbidity of mesentery
Turnbull RB Jr. Left-sided
colitis: is high
study of di-
Anterior resection: right
to rectal anastomo-
using
Anastomotic Leak/Pelvic Abscess
Seok Byung Lim and Jose G. Guillem
32
Introduction
Anastomotic leakage is a major postoperative
complication that can occur following a low anterior resection in 2–12 % of cases [1, 2]. The
reported incidence varies according to the clinician’s definition of leakage. Although there is no
single acknowledged definition for anastomotic
leakage, several terms such as anastomotic failure, defect, or dehiscence have been used to describe the complication that is characterized by
peritonitis, fecal drainage from wound or drain,
and systemic symptoms associated with infection. The International Study Group of Rectal
Cancer has proposed three clinical scenarios to
characterize anastomotic leakage: (1) a communication between the intra- and extraluminal
compartments owing to a defect at the anastomosis between the colon and rectum or the colon and
anus, (2) a leakage originating from the suture or
staple line of a neorectal reservoir (e.g., J-pouch
or transverse coloplasty), and (3) a pelvic abscess
in the proximity of the anastomosis [3].
The severity of the anastomotic leak dictates
the management approach and the degree of urgency as well as the risk to the patient. Clearly, in
severe cases, mortality may reach up to 12 % [4],
and it can account for nearly one-third of post-
J. G. Guillem () · S. B. Lim
Memorial Sloan-Kettering Cancer Center,
1275 York Ave, Room C-1077,
New York, NY 10065 USA
e-mail: guillemj@mskcc.org
S. B. Lim
e-mail: vicryl3@gmail.com
operative deaths following colorectal surgery
[5]. In addition, due to associated stricturing at
the anastomosis, as well as lack of compliance of
bowel in the vicinity of the anastomosis, function
is often impaired following an anastomotic leak
[6]. Finally, the associated chronic inflammation
that may persist at the site of a localized anastomotic leak/fistula track may be associated with
worse oncologic outcomes [7].
Prevention
The prevention of an anastomotic leak following
a low anterior resection consists of several strategies. Most importantly, it is imperative to adhere
to basic principles of optimal surgical technique.
The anastomosis needs to have a good blood
supply, be tension free with full sacralization in
the pelvis, and be properly oriented. In order to
assure adequate bowel length for a tension-free
anastomosis using diverticula-free, supple colon,
a splenic flexure mobilization may be required.
The intraoperative air insufflation test via a sigmoidoscope is used to detect an air leak after
anastomosis; if an air leak is detected, then that
would be an indication for performing a diverting
proximal protecting loop ileostomy, which would
help diminish the severity of an anastomotic leak
should one occur. Although some recommend
a side-to-end or colonic pouch anastomosis to
minimize the risk of anastomotic leakage [8],
anastomosis type has not been associated with
risk of anastomotic leakage nor necessity to create a stoma [9]. Recent meta-analysis of four randomized controlled trials demonstrated that there
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_32,
© Springer Science+Business Media New York 2015
341
342 S. B. Lim and J. G. Guillem
was a significantly lower number of clinically
symptomatic leaks and fewer reoperations in the
group of patients with a defunctioning stoma and
recommended the usage of a proximal protecting
stoma following surgery for a low rectal cancer
[10]. However, there are a number of potential
problems associated with creation of a stoma
including reduced patient satisfaction and selfimage, quality of life, stoma-related morbidity,
bowel obstruction, need for a second hospitalization and reoperation for stoma closure, as well
as the possibility of ending up with a permanent
stoma. Therefore, a protective stoma should be
used selectively.
Many factors are associated with the risk of
leakage, including patient factors such as male
gender, obesity, hypoalbuminemia, malnutrition, anemia, weight loss, use of alcohol, and a
history of heavy smoking (more than 40 packyears); tumor factors include distal location requiring a low anastomosis, while treatment factors include usage of preoperative radiotherapy,
adverse intraoperative events, and long operative
time [11–15].
The widespread introduction of preoperative
chemoradiation therapy in the multimodality
management of locally advanced rectal cancer
and the introduction of minimal access surgical
techniques have raised concerns over the impact
that these would each have on anastomotic leak
rates. Although a national cohort study in Norway reported that patients receiving preoperative
radiotherapy showed a higher rate of anastomotic
leakage [16], recent randomized trials have failed
to confirm this observation [17, 18]. In terms of
laparoscopy, the reported leakage rates of the laparoscopic approach appear similar to those of an
open approach as demonstrated by the CLASICC
trial (open 7 % versus laparoscopic 8 %) [19].
