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Managementofanastomoticcomplicationsofcolorectalsurgery
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Managementofanastomoticcomplicationsofcolorectalsurgery
Authors
RobinBoushey,MD
LaraJWilliams,MD,MSc,FRCSC

SectionEditor
MartinWeiser,MD

DeputyEditor
WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:May05,2016.
INTRODUCTIONThesafetyofcolorectalsurgery,asperformedinpatientswithcolorectalcancerandinflammatory
boweldisease,hasimproveddramaticallyoverthelast50yearsduetoimprovementsinpreoperativepreparation,
antibioticprophylaxis,surgicaltechnique,andpostoperativemanagement[1].Nevertheless,complicationssuchas
thoserelatedtocolorectalanastomosescontinuetooccur.(See"Overviewofthemanagementofprimarycolon
cancer"and"Overviewofsurgeryforthetreatmentofprimaryrectaladenocarcinoma"and"Surgicalmanagementof
ulcerativecolitis".)
Therisks,management,andoutcomesofanastomoticcomplicationsofcolorectalsurgerywillbereviewedhere.
Thesecomplicationsincludebleeding,dehiscenceandleakage,strictures,andfistulas[2].Therisks,management,
andoutcomesofintraabdominal,pelvic,andgenitourinarycomplicationsfollowingcolorectalsurgeryarereviewed
elsewhere.(See"Managementofintraabdominal,pelvic,andgenitourinarycomplicationsofcolorectalsurgery".)
MORBIDITYANDMORTALITYRISKFACTORSColorectalsurgeryisassociatedwithappreciablemorbidityand
mortality.Prospectivestudies,bothmulticenterandsinglecenter,haveevaluatedpatientoutcomesaftercolorectal
surgery[39].Therateofmajormorbidityrangedfrom20to35percent[4,7]andthe30daymortalityraterangedfrom
2to9percent[49].Theredoesnotappeartobeasignificantdifferencein30daymortalityratebetweenmalignant
versusbenignindicationsforsurgery[4,7,9].
Independentpreoperativeriskfactorsthatareassociatedwithanincreasedriskofinhospitalcomplicationsinclude
[4,7]:

Agegreaterthan70years
AmericanSocietyofAnesthesiologists(ASA)physicalstatusscoreGradeIIItoV
Emergencysurgery
Neurologiccomorbidity
Cardiorespiratorycomorbidity
Hypoalbuminemia
Longdurationofoperativeprocedure
Peritonealcontamination
Rectalexcision

Independentpreoperativeriskfactorsthatareassociatedwithanincreasedriskofinhospitaland30daymortality
include[49]:

Emergencysurgery
Lossofgreaterthan10percenttotalbodyweight
Neurologiccomorbidity
Agegreaterthan70years
StageIVcancer(versusearlierstagecancer)
ASAphysicalstatusscoreGradeIIItoV
Lowsurgeoncasevolume

ANASTOMOTICCOMPLICATIONSIntestinalanastomoticcomplicationsareassociatedwithanincreasedpatient
mortalityandmorbidity,includingthepotentialneedforemergentreoperationandprolongedhospitalization.Themost
commoncomplicationsinclude:
Minorandmajorbleeding
Dehiscenceandleaks
Strictures
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Fistulas
MinorbleedingMinorbleedingisdefinedasbleedingthatdoesnotrequirebloodtransfusionand/orintervention
(endoscopic,angiographic,orsurgical).Itusuallyceaseswithin24hours.Minoranastomoticbleedingafterhandsewn
orstapledanastomosesiscommonbutrarelyreported.Itisusuallymanifestedbytheselflimitedpassageofdark
bloodwiththepatient'sfirstfewbowelmovements.Itisestimatedthatapproximately50percentofpatientswho
presentinitiallywithminorbleedingwillprogresstomajorbleedingandrequireabloodtransfusion[10].Thereareno
highqualitydatafromprospectivestudiesthathaveaddressedthisissue.
Itishypothesizedthatanastomoticbleedingoccurssecondarytoinadequateclearanceofthemesenterypriorto
divisionand/orstaplingofthebowel.Theriskofbleedingisincreasedinpatientswithableedingdiathesis.Proposed
techniquestoreduceminorbleedinginclude[11]:
Carefulinspectionofthestapleline,especiallyforsidetosideandfunctionalendtoendanastomoses
Inversionandinspectionofthelinearstaplelinepriortoclosureoftheenterotomythroughwhichastapling
instrumentwaspassedhasbeenadvocatedbysomeexperts.
