Clinics in Colon and Rectal Surgery
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Published By Georg Thieme Verlag Kg

1521-5741, 1531-0043
Updated Wednesday, 24 November 2021

2021 ◽  
Vol 34 (06) ◽  
pp. 385-390
Author(s):  
Naomi M. Sell ◽  
Todd D. Francone

AbstractAnastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.


2021 ◽  
Vol 34 (06) ◽  
pp. 357-358
Author(s):  
Anuradha R. Bhama
Keyword(s):  

2021 ◽  
Vol 34 (06) ◽  
pp. 379-384
Author(s):  
Abhineet Uppal ◽  
Alessio Pigazzi

AbstractLeaks from anastomoses can be a serious complication of any gastrointestinal resection. Leaks lead to increased morbidity, delayed postoperative recovery, and potential delays in adjuvant treatment in cancer cases. Prevention of anastomotic leak has been an area of ongoing research for decades. Methods of assessing bowel perfusion have been developed that may provide forewarning of anastomotic compromise. Physical reinforcement of the anastomosis with buttressing material is an available method employed with the goal of preventing leaks. Liquid-based sealants have also been explored. Lastly, interactions between the gut microbiome and anastomotic healing have been investigated as a mean of manipulating the microenvironment to reduce leak rates. Though no single technology has been successful in eliminating leaks, an understanding of these developing fields will be important for all surgeons who operate on the gastrointestinal tract.


2021 ◽  
Vol 34 (06) ◽  
pp. 366-370
Author(s):  
Joanne Favuzza

AbstractAnastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.


2021 ◽  
Vol 34 (06) ◽  
pp. 426-430
Author(s):  
Christy E. Cauley ◽  
Matthew F. Kalady

AbstractAnastomotic leak in patients with rectal cancer has the potential to cause worse oncologic outcomes in addition to major morbidity and mortality risk of this dreaded complication. Anatomic location of the rectal cancer determines the ability to perform a restorative operation and the height of the anastomosis in relation to the anal canal. Clinical staging dictates the need for neoadjuvant treatment (such as chemotherapy and radiation) which may also contribute to anastomotic leak risk. In addition to oncologic outcomes, anastomotic leak can impact bowel function, the need for permanent stoma, and long-term quality of life. This study will discuss special considerations for anastomotic leak prevention and clinical implications of this complication in patients with rectal cancer.


2021 ◽  
Vol 34 (06) ◽  
pp. 371-378
Author(s):  
Jeannette Man ◽  
Jennifer Hrabe

AbstractDetermining when to perform a bowel anastomosis and whether to divert can be difficult, as an anastomosis made in a high-risk patient or setting has potential for disastrous consequences. While the surgeon has limited control over patient-specific characteristics, the surgeon can control the technique used for creating anastomoses. Protecting and ensuring a vigorous blood supply is fundamental, as is mobilizing bowel completely, and employing adjunctive techniques to attain reach without tension. There are numerous ways to create anastomoses, with variations on the segment and configuration of bowel used, as well as the materials used and surgical approach. Despite numerous studies on the optimal techniques for anastomoses, no one method has prevailed. Without clear evidence on the best anastomotic technique, surgeons should focus on adhering to good technique and being comfortable with several configurations for a variety of conditions.


2021 ◽  
Vol 34 (06) ◽  
pp. 355-356
Author(s):  
Conor P. Delaney

2021 ◽  
Vol 34 (06) ◽  
pp. 431-438
Author(s):  
Deborah S. Keller ◽  
K. Talboom ◽  
C.P.M van Helsdingen ◽  
Roel Hompes

AbstractDespite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.


2021 ◽  
Vol 34 (06) ◽  
pp. 406-411
Author(s):  
Anuradha R. Bhama ◽  
Justin A. Maykel

AbstractChronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.


2021 ◽  
Vol 34 (06) ◽  
pp. 391-399
Author(s):  
Paul T. Hernandez ◽  
Raj M. Paspulati ◽  
Skandan Shanmugan

AbstractAnastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.


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