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World J Gastrointest Surg. Dec 27, 2015; 7(12): 378-383
Published online Dec 27, 2015. doi: 10.4240/wjgs.v7.i12.378
Management of low colorectal anastomotic leak: Preserving the anastomosis
Jennifer Blumetti, Herand Abcarian
Jennifer Blumetti, Herand Abcarian, Division of Colon and Rectal Surgery, John H. Stroger Hospital of Cook County, Chicago, IL 60612, United States
Author contributions: Blumetti J is main author and contributed data and reference collection; Abcarian H contributed to manuscript revisions and edition.
Conflict-of-interest statement: There is no conflict of interest associated with any of the authors.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jennifer Blumetti, MD, FACS, FASCRS, Attending Surgeon, Division of Colon and Rectal Surgery, John H. Stroger Hospital of Cook County, 1900 W. Polk St, Suite 404, Chicago, IL 60612, United States. jblumetti5@gmail.com
Telephone: +1-312-8645253 Fax: +1-312-8649642
Received: June 17, 2015
First decision: August 14, 2015
Revised: September 5, 2015
Accepted: October 12, 2015
Article in press: October 13, 2015
Published online: December 27, 2015
Abstract

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.

Keywords: Anastomotic leak, Colon and rectal surgery, Colorectal anastomosis, Management anastomotic leak, Endoscopic treatment, Surgical complications

Core tip: The treatment of the leaking colorectal or coloanal anastomosis continues to be challenge for surgeons to manage. This paper presents both older and new techniques in the treatment of low pelvic anastomotic leak, focusing primarily on salvage of the leaking anastomosis.