Sutureligation,asopposedtoelectrocauterization,ofsignificantlybleedingpoints
Utilizationoftheantimesentericbordersofeachlimbtoconstructtheanastomosis,therebyavoidinginclusionof
themesenteryintothestapleline
Reinforcementoftheanastomosiswithanabsorbablesutureisanoptionusedbysomesurgeons
MajorbleedingMajorbleedingisdefinedasoneormoreofthefollowing:
Hemodynamicinstability
Bloodtransfusion
Anemergencyprocedureiswarranted(eg,endoscopic,angiographic,surgical).
Thereportedrateofmajorbleedingfromananastomosisfollowingcolorectalsurgeryrangesinmoststudiesfrom0.5
to4.2percent[10,1214].Dataarelimitedforileocolicanastomoses[2].Thereisnosignificantassociationbetween
theriskofbleedingandthetechniqueofperformingtheanastomosis(handsewnversusstapledcolocolic
anastomoses)[14].Specificriskfactorsformajoranastomoticbleedinghavenotbeenidentified,atleastinpartdueto
thesmallnumberofreportedcases.
ManagementThemanagementofpatientswithanastomoticbleedingshouldfollowthesameprinciplesasthe
managementofpatientswithlowergastrointestinalbleedingfromothercauses.(See"Approachtoacutelower
gastrointestinalbleedinginadults"and"Lowergastrointestinalbleedinginchildren:Causesanddiagnosticapproach".)
Surgicalinterventionshouldbereservedforunstablepatientsorthosewhofailconservativemeasures[13].We
suggestthefollowingapproach:
Initialmanagementshouldbeconservativewithsupportivecare,includingbloodtransfusionsandcorrectionof
anyunderlyingcoagulopathy.Operativemanagementshouldbeconsideredearlyforpatientswithhemodynamic
instabilitydespiteaggressiveresuscitation.
Forpersistentbleedingfromalowanastomosis,atransanaloperativeapproachisadvocated:
Proctoscopyisperformedtoevacuateclot
Bleedingpointsaresutureligated
Forpersistentbleedingfromhighercolorectalorileocolicanastomoses,initialendoscopicmanagementhasbeen
advocated[10,12,13].However,thenumberofpatientswithanastomoticbleedingineachofthesestudiesis
small(6to17),therebylimitinganassessmentofthetruesuccessrate.Inaseriesof1389colorectal
procedures,forexample,sevenpatients(0.5percent)developedananastomoticbleed:sixweretreated
endoscopicallytocontrolthebleedingandonerequiredoperativemanagement[13].Apotentialcomplicationof
earlypostoperativeendoscopyisanastomoticdehiscence[10].Someauthorsadvocatewaterimmersion
endoscopyforacutelowergastrointestinalbleedingintheearlypostoperativeperiodaftercolorectalanastomoses
tolimittheriskofcolonicleakage[15].
Endoscopicmanagementofbleedingincludes[10,12]:

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Isotonicsalinewashout
Electrocoagulation
Epinephrineinjection
Applicationofhemostaticclips
Forpersistentbleedingfromhighercolorectalorileocolicanastomoses,angiographiclocalizationandcontrolusing
intraarterialvasopressinhasbeeneffective[16].However,theoretically,thereisariskofischemiaandanastomotic
dehiscenceafterangiography[13].
Reoperationwithresectionofthebleedinganastomosisisnecessarywhenendoscopicmanagementisnotsuccessful
[13].Thereisnoconsensusregardingwhatconstitutesafailureofendoscopicmanagementinthissetting.Onemay
extrapolatefromthepublishedliteratureonthemanagementoflowergastrointestinalbleedingfromothercauses.(See
"Approachtoacutelowergastrointestinalbleedinginadults",sectionon'Colonoscopy'.)
OutcomesAsindicatedbytheaboveobservations,dataonthemanagementofanastomoticbleedingafter
colorectalsurgeryislimitedtostudiesofsmallnumbersofpatients.Inaliteraturereviewof17patientswith
anastomoticbleeding,nonoperativemanagementwithendoscopicelectrocoagulationorbloodtransfusionalonewas
successfulin14(82percentofpatients)[10].Therearenodatafromprospectivetrialsaddressingissuessuchas
mortalityandmorbidity.
