Anastomotic Leak Management Following Low Anterior Resections


Patient population

Intervention

Comparator
 
Patients with anastomotic leak following LAR

Anastomotic salvage

Anastomotic takedown and end stoma

Morbidity, mortality, functional outcomes





Search Strategy


Relevant studies published between January 2000 and December 2016 were identified from the search of the Medline databases and Cochrane databases. The following search terms were used: rectal, rectum, proctectomy and leakage, failure, integrity, insufficiency, breakdown, defect, separation, dehiscence. Further articles were then selected based upon a review of the citations found in selected papers from the first search. All English language publications which primarily focused on the management of anastomotic leaks following low anterior resections were selected. Exclusion criteria included: (1) studies primarily focusing on risk factors, prevention, recurrence, or the treatment of other types of complications; (2) studies in which the majority of leaks were not involving a rectal anastomosis (ileo-colic, colo-colonic, ileo-anal); (3) non-English papers; (4) animal or laboratory studies. To avoid redundant studies, all of the authors and organizations, community of patients and study dates were routinely checked. When a study reporting the same patient cohort was included in several publications, only the most recent or complete study was selected.

The patients that are the most in need of infectious source control are those with generalized peritonitis and/or sepsis. Most surgeons would agree on the need for fluid resuscitation, antibiotics and operative intervention to drain and divert. However, aside from gross ischemia or complete dehiscence, there continues to be controversy over whether the anastomosis should be taken down or salvaged. We specifically wanted to know whether or not anastomotic salvage leads to inferior source control and therefore higher mortality rates as compared to anastomotic takedown. Also, as has been suggested in prior studies, does anastomotic salvage provide any benefits over takedown in terms of the ability to re-establish intestinal continuity and prevent the number of permanent stomas?

There is very little consensus regarding the best methods for preserving or reestablishing intestinal continuity. Despite the high rates of permanent stomas and poor rectal function in patients with anastomotic leak, many surgeons continue to rely on a wait and see approach. Definitive treatment to allow for complete closure is therefore delayed in the hopes of spontaneous healing. Ultimately, this approach has been and will continue to be challenged by the emergence of active therapies to treat anastomotic leaks.

At our institution we have used endoluminal vacuum (E-Vac) therapy in the treatment of anastomotic leaks. While this therapy is not commonly utilized in the US, it has been used primarily in Germany since around 2002 [8]. Without any established gold standard for comparison, we decided to create PICO tables that compared E-Vac therapy to redo surgery, and conservative management (including the “wait and see approach,”). Other methods such as endoscopic stent placement will be less formally reviewed as it was anticipated that available studies concerning these methods would be limited.

A manual search was also performed focusing on the search terms endoluminal vacuum therapy, endoscopic vacuum therapy, endo-SPONGE, endosponge, endo sponge, and endoluminal negative pressure therapy. Additional articles were found using a Google Scholar search using the same search terms as well as from a review of the citations of selected articles. All studies evaluating the use of E-Vac therapy were reviewed and assessed for treatment related complications. Only studies including ten or more patients treated with E-Vac therapy were used in comparing outcomes between interventions. One final manual search was performed for a better evaluation of the baseline risk of permanent stoma in patients with and without anastomotic leak. Keywords used were “permanent stoma,” “definitive stoma,” “permanent ostomy”, “definitive ostomy.”


Recommendations Based on the Data


Traditionally the treatment of choice for a leaking colorectal anastomosis has been resection with end colostomy. This is despite the limited evidence to support this practice (Table 49.1a, b). In fact, one of the commonly referenced studies which emphasized the need for anastomotic takedown contained only three patients so treated [13]. More recently, the need for anastomotic takedown has been questioned and the trend continues to be moving away from this approach and towards performing anastomotic salvage.


Table 49.1
Outcomes following anastomotic takedown compared to anastomotic salvage for the treatment of anastomotic leak





































(a) Mortality

№ of participants (studies)

Risk of bias

Publication bias

Outcome

Overall quality of evidence

Anastomotic salvage

Anastomosis takedown

125 (1 observational study) [9]

Very seriousa

Very strong association. Residual confounding would reduce demonstrated effect.