Currently, most surgeons use a mechanical
bowel preparation before rectal surgery. Although
recent meta-analysis demonstrates no statistically significant decrease in the rate of leakage
when using a mechanical bowel preparation [20,
21], a recent randomized trial suggested a benefit
[22]. In our practice, we continue to use a full
(mechanical as well as oral and IV antibiotics)
bowel preparation for all rectal cancer resections.
In general, with some exceptions, we tend to
perform a diverting loop ileostomy in patients
with a low-lying anastomosis (within 5 cm of the
anal verge or within 1 cm above the upper part
of the anorectal ring), elderly patients, patients
receiving preoperative chemoradiation, malnourished patients, patients on steroids, diabetic patients, and postmenopausal females with an anastomosis juxtaposed to a thin rectovaginal septum.
An absolute indication for proximal diversion is a
patient in whom air bubbles are noted to emanate
from the staple line under a fluid-filled pelvis following air insufflation via a sigmoidoscope.
Diagnosis and Management
Diagnosis
Anastomotic leakage following a low anterior resection usually becomes clinically evident by the
fifth to seventh postoperative day. Patients may
present in a variety of ways. Some develop the
classical signs of peritonitis such as abdominal
pain, tachycardia, high fever, hypotension, low
urine output along with foul odor, fecal-like discharge from drain or incision, and a rigid abdomen. In these cases, clinical findings alone are
sufficient to diagnose leakage, and radiologic
studies are more confirmatory and are likely to
show obvious leakage of contrast material. However, the majority of patients with an anastomotic
leak present in a more insidious fashion with
nonspecific signs such as a mild fever, ileus, and
failure to thrive. These nonspecific signs may be
overlooked and may delay establishing a diagnosis of an anastomotic leak. In fact, it has been
shown that approximately 12–30 % of all anastomotic leaks are diagnosed more than 30 days after
surgery [23, 24]. This underscores the importance
of maintaining a high index of clinical suspicion
during the immediate postoperative period as well
as postdischarge period in order to detect an anastomotic leak and treat it in a timely fashion.
The clinical signs or symptoms depend greatly
on a number of factors including the severity of
leakage, the degree of contamination (peritoneal
versus walled-off, localized), the timing of the
34332 Anastomotic Leak/Pelvic Abscess
leakage (early versus late), and whether a proximal diverting stoma had been created at the time
of the initial operation. There are several imaging
modalities that help to secure a diagnosis of anastomotic leakage. The most commonly used are a
Gastrografin enema and/or a CT of the abdomen
and pelvis with and without oral and IV contrast
and rectal contrast, when possible.
The usage of rectal contrast during a CT scan
facilitates the detection of a small leak while IV
and oral contrast are useful in detecting a walledoff abscess/pocket adjacent that perhaps no longer
communicates with the anastomotic defect. For
the patients with an insidious presentation, CT
can be quite effective at detecting intra-abdominal
and pelvic abscesses with sensitivity and accuracy
over 90 %. Gastrografin enema, while helpful for
detecting and delineating the trajectory and possibly the extent of anastomotic leakage, is limited
in detecting a walled-off, noncommunicating yet,
drainable abscess. Digital rectal examination and
sigmoidoscopic evaluation may be useful while
under anesthesia but should not be relied upon to
rule out an anastomotic separation in the awake
patient since edematous mucosa and patient discomfort limit a thorough examination.
Management
The management of a patient with an anastomotic leak following a low anterior resection for rectal cancer can be challenging and requires careful consideration of numerous factors, thoughtful judgment, and deliberate interventions in a
timely manner. The first determination to make is
whether the patient needs to go to the operating
room immediately or can wait. Once that is established and broad-spectrum IV antibiotics and
hydration are begun, the next question is what
type of intervention is required and is the patient
stable to go to the operating room or needs aggressive resuscitation first. If the patient is stable
enough to be evaluated, imaging as described
above should ensue. If time and patient stability allow, an enterostomal nurse should mark the
patient in all four quadrants for possible stoma
placement based upon intraoperative findings.
Anastomotic leaks can be categorized into
three types (Fig. 32.1) Type I is one associated
with generalized peritonitis or sepsis. Type II is
one associated with a CT image of a localized
pelvic abscess around anastomosis. Type III is
one associated with drainage of foul odor fluid
or fecal contents from skin, urine, or vagina via
fistula. In a stable patient with a well-drained fistula, conservative management may be considered. A fistulogram may be helpful in evaluating
the location and severity of fistula and determine
the necessity of exploration.
Type I: Generalized Peritonitis
Approximately 40–45 % of all anastomotic leaks
present in this fashion. Patients complain of severe
abdominal pain and have a high fever, tachycardia, marked leukocytosis, and signs of generalized
peritonitis such as rebound abdominal tenderness
and/or rigidity. In these cases, imaging is not required to make a diagnosis of an anastomotic leak.