Dehiscenceandleaks
IncidenceTheoverallincidenceofanastomoticdehiscenceandsubsequentleaksis2to7percentwhen
performedbyexperiencedsurgeons[3,1719].Thelowestleakratesarefoundwithileocolicanastomoses(1to3
percent)andthehighestoccurwithcoloanalanastomosis(10to20percent)[11].
Mostanastomoticleaksusuallybecomeapparentbetweenfiveandsevendayspostoperatively.Onestudyreported
thatalmosthalfofallleaksoccurafterthepatienthasbeendischarged,andupto12percentoccurafterpostoperative
day30[18].Lateleaksoftenpresentinsidiouslywithlowgradefever,prolongedileus,andnonspecificsymptoms
attributabletootherpostoperativeinfectiouscomplications.Small,containedleakspresentlaterintheclinicalcourse
andmaybedifficulttodistinguishfrompostoperativeabscessesbyradiologicimaging,makingthediagnosisuncertain
andunderreported.
DefinitionandmanifestationsThereisnouniformdefinitionofananastomoticdehiscenceandleak[17].Ina
reviewof97studies,asanexample,56differentdefinitionsofananastomoticleakwereused[20].Themajorityof
reportsdefineananastomoticleakusingclinicalsigns,radiographicfindings,andintraoperativefindings[21,22].
Theclinicalsignsinclude:

Pain
Fever
Tachycardia
Peritonitis
Feculentdrainage
Purulentdrainage

Theradiographicsignsinclude:
Fluidcollections
Gascontainingcollections
Theintraoperativefindingsinclude:
Grossentericspillage
Anastomoticdisruption
RiskfactorsRiskfactorsforadehiscenceandleakareclassifiedaccordingtothesiteoftheanastomosis
(extraperitonealorintraperitoneal).Aprospectivereviewof1598patientsundergoing1639anastomoticproceduresfor
benignormalignantcolorectaldiseasefoundasignificantlyincreasedriskofanastomoticleakwithextraperitoneal
comparedwithintraperitonealanastomoses(6.6versus1.5percent2.4percentoverall)[23].
ExtraperitonealanastomoticleakMajorriskfactorsforanextraperitonealanastomoticleakinclude:
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ThedistanceoftheanastomosisfromtheanalvergePatientswithalowanteriorresectionandan
anastomosiswithin5cmfromtheanalvergearethehighestriskgroupforananastomoticleak[23,24].Inthe
abovementionedseriesof1639procedures,theriskofaleakwashighest(8percent)withultralowanterior
anastomoses[23].
AnastomoticischemiaTwoprospectivestudiesusinglaserDopplerflowmetryassessedbloodflowtothe
colonandrectumbeforeandaftermobilizing,dividing,andanastomosingthecolon[17,25,26].Adecreasein
colonictissueperfusionproximaltotheanastomoticsite,attheanastomoticsite,andattherectalstumpwas
reported.Themagnitudeofdecreaseinbloodflowcorrelatedwiththesubsequentdevelopmentofananastomotic
leak.
MalegenderInaprospectivestudyof196patientsundergoingrectalcancerresections,multivariateanalysis
showedasignificantlyhigherrateofanastomoticleakinmenwithananastomosislessthan5cmfromtheanal
verge[21].Itislikelythatmalegenderhasthegreatestinfluenceonanastomoticleakratesbecauseoperatingin
thenarrowermalepelvisistechnicallymorechallenging.Incontrast,malegenderdoesnotappeartobearisk
factorforintraperitonealanastomoticleaks[27].
ObesityDataareconflictingregardingtheroleofobesityinanastomoticleakcomplications.Aprospective
reviewof1417patientsfoundnoassociationbetweenobesityandtheriskofanintraperitonealanastomoticleak
[27].However,obesitymaybeariskfactorforananastomoticleakforlowcolorectalanastomoses.A
retrospectivereviewof131patientsfoundobesepatientsundergoingananteriorresectionlessthan5cmfrom
theanalvergehadasignificantlyincreasedriskofanastomoticleakcomparedwithnonobesepatients(33
versus15percent)[28].
