Anastomotic Complications
Anastomotic complications are among the most feared and difficult problems that colorectal surgeons commonly encounter in clinical practice. The consequences of a failed intestinal anastomosis can be devastating to the patient, family, and surgeon alike.
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Key Concepts • Patients who develop diffuse peritonitis after intestinal resection with anastomosis should undergo prompt exploratory laparotomy. • Colorectal anastomoses should be routinely tested prior to abdominal closure. • Hemodynamically unstable patients who develop a leak after sigmoid resection should undergo a Hartmann procedure. • Late anastomotic leaks commonly present with subtle and insidious symptoms such as failure to thrive. • Endoscopic balloon dilation is the procedure of choice for short anastomotic strictures. • Most cases of anastomotic bleeding resolve with conservative measures. • Persistent anastomotic bleeding should be treated by colonoscopy with epinephrine injection and/or endoscopic clips.
Anastomotic Leak Overview Anastomotic leak is perhaps the most feared and dreaded complication after bowel resection [1]. The consequences of a failed intestinal anastomosis can be devastating to the patient, family, and surgeon alike. Management of an anastomotic leak typically necessitates a lengthy hospitalization with considerable morbidity, suffering, as well as the very real possibility of breathtaking cost and resource utilization [2]. This can include a prolonged stay in the intensive care unit, reoperations in a hostile and hazardous environment to control sepsis, and creation of an intestinal stoma when none was initially expected or planned [3]. Patients often require repeated imaging studies, a wide variety of invasive interventions, and many complex decisions surrounding the necessity, timing, and risk/benefit ratio of the pertinent diagnostic and therapeutic interventions.
Despite the serious and overwhelming burden that can be imposed by an anastomotic leak, we often do not know why the leak occurred in any particular patient or circumstance. There are a wide variety of factors that have been associated with an increased risk of anastomotic dehiscence, some of which may be at least partially remediable [4–10]. In general, sicker patients with more comorbidities are at higher risk. But we seldom know which of the associated factors are actually causative and particularly worthy of focus, since so many of them cluster together in the same patient. For example, patients with Crohn’s disease may be considered to be at increased risk for anastomotic complications; but these patients may also be on steroids, other immunomodulatory agents, have preexisting local sepsis, and suffer from hypoproteinemia preoperatively [11]. Despite the critical importance of preventing leaks and understanding the pathophysiology of this potentially devastating problem, relatively little is known about why they actually occur. Avoiding tension on the anastomosis and assuring adequate perfusion to the two ends of the intestine to be joined remain valid and fundamental surgical principles; optimization of comorbid conditions and suspected risk factors is also of value [12]. But leaks often occur when no technical error, defect in surgical judgment, or patient-specific factor can be readily identified. Since we cann
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