Failure of Colorectal Anastomosis: Risk Factors, Prevention, Diagnosis, Therapeutic Tactics

Aim. To analyse and generalize available literature data on the problem of colorectal anastomotic leakage after rectal resection.

Key findings. Over the last decade, there has been an increasing trend towards sphincter-preserving operations in modern colorectal surgery. The widespread use of suturing devices of various diameters allows the formation of ultra-low anastomoses (at the level of the pelvic floor). One of the menacing complications after rectal resection is anastomotic leakage, which frequency can reach 21%. The mortality from anastomotic leakage can reach 40%. The analysed literature sources discuss a variety of risk factors, both preoperative and intraoperative, affecting the healing of the inter-intestinal anastomosis. In almost all studies, the height of the tumour and the anastomosis from the anus, preoperative radiotherapy and male sex are independent risk factors for the development of colorectal anastomotic leakage. Concerning other factors, there are conflicting opinions. The timely use of preventive measures and early diagnosis of colorectal anastomotic leakage can reduce the number and severity of postoperative complications.

Conclusion. Individual consideration of risk factors and their adequate assessment in terms of possible complications are decisive in the choice of the extent of surgical intervention, which will undoubtedly improve the immediate and long-term results of the surgical treatment of colorectal cancer.

1. Ermakov D.F. Risk factors for hardware anastomosis failure after the anterior rectal resection: Dis. Cand. Sci. (Med.). Moscow, 2012 (In Rus.)

2. Cherdantsev D.V., Pozdnyakov A.A., Shpak V.V., Ryabkov Yu.V., Popov A.E. Colorectal anastomosis failure. The current state of the problem (literature review). Coloproctology. 2015;4(54):57–64 (In Rus.)

3. Shatrova N.A. Prediction, prevention and treatment of colonic anastomoses failure: Dis. Cand. Sci. (Med.). Perm, 2012 (In Russ.)

4. Mine M., Yamamoto T. Desing of a mechanical anastomosis machine for esophagus, stomach and intestines. In: The 37th Annual meeting of Japanese Society of Medical Istrumentation. 1962:377 (in Japan.).

5. Vakalopoulos K.A., Daams F., Wu Z., Timmermans L., Jeekel J.J., Kleinrensink G.J., van der Ham A., Lange J.F. Tissue adhesives in gastrointestinal anastomosis: a systematic review. J Surg Res. 2013;180(2):290–300.

6. Gorsky V.A., Agapov M.A., Klimov A.E., Andreev S.S. The problem of the intestinal suture failure. Practical medicine. 2014;5(81):33–37 (In Rus.)

7. Popov D.E. Risk factors for colorectal anastomosis failure in patients with rectal cancer. Coloproctology. 2014;2(48):48–56 (In Russ.)

8. Kang C.Y., Halabi W.J., Chaudhry O.O. et al. Risk Factors for Anastomotic Leakage After Anterior Resection for Rectal Cancer. JAMA Surg. 2013;148(1):65–71. DOI: 10.1001/2013.jamasurg.2

9. Park J.S., Choi G.S., Kim S.H. 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;257:665–71.

10. Polovinkin V.V. Total mesorectal excision — a factor in increasing the effectiveness of treatment of mid-ampullar and low-ampullar rectal cancer: Dis. Dr. Sci. (Med.). Krasnodar, 2015 (In Rus.)

11. Zhebrovsky V.V. Complications in abdominal surgery. Moscow: MIA, 2006. 446 p. (In Russ.)

12. Tsarkov P.V., Kravchenko A.Yu., Tulina I.A., Tsugulya P.B. Does stapled colorectal anastomosis in anterior resection always guarantee restoration of intestinal continuity? Ross z gastroenterol gepatol koloproktol. 2012;22(4):73–80 (In Rus.)

13. Hirst N.A., Tiernan J.P., Millner P.A. et al. Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Colorectal Disease. 2014;16(2):95–109.

14. Leung J.M., Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J. Am. Geriatr. Soc. 2001;49:1080–5.

15. Kotelnikova L.P., Shatrova N.A., Belyakova Ya.V. Long-term results of resections of the left half of the colon and rectum. Modern problems of science and education. 2012;2:78 (In Rus.)

