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The American Journal of Surgery (2012) 204, 671– 676

Clinical Science

Management of colorectal anastomotic leakage:


differences between salvage and anastomotic takedown
Domenico Fraccalvieri, M.D., Sebastiano Biondo, M.D.*, Jose Saez, M.D.,
Monica Millan, M.D., Esther Kreisler, M.D., Thomas Golda, M.D.,
Ricardo Frago, M.D., Bernat Miguel, M.A.

Department of Surgery, Colorectal Unit, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain

KEYWORDS: Abstract
Colorectal BACKGROUND: The aim of this study was to evaluate and compare the morbidity associated with
anastomosis; 2 strategies of treatment of colorectal anastomotic leakage: surgical drainage of anastomosis with loop
Leakage; ileostomy versus anastomotic takedown.
Anastomotic METHODS: An observational study of patients operated on for ileocolic or colorectal anastomotic
takedown; leakage between 2001 and 2009. Patients were classified into 2 groups: group 1, salvage of the
Salvage; anastomosis, and group 2, anastomotic takedown. Mortality and morbidity were assessed. Morbidity
Bowel restoration and mortality of bowel restoration were also evaluated.
RESULTS: Thirty-nine patients were included into group 1 and 54 into group 2. Mortality was 15%
for group 1 and 37% for group 2 (P ⫽ .022). The rate of patients suitable for stoma reversal was 91%
for loop ileostomy and 38% for end stoma (P ⬍ .001). Morbidity was 18% after loop ileostomy closure
and 71% after end stoma reversal (P ⫽ .021). Hospitalization was 10 days and 21 days, respectively
(P ⫽ .009). There was no mortality.
CONCLUSIONS: Salvage of anastomosis with loop ileostomy is an effective strategy to control
peritoneal sepsis for colorectal anastomotic leakage.
© 2012 Elsevier Inc. All rights reserved.

Anastomotic leakage (AL) is the most feared and dread- also result in a poorer functional outcome and increase the
ful specific complication of colorectal surgery, leading to risk of permanent stoma formation.7–9
significant morbidity, increased mortality, and prolonged There is no universally accepted definition of colorectal AL.
hospital stay. There is also a significant increase in the use It may present as diffuse peritonitis requiring abdominal reop-
of hospital resources and costs after AL.1 The reported eration; as fecal discharge from the wound or drain; as a
incidences vary from .5% to over 30%2–5 depending on the localized abscess, which may be amenable to computed to-
inclusion criteria, the case mix, and the definition of leak. mography scan– guided percutaneous drainage; or as extrava-
In emergency colorectal procedures, AL occurs in 2% to sation of radiologic contrast in an otherwise asymptomatic
16% of cases of colonic obstruction and in 6% to 19% of patient, which may only require surveillance.10
cases operated on for colonic peritonitis.6 AL adversely Conventional management of a clinical AL with local or
affects the morbidity and mortality of postoperative patients diffuse peritonitis often requires taking down the anastomo-
with a mortality rate of 25% to 35% in large series. It may sis, with creation of an end colostomy or ileostomy; the
distal bowel is closed and left within the abdominal cavity
* Corresponding author: Tel.: ⫹34-93-260-7485; fax: ⫹34-93-260-7485. or is exteriorized as a mucosal fistula. However, the salvage
E-mail address: sebastianobiondo@yahoo.com of a leaking colorectal or coloanal anastomosis using sur-

0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.04.022
672 The American Journal of Surgery, Vol 204, No 5, November 2012

gical drainage and a proximal diverting stoma (avoiding


anastomotic resection) has been proposed as an alternative
management and reported in selected cases.11–13 The aim of
this observational study was to compare 2 surgical strategies
to treat patients with AL after colorectal surgery: salvage of
the anastomosis with derivative loop ileostomy versus anas-
tomotic takedown.

