INTRODUCTION

Surgery plays an important role in the management of complicated structural, inflammatory, or neoplastic diseases of the colon and rectum. Colorectal surgery in benign or malignant colorectal disorders involves resection, reconstruction, fecal diversion, or bypass. Anastomosis of two bowel segments, closure of blind stump (e.g., the Hartmann procedure), and construction of an ileal pouch or ostomy all involve suturing or stapling. The leak at the suture line or staple line is generally termed an anastomotic leak (AL).

Acute AL is generally defined as dehiscence occurring within 30 days operatively. The AL can be extraperitoneal or intraperitoneal. The reported frequency of AL ranged from 2% to 7%, with the lowest leak rate in ileocolonic anastomoses (ICA), and the highest in coloanal anastomosis (CRA). Purported risk factors for AL include age >70 years, emergent surgery, underlying inflammation location of the anastomosis, anastomotic techniques, comorbidities (particularly severe organ malfunctions, hyperalbuminemia, and anemia), perioperative use of corticosteroids, high American Society of Anesthesiologists (ASA) physical status score, peritoneal contamination, and rectal excision, radiation, surgical expertise, and a long operative time. ^, The risk factors for the anastomotic complications are discussed in Chapter 3 . Acute AL can result in detrimental morbidities or even mortality and is one of the common causes of reoperation. Early recognition and diagnosis, timely intervention, and a multidisciplinary approach are the keys to preventing further adverse sequelae. Endoscopic treatment is a part of multidisciplinary efforts and may be attempted in candidate patients. The main focus of this chapter is endoscopic treatment modalities, including endoscopy-guided incision and drainage, pigtail stent, self-expandable metal stent, vacuum sponge suction, clipping, and their applications in different diseases and surgeries. Endoscopic technology is evolving with new devices becoming available, such as endoscopic tack and suture systems. The principles of endoscopic therapy of acute AL are to try the endoscopic intervention early when tissue dehiscence is still fresh, drain and flush the abscess endoscopically, radiographically, or surgically, and administer antibiotic and fibrosing (e.g., hypertonic glucose) agents to the abscess cavity, and close the defect with clips. Endoscopic closure for chronic AL is far less effective than acute AL. Endoscopic management of chronic anastomotic leaks and detailed techniques are discussed in Chapter 17 .

DIAGNOSTIC EVALUATION

Anastomotic leaks and their consequences are diagnosed based on a combined assessment of clinical presentations and radiographic features. Patients with AL often present with fever, tachycardia, abdominopelvic pain, feculent or purulent drainage, and leukocytosis. Cross-sectional imaging, such as computed tomography and magnetic resonance imaging usually show fluid collection, gas-containing collections, and occasionally separation of stapled anastomosis. Water-soluble contrast enema may help further delineate AL. In patients with ileal pouches, analysis of drain fluid amylase may help early detection of acute AL.

ACUTE ANASTOMOTIC LEAKS IN ULCERATIVE COLITIS SURGERY

Restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis (IPAA) is performed in patients with refractory UC, colitis-associated neoplasia (CAN), or familial adenomatous polyposis who require colectomy. The reconstructive nature of RPC and IPAA involves stapling, suturing, and anastomosis at the stoma closure site, the tip of the “J,” vertical staple line, and anastomosis. The classification of leaks in the ileal pouch is listed in Chapter 18 ( Table 18.1 ). ^,

Stoma Closure Site

Diverting end or loop ileostomy is often performed as a part of staged pouch surgery. End-to-end or side-to-side anastomosis is performed to close the stoma. Suture line or staple line leaks can occur at the anastomosis or transverse staple line in side-to-side anastomosis. AL can cause an intra-abdominal abscess or wound infection at the stoma site. Acute or fresh AL in the area may be treated with endoscopic closure with a through-the-scope clip (TTSC) ( Fig. 16.1 ) or over-the-scope clip (OTSC) ( Fig. 16.2 ).

Anastomotic leak at the stoma closure site in ileal pouch–anal anastomosis treated with endoscopic closure. (A) The leak was detected by a soft-tip guidewire. (B) Placement of through-the-scope clips.

Anastomotic leak at the stoma closure site in ileal pouch-anal anastomosis treated with endoscopic closure. (A) A small leak at the blind end of side-to-side anastomosis ( green arrow ). (B) Placement of an over-the-scope clip.

The Tip of the “J”

The tip of the “J” is another vulnerable area to surgical leaks in patients with IPAA. In contrast to chronic AL ( Chapter 18 ), acute AL at the tip of the “J” is not common. This author, however, encountered a few patients with acute AL at the site following surgical repair of a chronic leak at the tip of the “J”. Patients were treated with endoscopic clipping in the operating room with a colorectal surgeon team on guard ( Fig. 16.3 ).

Endoscopic closure of a leak at the tip of the “J” in ileal pouch anastomosis. (A) A small leak at the tip of the “J”. (B) The orifice of the leak was debrided with argon plasma coagulation. (C) Placement of the over-the-scope clip.

Pouch-Anal Anastomosis

Of all locations in the IPAA, the most common location of AL is at the pouch-anal anastomosis, which can present with presacral abscess, pelvic abscess, perianal abscess, or pouch-vaginal fistula. Notably, a small amount of free pelvic fluid immediately after pouch construction can be “normal.”

Anastomotic leaks can occur in both stapled or hand-sewn anastomosis in patients with or without mucosectomy. One of the reasons for a temporary diverting loop ileostomy at the stage of pouch construction is to protect the integrity of the anastomosis. This is particularly true in those with difficult operative time and suspected of having compromised anastomosis. Acute AL in IPAA is traditionally managed through observation with antibiotics, transcutaneous drainage by interventional radiologists, and transanal drainage by a colorectal surgeon. The latter includes a hand-crafted endoluminal vacuum-assisted closure system. Patients who fail the conservative approach may require reoperation with resection of the anastomosis and pouch advancement. Transanal drainage of abscesses can be performed with endoscopic vacuum therapy. ^, Patients with perianal abscesses resulting from acute AL may be treated with endoscopic incision and drainage in the endoscopy suite under topical and monitored anesthesia ( Fig. 16.4 ).

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