16. Xiao L., Zhang W.B., Jiang P.C., Bu X.F., Yan Q., Li H., Zhang Y.J., Yu F. Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study. World J. Surg. 2011;35(6):1367–77. DOI: 10.1007/s00268-011-1053-3

17. Asteria C.R., Gagliardi G., Pucciarelli S. et al. Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian of Colorectal Surgery. Tech. Сoloproctol. 2008;12(2):103–10. DOI: 10.1007/s10151-008-0407-9

18. Moran B.J. Predicting the risk and diminishing the consequences of anastomotic leakage after anterior resection for rectal cancer. Acta Chir. Iugosl. 2010;57(3):47–50.

19. Vermeer T.A., Orsini R.G., Daams F., Nieuwenhuijzen G.A., Rutten H.J. Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment. Eur J Surg Oncol. 2014;40(11):1502–9.

20. Polovinkin V.V., Volkov A.V., Khalafyan A.A. Duration of operation and intraoperative blood loss during total mesorectal excision. Siberian Medical Review. 2013;2(80):54–59 (In Rus.)

21. Wang L., Gu J. Risk factors for symptomatic anastomotic leakage after low anterior resection for rectal cancer with 30 Gy/10f/2w preoperative radiotherapy. World J Surg. 2010; 34(5):1080–5.

22. Linev K.A., Vysotsky A.A. Tactics of surgical treatment of failure of the colon anastomosis seams. Bulletin of emergency and restorative medicine. 2013;14(4):474–477 (In Rus.)

23. Lagoutte N., Facy O., Ravoire A. et al. C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients. J Visc Surg. 2012;149(5):345–9.

24. Gostishchev V.K., Dibirov M.D., Khachatryan N.N., Evseev M.A., Omelkossky V.V. New opportunities for the prevention of postoperative complications in abdominal surgery. Surgery. 2011;10:56–60 (In Rus.)

25. Giaccaglia V., Salvi P.F., Cunsolo G.V. et al. Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery. J Crit Care. 2014:29(4);528–32.

26. Pedersen T., Roikjær O., Jess P. Increased levels of C-reactive protein and leukocyte count are poor predictors of anastomotic leakage following laparoscopic colorectal resection. Dan Med J. 2012;59(12):A4552.

27. Akhmetzyanov F.Sh., Shaikhutdinov N.T., Valiev N.A., Shemeunova Z.N., Egorov V.I. Aspiration drainage in the prevention of postoperative septic complications in the abdominal-anal rectal resection. Kazan Medical Journal. 2015;96(6): 935–9 (In Rus.)

28. den Dulk M., Marijnen C.A., Collette L., Putter H., Påhlman L., Folkesson J., Bosset J.F., Rödel C., Bujko K., van de Velde C.J. Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg. 2009;96(9):1066–75.

29. Groshilin V.S., Sultanmuradov M.I., Kharagezov A.D., Khoronko R.Yu. Patent of the Russian Federation for invention No. 2523822. Method for postoperative prophylaxis of the colonic anastomosis failure. 2014 (In Rus.)

30. Guenaga K.F., Matos D., Castro A.A. et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst. Rev. 2003;(2):CD001544.

31. Zitta D.V., Subbotin V.M., Terekhina N.A. Effect of mechanical preoperative preparation of the intestine on the course of the early postoperative period. Coloproctology. 2010;3(33):14–19

32. Guenaga K.F., Matos D., Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst. Rev. 2011:7;(9):CD001544. DOI: 10.1002/14651858.CD001544.pub4

33. Komen N., Slieker J., Willemsen P. et al. APPEAL Study Group. Acute phase proteins in drain fluid: a new screening tool for colorectal anastomotic leakage? The APPEAL study: analysis of parameters predictive for evident anastomotic leakage. Am J Surg. 2014;208(3):317–23.

34. Jafari M.D., Wexner S.D., Martz J.E. et al. Perfusion assessment in laparoscopic Left-Sided/Anterior resection (PILLAR II): A Multi-Institutioanal Stady. J. Am. Coll Surg. 2015;220(1):82–92.

35. Gouya H., Oudjit A., Leconte M. et al. CT antegrade colonography to assess proctectomy and temporary diverting ileostomy complications before early ileostomy takedown in patients with low rectal endometriosis. AJR Am. J. Roentgenol. 2012;198:98–105.

36. Rondelli F., Bugiantella W., Vedovati M.C. et al. To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and metaanalysis. Colorectal Dis. 2014;16:35–42.