Patients and Methods


Between January 2001 and May 2009 at Bellvitge Uni-
versity Hospital, all patients who underwent reoperation for
AL after elective or emergency colorectal surgery were
entered into the study. Patients were identified from a pro- Figure 1 A flowchart of surgical management of patients with
anastomotic leak.
spective database of elective and emergency colorectal pro-
cedures performed at our institution.
AL was defined as generalized or localized peritonitis, Chicago, IL). The level of statistical significance was set at
the presence of pelvic abscess, or discharge of feces, pus, or P ⱕ .05. To perform bivariable analysis, the chi-square and
gas from the abdominal drain or wound. All anastomotic Fisher exact tests were used for the qualitative data; the
leaks were confirmed by one or more of the following Student t test or Mann-Whitney U tests were used for the
methods: an abdominopelvic computed tomography scan, quantitative data depending on data-application conditions.
water soluble contrast enema, digital rectal examination,
and laparotomy. Patients with a preoperative diagnosis of
AL not confirmed during laparotomy were excluded. None
of the patients included had a protective stoma at the orig- Results
inal surgery.
Ninety-three consecutive patients, 61 men (65.6%) and
According to the operation performed for the AL, pa-
32 women (34.4%), with an average age of 67.9 years
tients were classified into 2 groups: patients treated by
(range 18 – 89), were included in the study. Indications for
salvage of the anastomosis (with or without reanastomosis)
the first operation were colorectal cancer in 76 patients
and diverting loop ileostomy (group 1) and patients man-
(81.7%) and benign disease in 17 patients (18.3%). Sixty-
aged by anastomotic takedown with creation of an end
eight patients (73.1%) had undergone elective procedures,
colostomy or end ileostomy (group 2). Operations for AL
whereas 25 patients (26.9%) were operated on as an emer-
were performed by a general surgeon or a colorectal sur-
gency.
geon (member of the colorectal surgery unit). The decision
Fifty-three patients (57.0%) were classified as ASA
to perform one procedure or the other was left to the dis-
grade 2, 38 patients (40.9%) as ASA 3, and 2 patients
cretion of the surgeon on call. Mortality was defined as
(2.2%) as ASA 4. Eighty-four patients (90.3%) had one or
in-hospital death irrespective of the interval between pri-
more associated diseases. Clinical suspicion of AL was
mary operation and death.
confirmed by radiologic studies in 67 cases. At reoperation,
Demographic, physiological, clinical, and surgical data
local peritonitis was found in 15 cases (16.1%) and diffuse
relating to the original operation and the surgery for leakage
peritonitis in 78 patients (83.9%).
were collected for each patient. Age, sex, American Society
Group 1 included 39 patients (41.9%), 21 patients with
of Anesthesiologists (ASA) grade, presence of comorbidi-
drainage of the anastomosis and derivative loop ileostomy
ties, indication for surgery, grade of peritonitis, type of
and 18 patients with reanastomosis and ileostomy. Group 2
resection, setting of surgery, type and location of the anas-
included 54 patients (58.1%). All these patients underwent
tomosis, presence of leukocytosis and preoperative organ
anastomotic takedown, 32 with an end colostomy and 22
failure, length of stay and postoperative complications were
with an end ileostomy (Fig. 1). Table 1 shows the number of
the main variables evaluated. All patients fit for stoma
patients according to the type of anastomosis performed in
reversal had a water-soluble contrast enema before surgery
the original operation. Comparative analysis between the 2
to rule out anastomotic leak or stenosis.
groups showed no differences in terms of patients’ charac-
teristics. Significant differences were found regarding the
type of surgeon and type of operation performed (Tables 2
Statistical analysis and 3).
The overall morbidity rate was 80.6% (75/93 patients).
Statistical analysis was performed using the SPSS soft- Table 4 shows postoperative complications. There were no
ware package (SPSS for Windows, version 15.0; SPSS Inc, differences between the groups. Patients with an end stoma
D. Fraccalvieri et al. Treatment of colorectal anastomotic leakage 673

Table 1 Site of anastomosis and treatment Table 3 Patients’ characteristics at the reoperation
and their differences according to the anastomotic
All patients Group 1 Group 2 leakage treatment
93 39 54
Intraperitoneal 79 (84.9) 32 (82.1) 47 (87.0) All patients Group 1 Group 2
Proximal 45 (48.4) 23 (59.0) 22 (40.7) 93 39 54 P value
Distal 34 (36.6) 9 (23.1) 25 (46.3) Hinchey score .329
Extraperitoneal 14 (15.1) Hinchey I–II 15 (16.1) 8 (20.5) 7 (13.0)
Low rectum 14 (15.1) 7 (17.9) 7 (13) Hinchey III-IV 78 (83.9) 31 (79.5) 47 (87.0)
Values in parentheses are percentages. Blood white cells .056
Group 1: salvage of the anastomosis and loop ileostomy, group 2: 4000–10,000 44 (47.3) 23 (59.0) 21 (38.9)
anastomosis takedown. ⬎10,000 49 (52.7) 16 (41.0) 33 (61.1)
Renal failure 29 (31.2) 11 (28.2) 18 (33.3) .598
Respiratory 17 (18.3) 5 (12.8) 12 (22.2) .247
failure
Hemodynamic 18 (19.4) 6 (15.4) 12 (22.2) .410
after anastomotic takedown needed further surgery more failure
frequently than those with salvage of the anastomosis and Type of surgeon .001
loop ileostomy (18.5% vs 7.7%) without statistical differ- Colorectal 48 (51.6) 28 (71.8) 20 (37.0)
ences. General 45 (48.4) 11 (28.2) 34 (63.0)
The overall mortality rate was 28.0% (26/93). Six of 39 Values in parentheses are percentages.
patients in group 1 died (15.4%), whereas in group 2 the Group 1: salvage of the anastomosis and loop ileostomy, group 2:
anastomosis takedown.
death rate was 37% (20/54 patients) (P ⫽ .022). The length
of hospital stay was 32.15 days (standard deviation [SD] ⫽