Initial efforts should focus on broad-spectrum
antibiotics and aggressive fluid resuscitation.
With the patient in a modified Lloyd-Davies
position, an examination under anesthesia will
allow for an assessment of the anastomosis, as
well as access to the rectum in the event that rectal washout is indicated after abdominal–pelvic
exploration. The operative exploration aims to
identify the site and extent of leakage, contain
further leakage, and aggressively lavage the entire abdominal/pelvic cavity. In cases where the
anastomotic disruption and contamination are
minimal, pelvic drainage and a proximal diverting stoma may be all that is required. Depending on the long-term plans, a temporary loop
ileostomy is a quick option, but the possibility
of high output and associated dehydration needs
to be taken into consideration in the context of
the patient’s age and overall comorbidities. In
cases where dehydration is of concern and/or a
permanent proximal diversion is envisioned, a
left upper quadrant, end-loop (Prasad–Abcarian)
colostomy is an option that prevents further contamination, yet affords passage of mucus from
the efferent limb should a distal obstruction from
a stricture at the anastomosis develop. If the colon
is full of feces and therefore a source of further
344 S. B. Lim and J. G. Guillem
Fig. 32.1 Postoperative diagnostic and therapeutic algorithm. PCD percutaneous drainage
ongoing contamination, a proximal end or endloop colostomy with distal limb rectal washout is
indicated. When creating an end-loop colostomy,
great care must be exercised to avoid damage to
the marginal artery, which perfuses the afferent
limb of the anastomosis, and may be the only
source of perfusion in cases where the left colic
artery is sacrificed during the initial resection. In
cases where a large anastomotic disruption and
contamination have occurred, a redo low anterior
resection is not a viable option, and these cases
are best managed by bringing the afferent limb
out as an end colostomy and attempting to suture/staple shut the efferent limb; one should then
create a Hartmann’s pouch and assure adequate
drainage of the pelvis with drains.
Type II: Localized Pelvic Abscess
About 30–40 % of patients with an anastomotic
leak present with vague abdominal pain, prolonged
ileus, mild fever, leukocytosis, and abdominal
distension associated with ileus and localized peritoneal signs. Such patients warrant an abdominal
pelvic CT scan with oral, IV, and rectal contrast,
when possible. When no extravasation of contrast
is noted, it is sometimes difficult to distinguish
between an anastomotic leak and a postoperative
abscess. If the abscess is of reasonable size and
walled off, it should be drained percutaneously
under radiologic guidance. Success rates for CTguided placement of a percutaneous drainage
catheter are about 80 % [25]. Following successful
drainage, some patients go on to develop a chronic enterocutaneous fistula or sinus, which can be
managed conservatively. Although most of these
patients do not usually require a reexploration,
some fail this conservative approach and develop
symptoms late after discharge from the hospital.
Long-term close follow-up is therefore warranted.
Type III: Fistula
A fistula may be a long-term sequelae in upward of 25–30 % of anastomotic leaks following
a low anterior resection. A thorough evaluation
includes a careful physical examination as well
as optimal contrast imaging with a CT scan and
34532 Anastomotic Leak/Pelvic Abscess
fistulogram in order to delineate a fistula track
and rule out distal obstruction. Endoscopy may
be helpful in evaluating the orifices of a fistula.
If the fistula is well drained and the overall nutritional condition of the patients is adequate, a conservative approach including optimal skin care
with a stoma appliance, low suction device, with
or without antibiotics, and somatostatin are often
sufficient to control the fistula. In cases with a
persistent, poorly drained, or intolerable fistula,
a surgical approach should be considered. Local
therapy with fibrin glue or plugs is rarely effective in this setting. Surgical options include creation of proximal diverting stoma versus primary
closure of a rectovaginal fistula via a transanal
approach with an advancement flap and temporary stoma or redo low anterior resection.
Long-Term Outcome
In addition to the immediate impact on postoperative morbidity and mortality, anastomotic leakage also impacts long-term functional outcome
and possibly even long-term prognosis of the
rectal cancer patient.
Need for a Permanent Stoma
Following an anastomotic leak, some patients
may be left with a permanent stoma because the
leakage and associated contamination may result in such profound fibrosis and scarring of the
pelvis and residual rectum so as to prohibit a reresection and creation of a supple and functional
primary colorectal or coloanal anastomosis. In
addition, because of fear of further complications, the surgeon and patient alike may choose to
not pursue further major surgery. In these cases,
the patient is left with either the initially created
protecting proximal stoma or the stoma created
during the reoperation following the anastomotic
leak. In these situations, a reoperation may nevertheless be required in order to convert an ileostomy into a colostomy resulting in fewer evacuations and less volume loss. The reported rates for
the need of a permanent stoma in these circumstances are 2.9
~ 19 % [
26–29].
