Colonic anastomotic leaks can occur in the early or late postoperative phase when an enteric anastomosis fails. This results in the leak of intraluminal content extraluminally 4.
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Terminology
If an anastomotic leak occurs within 30 days post-operation, it is termed an "early" anastomotic leak, while those that occur after 30 days are termed a "late" anastomotic leak 5.
Anastomotic leaks can be classified as 4:
free/generalized leak: complete dehiscence resulting in general peritonitis due to general contamination of the abdomen by the bowel contents
contained leak: limited contamination of abdominal cavity and localized peritonitis
Epidemiology
The incidence of anastomotic leakage varies from 1% to 19% and is more common after rectal cancer surgery 1,4. The median development of generalized leak is 4 days postoperatively, whilst a contained leak develops at 15 days post-operation 4.
Clinical presentation
Free leakage can present with abdominal pain, fever, leukocytosis, hypotension, altered mental status 4, and/or fecal discharge through a surgical drain 5. The clinical features of contained leakage are non-specific, e.g. perianal pain, scrotal swelling, intestinal obstruction, perirectal, rectovaginal or rectovesical fistula 4, and/or pelvic abscess near the anastomosis 5.
Radiographic features
Fluoroscopic water soluble enema or CT with rectal contrast are the usual methods of radiological assessment, with MRI enema being an emerging imaging tool 2.
CT
The most common findings are 3:
extraluminal fluid
Treatment and prognosis
Laparotomy or diverting loop ileostomy are the more commonly performed in the free leakage group while percutaneous drainage of collection, non-operative management such as dietary modification, antibiotics, fluid resuscitation, or primary repair of the anastomotic site are commonly performed in contained leakage group 4,5.
Practical points
The use of barium sulfate contrast medium is contraindicated because if there is a leak and spill of barium into the peritoneal cavity it may cause a chronic chemical peritonitis.
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