Colorectal anastomosis leakage

Case contributed by Rafael Lourenço do Carmo
Diagnosis certain


Patient presenting with abdominal pain, fever and tachycardia on 7th postoperative day of rectosigmoidectomy due to metastatic colonic cancer (palliative surgery).

Patient Data

Age: 80 years
Gender: Male

Non-contrast CT shows hyperdense linear material at the colorectal anastomosis site ("stapled" surgical technique), adjacent to which a small focus of trapped, extraluminal air is seen. Extensive pneumoperitoneum and a small amount of free peritoneal fluid are also present. 

Portal venous phase with rectal contrast material administration shows extravasation of bowel contrast into the extraluminal air mentioned earlier. A thin, discrete track is also observed (arrow on annotated image), as well as two small peripheral enhancing fluid collections close to the surgical site.

Multiple metastatic liver nodules, multiple homeostatic clips, aortic atherosclerosis, a left renal cyst (Bosniak I) and signs of vertebral column degenerative disease are additional findings.

Case Discussion

Colonic/colorectal anastomotic leakage is a serious potential complication of any colorectal anastomosis. It is associated with high morbidity and mortality, the latter being as high as 50% of the symptomatic cases 1. Leaks occur in 2% to 51% of colorectal surgeries.

Symptoms usually manifest in the first two postoperative weeks, with most of the cases between days 5 and 7. They consist of fever, intense abdominal pain, tachycardia, guarding and rebound tenderness. Often leaks are completely asymptomatic (occult leaks) 1.

Multidetector CT is currently the method of choice in diagnosing this condition. Diagnostic certainty is increased when extravasation of luminal contrast material, air, and possible stool is seen outside of the bowel. This appearance can mimic the rectum ("double rectum" sign).

Radiologic findings don't always represent the severity of the leakage, and the management is mostly based on the clinical status1.

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