IntraperitonealanastomoticleakMajorriskfactorsforanintraperitonealanastomoticleakinclude:
AmericanSocietyofAnesthesiologists(ASA)scoreGradeIIItoVAretrospectivereviewof1417patients
foundasignificantlyincreasedriskofleakwithASAscoreGradeIIItoVafteranintraperitonealanastomosis
comparedwiththosewithanASAscoreGradeItoII(4.6versus0.8percent)[27].
EmergentsurgeryThesameretrospectivereviewfoundasignificantlyincreasedriskofleakwithemergency
surgeryafteranintraperitonealanastomosiscomparedwithelectivesurgery(4.4versus1.0percent)[27].For
patientswithbothanASAscoreGradeIIItoVandanemergencyoperation,theriskofananastomoticleakwas
8.1percent.
ProlongedoperativetimeAprospectivestudyof391electivecolorectalresectionsidentifiedasignificantly
higherleakratewhentheoperativeprocedurewas4hoursindurationcomparedwithshorterprocedures(5.1
versus0.5percent)[24].Moredifficultdissectionsandanastomoseswereattributedtothelongeroperatingtimes
andincreaseinanastomoticleaks.
HandsewnileocolicanastomosisInametaanalysisofsixtrialswith955participantswithbenignand
malignantdisease,handsewnanastomoseswereassociatedwithasignificantlyhigherrateofoverall
anastomoticleakscomparedwithstapledileocolicanastomoses(6.0versus1.4percent)[2].Forthesubgroupof
825patientswithcancer,handsewnanastomoseswerealsoassociatedwithsignificantriskofananastomotic
leak(6.7versus1.3percent).
Incontrasttobeingariskfactorforextraperitonealanastomoticleaksasnotedintheprecedingsection,neithermale
gendernorobesityappearstobeariskfactorforintraperitonealanastomoticleaks[27].
Controversial,inconclusive,ornegativeControversial,inconclusive,orpertinentnegativeassociations
betweenthefollowingvariablesandananastomoticleakhavebeenreported:
NeoadjuvantradiationtherapyRetrospectivestudieshavefoundapositive,inconclusive,andnoassociation
betweentheuseofneoadjuvantradiationtherapyandtheriskofananastomoticleak[4,17,2831].Thereareno
highqualitydatafromrandomizedtrialsthatspecificallyaddressneoadjuvantradiationtherapyasariskfactor.
DrainsItisunclearifdrainsareariskfactorforanastomoticleaksandthelocationoftheanastomosismaybe
important.Arandomizedtrialfoundnoincreaseinanastomoticleakswithdrainsinpatientsundergoingelective
colonicresection[32],whilealargeobservationalstudyfoundasignificantincreaseinanastomoticleakswith
drainsinpatientsundergoingalowanteriorresectionforrectalcancer[33].
ProtectivestomaThecontroversyregardingaprotectivestomainvolveswhetherornotthestomapreventsa
leakandreducesthecorrespondingclinicalconsequences.Proximalfecaldiversionbyaprotectivestoma(eg,
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loopileostomy,loopcolostomy,orendostomy)significantlyreducestheoverallriskofareoperationfollowingan
anastomoticleak.
Inaprospectivemulticenterstudyof2729patientsundergoingalowanteriorresectiontheoverall
anastomoticleakratewassimilarinpatientswithandwithoutastoma(14.5versus14.2percent)[34].
However,patientswithastomahadsignificantlylowerratesofleaksthatrequiredsurgicalintervention(3.6
versus10.1percent)andalowerrateofmortality(0.9versus2.0percent).
Ametaanalysisoffourrandomizedtrialsincluding358patientsundergoingalowanteriorresectionfor
rectalcancerfoundpatientswithaprotectivestomahadsignificantlyfeweranastomoticleakscompared
withpatientswhohadnoprotectivestoma(9.6versus22.8percent)[35].Patientswithaprotectivestoma
hadsignificantlyfewerreoperationsforleaks(oddsratio0.27,95%CI0.170.59).
Inarandomizedcontrolledtrialof234patientsundergoingalowanteriorresectionforrectalcancerthatwas
includedinthemetaanalysis,therateofanastomoticleakagewithaprotectivestomawassignificantly
lowercomparedwithnoprotectivestomainbothmen(10.0versus29.3percent)andwomen(10.9versus
26.7percent)[36].
HandsewncolorectalanastomosisHandsewncomparedwithstapledileocolicanastomosesareassociated
withasignificantincreaseinleaks[2].However,whetherornotthisistrueforcolorectalanastomosesisunclear
[14,37].