22.42) in group 1 and 35.79 days (SD ⫽ 30.24) in group 2


Table 2 Patients’ characteristics at the first operation without significant differences (P ⫽ .578).
and their differences according to the anastomotic Among the 33 patients who survived after salvage treat-
leakage treatment ment by proximal loop ileostomy with reanastomosis or
All
patients Group 1 Group 2
93 39 54 P value Table 4 Postoperative outcome
Age (y) .188
Group 1 Group 2
ⱕ70 45 (48.4) 22 (56.4) 23 (42.6)
(n ⫽ 39) (n ⫽ 54) P value
⬎70 48 (51.6) 17 (43.6) 31 (57.4)
Sex .113 Mortality 6 (15.4) 20 (37.0) .022
Male 61 (65.6) 22 (56.4) 39 (72.2) Overall morbidity 34 (87.2) 41 (75.9) .175
Female 32 (34.4) 17 (43.6) 15 (27.8) Wound infection 21 24 (44) .371
ASA grade .239 Evisceration 1 1 1.000*
ASA I–II 53 (57.0) 25 (64.1) 28 (51.9) Anastomotic stenosis 1 — NA
ASA III–IV 40 (43.0) 14 (35.9) 26 (48.1) Anastomotic dehiscence* 1 — NA
Cardiac disease 19 (20.4) 6 (15.4) 13 (24.1) .305 Intraperitoneal 1 2 1.000
Coped 18 (19.4) 6 (15.4) 12 (22.2) .410 hemorrhage
Immunosuppression 4 (4.3) 2 (5.1) 2 (3.7) 1.000* Abdominal abscess 11 13 .653
Steroids 8 (8.6) 4 (10.3) 4 (7.4) .716* Reoperation 3 10 .137
Obesity 6 (6.5) 2 (5.1) 4 (7.4) 1.000* Bowel ischemia 1 2 1.000*
(BMI ⱖ35) Pancreatitis 1 0 .419*
Anemia (Hb ⱕ11 7 (7.5) 2 (5.1) 5 (9.3) .695* Myocardial infarction 1 2 1.000*
mg/dL) Pulmonary complications 12 20 .530
Malignant disease 76 (81.7) 33 (84.6) 43 (79.6) .539 Progressive septic shock 6 10 .693
Emergency surgery 25 (26.9) 7 (17.9) 18 (33.3) .099 Gastrointestinal bleeding 2 1 .570*
Site of anastomosis .072 Renal failure 3 6 .730*
Proximal 45 (48.4) 23 (59.0) 22 (40.7) Cerebrovascular accident 1 4 .395*
Distal 34 (36.6) 9 (23.1) 25 (46.3) Cardiac dysrhythmia 4 10 .272
Low rectum 14 (15.1) 7 (17.9) 7 (13.0) Urinary tract infection 2 2 1.000*
Values in parentheses are percentages. Values in parentheses are percentages. Some patient presented one
ASA ⫽ American Society of Anaesthesiologist classification; COPD ⫽ or more complications.
chronic obstructive pulmonary disease; BMI ⫽ Body Mass Index. Group 1: salvage of the anastomosis and loop ileostomy, group 2:
Group 1: salvage of the anastomosis and loop ileostomy, group 2: anastomosis takedown.
anastomosis takedown. *One of 18 cases of drainage with loop ileostomy and reanastomo-
*Fisher exact test. sis (Fisher exact test).
674 The American Journal of Surgery, Vol 204, No 5, November 2012