Stenosis or Stricture
The rate of clinically significant stenosis or stricturing of a colorectal anastomosis ranges from 3 to
30 %, depending on the criteria employed. The most
common cause of anastomotic stenosis/stricture is
anastomotic leakage [30, 31]. Management, which
depends on the severity of the stenosis, includes
simple dilatation (digital or Hagar), balloon dilatation (radiologic or endoscopic), proximal diverting stoma, Hartmann procedure with/or without
resection of stricture site, and redo low anterior
resection. Because local recurrence is the second
most common cause of anastomotic stricture after
sphincter-preserving surgery for rectal cancer, a biopsy of the stricture should be obtained whenever
feasible in order to exclude cancer.
Anorectal Dysfunction and Quality
ofLife
Following a sphincter-preserving low anterior resection, anorectal dysfunction in the form of fecal
incontinence, evacuation problems, and clustering of bowel movements is frequently noted [32].
Anastomotic leakage has been identified as a predictive factor of anorectal dysfunction. Although
there are few reports addressing bowel function
and quality of life after an anastomotic leak of a
low anterior resection (Table 32.1) [6, 33, 34], it
is generally agreed upon that long-term function
is impaired in patients with anastomotic leakage.
Local Recurrence
Great controversy exists on whether anastomotic
leakage following a rectal cancer resection is a
prognostic factor for local recurrence and/or
survival (Table 32.2) [16, 35–42]. Conflicting
results may be due to varied definitions of anastomotic leaks, patient selection, heterogeneity
of cases (colon and rectal cancer versus rectal
346 S. B. Lim and J. G. Guillem
significantly reduced in patients with leakage
Long-term functional outcome may be impaired
Reduced neorectal capacity, more evacuation problem, and a trend
Neorectal volume, compliance, urgency, and MTV were
toward more fecal urgency and incontinence
frequent daytime and nighttime bowel movements, and worse
control of solid stool
One year: worse physical and mental component scores, more
of perineal pads
Early adverse consequences on bowel function and QoL
Tools Results and conclusion
Bowel function QoL
rate (%)
1996 Case-matched 38 30 months – Manometry – There was no difference in sphincter function
Short-Form 36 Recent: worse mental component scores and increased use
Global QoL
questionnaire
2 years – Manometry
– Long-term anorectal function had been impaired
2001 Case-matched 22
2012 Retrospective 864 3.2 years 6.0 FISI Cleveland
al.
Authors Year Study No of pts F/U period Leakage
Table 32.1 Impact of anastomotic leakage after low anterior resection for rectal cancer on bowel function and quality of life
Hallböök et al.
[8]
Nesbakken
et al. [6]
]
[34
Ashburn et
FISI fecal incontinence severity index, MTV maximal tolerable volume
34732 Anastomotic Leak/Pelvic Abscess
p value
AL (+) AL (−)
p value
AL (+) AL (−)
p value
AL (+) AL (−)
0.05
0.94
87
87
Ile (−) 83
0.83 Ile (+) 89
91
89
Ile (−) 93
46 0.092 Ile (+) 88
Ile (-) 5
2007 Multicenter 2044 40 month 14.8 17.5 10.1 0.006 70.9 75.4 0.020 – – –
Ptok et al. [37]
Eriksen et al. [16] 2005 National cohort 1958 7.6 years 11.6 11.6 10.5 0.608 – – – 59.0 67.4 0.02
Bell et al. [36] 2003 Single center 403 – 12.7 25.5 10.0 0.001 – – – – – –
Merkel et al. [35] 2001 Single center 814 90 months 10.9 22.0 12.5 0.018 69.6 77.8 0.0035 – – –
Authors Year Study # pts F/U period Leak rate Local recurrence Cancer-specific survival Overall survival
Table 32.2 Impact of anastomotic leakage after low anterior resection for rectal cancer on oncologic outcomes
2009 Multicenter 2726 5.9 year 9.7 12.0 8.8 0.103 60.6 66.9 0.033 71.5 75.5 0.030
] 2008 Single center 1391 40.1 month 2.5 9.6 2.2 0.14 63 78.3 0.05 55.1 74.1 <
al. [38
den Dulk et al. [28]
Jung et
250 – – 8 9 0.97 79 77 0.50 63 66 0.38
National Registry
2011 Case-control
2010 National database 1494 3.77 year 10.9 13.4 9.9 0.17 – – – – – –
al. [40]
al. [41]
Jörgren et
Bertelsen et
Smith et al. [42] 2012 Single center 1127 5.6 year 3.5 Ile (+) 9
AL anastomotic leak, ile ileostomy, F/U follow-up