Areviewofnineprospectivetrialsof1233patientswithacolorectalanastomosisfoundnosignificant
differenceinoveralldehiscenceandleaksforastapledanastomosiscomparedwithahandsewn
anastomosis(13.0versus13.4percent)[14].
Inaprospective,multicentertrialof732patientswithacolorectalanastomosis,therewasanincreasein
radiographicallydetectedleaksinhandsewnanastomoses(14.4versus5.2percent),butnodifferencein
clinicallydetectedleakrates[37].Nopatientwitharadiographicleakwithoutclinicalsymptomshadan
increaseinmorbidity.Therewasnodifferenceinmorbidityandmortalityratesforpatientswithahandsewn
orstapledanastomosis.
FibringlueAretrospectivereviewof1148patientswithrectalcancerundergoingasphincterpreservation
procedurefoundthatuseoffibringluewasanindependentpredictorofpreventionofanastomoticleak(OR1.94
95%CI1.043.64).[38].Theanastomoticleakrateinthisserieswas6.6percent.
LaparoscopicprocedureRandomizedtrialscomparinglaparoscopicwithopencolorectalresectionforcancer
havefailedtoshowanydifferenceintherateofanastomoticleaks[39,40].
MechanicalbowelpreparationTheroleofmechanicalbowelpreparation(MBP)iscontroversial.Ameta
analysisof13prospectivetrialsfoundnosignificantdifferenceinoverallanastomoticleakrateforpatientswith
anMBPcomparedtothosenothavingaMBP(4.2versus3.4percent).Thisconclusionappliedtobothlow
anteriorresectionandintraperitonealanastomosis.
NutritionNutritionalfactors,includinghypoalbuminemia,alcoholintake,andweightlosshaveshownvariable
andconflictingresults[41,42].
PerioperativecorticosteroidsDataareinconsistentindeterminingtherelationshipbetweenperioperative
corticosteroidusageandriskofanastomoticleaks[3,24,4345].However,asystematicreviewthatincluded12
studiesdemonstratedasignificantlyhigherrateofanastomoticleakforpatientswhoreceivedcorticosteroidsin
thepreoperativeperiodcomparedwiththosewhodidnot(6.8versus3.3percent)[43].
Nonsteroidalantiinflammatorydrugs(NSAIDs)NSAIDsarecommonlyusedforpaincontrolinpatientswho
undergocolorectalsurgery.ExistingdatasuggestthatpostoperativeuseofNSAIDsmayincreasetheriskof
anastomoticleak.Inametaanalysisoffiverandomizedcontrolledtrialsandthreeretrospectivestudies,patients
whoreceivedNSAIDsdevelopedsignificantlymoreanastomoticleaksthanpatientswhodidnotreceiveNSAIDs
(10versus5percent)[46].Alargecohortstudypublishedafterthemetaanalysisreachedasimilarconclusion,
butonlyforpatientsundergoingnonelectivecolorectalsurgery[47].
IntravenousketorolacisapotentNSAIDthatiscommonlyusedinenhancedrecoverypathwaysforabdominal
surgery.Inonestudyof398,752patients,5percentofpatientsreceivedketorolacaftercolorectal(55percent)or
othergastrointestinalsurgery(45percent)[48].Ketorolacusewasassociatedwithmorereadmissionsfor
anastomoticcomplications(OR1.20,95%CI1.061.36).Inaddition,patientswhoreceivedketorolacweremore
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likelytorequirereintervention(OR1.20,95%CI1.081.32),emergencydepartmentvisit(OR1.44,95%CI1.37
1.51),orreadmission(OR1.11,95%CI1.051.18)within30daysofsurgery.Anotherstudyofpatients
undergoingcolorectalsurgery,however,failedtofindanassociationbetweenketorolacuseandanastomoticleak
[49].
ManagementOnceananastomoticleakhasbeenrecognized,patientsshouldreceiveintravenousfluid
resuscitationandbroadspectrumantibiotics.Furthermanagementisdictatedbytheclinicalscenarioand,ifpatient
stabilitypermits,radiologicinvestigationtolocalizetheleakanddetermineitsseverity.Managementstrategiesinclude
observation,bowelrest,percutaneousdrainage,colonicstenting,surgicalrevision,diversion,ordrainage[50].