Table 5 Postoperative complications after stoma reversal


contrast enema, or laparotomy. Although many reports on
anastomotic leaks examine etiology and risk factors, there is
Loop End comparatively less information on the outcome after leaks.
ileostomy stoma P The main weakness of this study is the lack of random-
(n ⫽ 17) (n ⫽ 7) value ization between the 2 surgical approaches. However, the
Mortality — — groups were comparable with respect to all variables at the
Overall morbidity 3 (17.6) 5 (71) .021* first surgery. At reoperation, the only factor with significant
Anastomotic leak — —
difference between the groups was the specialization of the
Need of additional surgery — 1 .292*
Wound hemorrhage — 1 .292* surgeon.
Wound infection 1 2 .194* The use of a protective loop ileostomy in elective surgery
Ileus 1 1 .507* to minimize the septic consequences of AL promoted our
Pneumonia — 1 .292* interest in evaluating the efficacy of proximal diversion by
Renal failure 1 1 .507*
Length of stay 10.2 ⫾ 7.4 21 ⫾ 12.2 .009† loop ileostomy and surgical drainage for the control of
abdominal sepsis in postoperative local or diffuse peritonitis
Values in parentheses are percentages.
*Fisher exact test.
because of ileocolic or colorectal anastomotic disruption.
†Mann-Whitney U test. We compared this more conservative surgical strategy with
the traditional management of AL in colorectal surgery
(resection of the anastomosis and creation of an end stoma).
Proximal diversion using a loop ileostomy without re-
preservation of the leaking anastomosis, 30 (90.9%) have section of the leaking anastomosis has been proposed as an
been judged suitable for stoma closure. Seventeen patients alternative strategy to treat the dehiscence of pelvic extra-
(56.6%) have just been operated on, and 13 (43.3%) are on peritoneal anastomoses for low rectal resection in selected
the waiting list for surgery. Only 3 patients (9.1%) did not cases.11–14 Recently, Hedrick et al15 used this procedure in
have stoma reversal caused by metastatic disease, advanced both intraperitoneal and extraperitoneal colon and rectal
age, and prostate cancer with high surgical risk, respec- anastomosis. Of 27 patients operated on for anastomotic
tively. Only 13 of the 34 patients (38.2%) in group 2 were leak, 15 patients were successfully managed with diverting
judged suitable for the restoration of bowel continuity, and, loop ileostomy and surgical drainage without resection of
to date, 7 patients (53.8%) have had surgery, and 6 (46.1%) the anastomosis (in 12 cases, the anastomosis was intraperi-
are on the waiting list for surgery. Twenty-one patients toneal). In the present series of 93 patients operated on in
(61.8%) did not undergo reversal of the end stoma because emergency surgery for AL, the original anastomosis was
of the following different reasons: advanced age (n ⫽ 1), intraperitoneal in 79 patients. Thirty-nine patients were
high risk because of severe comorbidity (n ⫽ 12), cancer treated with a more conservative surgery using a diverting
progression (n ⫽ 4), fear of complex surgery and possible loop ileostomy and surgical drains placed in close proximity
complications (n ⫽ 3), and death from other diseases (n ⫽ of the anastomosis.
1). The difference found in the rate of restoration of bowel The mortality rate was significantly lower among pa-
continuity between the 2 groups was statistically significant tients treated by anastomotic salvage and loop ileostomy
(P ⬍ .001).
than in the group treated by anastomotic takedown. Even
Postoperative morbidity after closure of loop ileostomy
though postoperative morbidity was similar in both groups,
was significantly lower than after surgery for end stoma
patients in group 2 needed reoperations more frequently. At
reversal with rates of 17.6% and 71.4%, respectively (P ⫽
our institution, colorectal emergency surgery may be per-
.021). There were no cases of anastomotic leak or fistula in
formed by both colorectal surgeons and general surgeons
either group. The average length of stay was 10.18 days (SD
depending on the organization chart of the emergency de-
⫽ 7.41) for closure of loop ileostomy and 21 days (SD ⫽
partment. Fifty-two percent of our patients were operated on
12.21) for restorative surgery in patients with an end stoma
by a colorectal surgeon, and the decision to perform one
(P ⫽ .009) (Table 5). No overall mortality was observed.
procedure or the other was left to the discretion of the
surgeon on call. Diverting loop ileostomy and surgical
drainage of anastomosis were performed mainly by colo-
Comments rectal surgeons, whereas anastomotic takedown with end
stoma was performed more often by a general surgeon.
There is a large variability in the literature about the Recently, the authors evaluated the impact of surgical spe-
incidence of AL. Many reports include patients with and cialization on colorectal emergency surgery in a large series
without a protective stoma and mix patients with symptom- of patients.16 The study showed that procedures performed
atic and asymptomatic anastomotic leaks; therefore, it be- by a colorectal surgeon are associated with better results in
comes difficult to interpret the results.2–5,10 In the present terms of postoperative mortality and morbidity. The choice
study, the authors only included patients with clinical AL of a more conservative management of AL by drainage and
confirmed by a computed tomography scan, water-soluble loop ileostomy could reflect more experience but also more
D. Fraccalvieri et al. Treatment of colorectal anastomotic leakage 675