15.4 %b (6/39 patients)

37.0 % (20/54 patients)

Very low

(b) Need for permanent soma

134 (4 observational studies) [9, 10, 11, 12]

Very seriousa

Very strong association. Residual confounding would reduce demonstrated effect.

5.6 %c (4/71)

61.9 % (39/63)

Low


aIn the selected studies, the choice between anastomotic takedown or salvage was not randomized or controlled

bStatistically significant p <0.05

cAll four studies showed reduced number of permanent stomas in patients treated with anastomotic salvage. Only two of four studies assessed for statistical significance with both showing a statistically significant decrease (p < 0.05) in permanent stomas in patients treated with anastomotic salvage

Comparisons between anastomotic takedown and salvage were limited to four studies reporting on two of the four important outcomes. Patients treated with anastomotic salvage had statistically significant fewer postoperative deaths [9] and permanent stomas [9, 12] compared to patients treated with anastomotic takedown. Patients treated with anastomotic takedown as compared to anastomotic salvage also had more episodes of recurrent sepsis [22.7 % (5/22) vs. 0 % (0/10)] [12] and underwent an additional laparotomy more often [18.5 % (10/54) vs. 7.7 % (3/39)] [9], respectively.

These differences must be analyzed with caution based upon the overall quality of the studies (low to very low). Treatment bias may result in severe leakage (larger defects, colon necrosis etc.) being treated with anastomotic takedown, but remains unlikely account for differences in outcomes.


Surgical Management of Anastomotic Leakage Following LAR in Patients with Generalized Peritonitis and/or Sepsis





  1. 1.


    In the absence of bowel ischemia/necrosis and/or major dehiscence, patients should be managed without resection or takedown the anastomosis and given a proximal diverting stoma. (Strong recommendation based upon low or very low-quality evidence)

     

The authors of all four included studies reported favoring the use of anastomotic salvage [9, 10, 12, 11]. In three of the four studies, anastomotic takedown with creation of an end stoma was only favored in the management of anastomoses with ≥ 50–100 % dehiscence or in the presence of bowel ischemia or necrosis [9, 11, 12]. In the absence of the above criteria, diverting ostomy and salvage of the anastomosis is an effective method of controlling peritoneal sepsis resulting from leakage of both intraperitoneal and extraperitoneal rectal anastomoses. Anastomotic salvage and diversion is also the favored approach when anastomoses are inaccessible or poorly visualized as a result of significant inflammation, exudate, and/or adhesions.


Reestablishing Intestinal Continuity in Patients with Symptomatic Anastomotic Leakage Following LAR





  1. 1.


    E-Vac therapy is an effective early treatment option for anastomotic leaks with an associated abscess cavity, with or without diverting stomas. (Table 49.2). Strong recommendation based upon low or very low-quality evidence.


    Table 49.2
    Outcomes of re-do surgery compared to endoluminal vacuum therapy in restoring intestinal continuity













































    (a) Permanent stoma

    № of participants

    (studies)

    Risk of bias

    Publication bias

    Need for permanent stoma

    Overall quality of evidence

    Redo surgery

    E-vac therapy

    349 (12 observational studies) 1 [1522, 8, 23, 22]

    Seriousa

    Publication bias strongly suspected

    15.0 % (21/140)

    18.9 % (18/95)

    ≤ 6 weeks

    15.9 % (10/63)

    + diversion

    7.70 % (1/13)

    Very low

    (b) Complete closure

    № of participants (studies)

    Risk of bias

    Publication bias

    Complete closure

    Overall quality of evidence

    Redo surgery

    E-vac therapy

    293 (11 observational studies; 8 E-Vac, 3 Redo) [20, 22, 19, 17, 21, 16, 15, 24, 23, 8, 18]

    Seriousa

    Publication bias strongly suspected. Residual confounding would reduce the demonstrated effect

    77.1 % (91/118)

    85.7 % (150/175)

    ≤ 6 weeks

    92.1 % (70/76)

    + diversion

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    Jul 13, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Anastomotic Leak Management Following Low Anterior Resections
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