Figure 2 An algorithm for the surgical management of colorectal anastomotic leak.

judgment and confidence in the case of a colorectal surgeon the study of Hedrick et al,15 63% of patients managed with
rather than simply technical skill. surgical drainage and proximal diversion had restoration of
Many authors recommend anastomotic resection because intestinal continuity compared with only 33% of the patients
of the high risk of ongoing sepsis caused by the stool who had an end stoma. In the present experience, 91% of
contained in the proximal colon when a leaking anastomosis patients who were treated with salvage of the anastomosis
is left in place. We consider that intraoperative colonic and loop ileostomy have been considered suitable for stoma
lavage performed through the distal opening of the loop closure. By contrast, only 38% of patients with an end
ileostomy decreases the fecal load of the proximal colon and colostomy or end ileostomy were selected for restoration of
may be a useful method to reduce the risk of further sepsis, bowel continuity.
abscess formation, or local peritonitis. The morbidity after loop ileostomy closure in the present
Restoration of bowel continuity after end stoma creation series was 17.6%, which is similar to other reports,24 –27 and
is associated with high morbidity rates, AL rates of 4% to significantly lower than in the end stoma reversal group. No
16%, and mortality rates of up to 4%.17 Major complex death was observed in either group. The length of stay was
surgery is often required with a full midline laparotomy, approximately twice as long for the reversal of end colos-
laborious takedown of adhesions, and difficult pelvic dis- tomy or end ileostomy compared with loop ileostomy. We
section to identify the rectal stump; in these circumstances, think these results should be taken into account because of
the risk of damage of pelvic vessels, ureters, or hypogastric its considerable effect on the use of hospital resources and
nerves is considerable. In many cases, partial or total resec- on overall health costs. Although we have not performed a
tion of the rectum is necessary, and a diverting loop ileos- cost analysis, reducing the length of stay would have con-
tomy is performed to protect the low rectal or coloanal siderable repercussion on the use of hospital resources and
anastomosis. Therefore, because of the high risk of postop- on overall health costs.
erative complications, restoration of intestinal continuity is Given the good results of anastomotic salvage and di-
never accomplished in a significant number of patients, and verting loop ileostomy, the authors propose an algorithm of
only those in a good general condition are selected for management of both intraperitoneal and extraperitoneal AL
stoma reversal.18 Loop ileostomy closure is usually a quite in colorectal surgery (Fig. 2). Patients who have critical
safe procedure, technically straightforward in most cases, hemodynamic conditions during surgery may benefit from a
and quick and often feasible through a small peristomal quick and effective procedure, so drainage of the leaking
incision, with a morbidity rate between 10% and 30% and anastomosis with loop ileostomy may be proposed as a good
mortality between 0% and 2%.19 –22 surgical option to manage a minor dehiscence of an intra-
Other authors have published good long-term results peritoneal anastomosis. In a hemodynamically stable pa-
after proximal diversion without anastomotic takedown in tient, we recommend performing a new anastomosis cov-
the management of colorectal AL. Parc et al23 reported ered by a loop ileostomy.
significant differences in the rate of stoma reversal between In cases of low rectal anastomosis, we begin by checking
patients with a diverting loop stoma (100%, 9 patients) the suture by digital examination. In the presence of major
versus 58% of those treated with Hartmann’s procedure. In disruption (more than half of the circumference) or isch-
676 The American Journal of Surgery, Vol 204, No 5, November 2012

emia, the anastomosis should be resected with the creation 8. Alves A, Panis Y, Pocard M, et al. Management of Anastomotic
of an end stoma. In the presence of minor dehiscence or leakage after nondiverted large bowel resection. J Am Coll Surg
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when firm adhesions make the defect not visible, we rec- 9. Law WL, Choi HK, Lee YM, et al. Anastomotic leakage is associated
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leaking anastomosis left in situ. In low rectal anastomoses, resection for malignancy. J Gastrointest Surg 2007;11:8 –15.
we consider it sensible and reasonable to avoid long pelvic 10. Bruce J, Krukowski ZH, Al-Khairy G, et al. Systematic review of the
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