IntraperitonealanastomoticleakManagementofanintraperitonealanastomoticleakisdependentuponthe
patientsclinicalcondition,thenatureoftheleak,and,ifanexploratorylaparotomyisperformed,theintraoperative
findings.Thefollowingtreatmentoptionsareavailable,dependingupontheclinicalstabilityofthepatient,radiographic
findings,andfeasibilityofimageguidedpercutaneousdrainage:
Asubclinicalleak,whichisdefinedasaleakdetectedradiographicallyinpatientswithnoclinicalabdominal
findings,canbemanagedexpectantly.
Forpatientswhopresentwithlocalizedperitonitisandlowgradesepsis,adiagnosticimagingworkupisinitiated.
WeperformaCTscanwithoral,intravenous,andrectalcontrast.Alternatively,awatersolublecontrastenema
maybeperformed,ifavailableinyourinstitution.Ifaleakispresent,themajoritywillbelocalized.
Ifafreeintraperitonealleakisdemonstrated,thepatientshouldbetakentotheoperatingroomforsurgical
management.
Ifthepatientisstablewithsmall,containedabscesses(<3cm),werecommendconservativemanagement
withbroadspectrumantibioticsandbowelrest.
Forlargerabscesses(>3cm),multiloculatedcollections,ormultiplecollections,anattemptatpercutaneous
drainageshouldbemade.Inthosecaseswhereimageguideddrainageisnottechnicallyfeasibleorwhere
thepatientsclinicalconditiondeterioratesdespitedrainage,surgicalinterventionintheformofan
exploratorylaparotomyshouldbeundertakenasdescribedinthefollowingparagraph.
Patientswhopresentwithgeneralizedperitonitisorhighgradesepsiswithhypotensionshouldberesuscitated
andbroughttotheoperatingroomforanexploratorylaparotomyonanemergentbasis.Surgicalmanagementis
dependentupontheintraoperativefindings.
Ifaninoperablephlegmonisencountered,thesafestapproachistoplaceparaanastomoticdrainsand
performproximaltemporaryfecaldiversionwitheitheraloopileostomyorcolostomy.
Forpatientswhohaveamajoranastomoticdefect(generallydefinedas>1cmorgreaterthanonethirdthe
circumferenceoftheanastomosis)[50],theoptionsincluderesectionoftheanastomosiswithcreationofanend
stomawith/withoutmucusfistula,resectionoftheanastomosiswithreanastomosisandproximaldiversion,or,
rarely,exteriorizationofbothendsofthestoma.
Inselectedpatientsinwhomthedefectisminorandthetissuequalityisadequate,onemayconsider
primaryrepairoftheanastomosiswithdrainplacementandproximaldiversion.
ExtraperitonealanastomoticleakInmostcases,managementofanextraperitonealanastomoticleakis
similartothatofanintraperitonealleak.Thefollowingtreatmentoptionsareavailable,dependingupontheclinical
stabilityofthepatient,radiographicfindings,andfeasibilityofimageguidedpercutaneousdrainage:
Forpatientswithgeneralizedperitonitisandhighgradesepsis,emergentoperativemanagementshouldbe
performed,asdescribedintheprevioussection.
Managementofpatientswithapelvicabscessdependsuponthepatientsclinicalcondition,locationofthe
abscess,andwhetherornottheabscessisincontinuitywithaleak.Considerationofproximaldiversionis
warrantedinsymptomaticpatients.Determinationofwhethertheabscessiscontainedorisincontinuitywiththe
leakcanbemadebyperformingawatersolublecontrastenema.
Patientswithacontainedabscessshouldbeplacedonintravenousantibioticsandundergoabscess
drainageifthecollectionislargerthan3cm.CTguideddrainageviaatransabdominal,transvaginal,
transanal,ortransrectalrouteshouldbeperformediftechnicallyfeasible.Rarely,atranssciaticor
transglutealapproachmaybenecessary.
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Forverylowpelvicabscessesthatareincontinuitywiththeanastomoticleakandwhichmaybe
anatomicallyinaccessiblebyimageguidedtechniques,weperformanexaminationunderanaesthesiawith
transrectalortransanastomoticdrainage.Thisapproachisfacilitatedbymakingawideopeninginthe
anastomosisand/orinsertingamushroomtippedcatheterintotheabscesscavity.
OutcomesAnastomoticdehiscenceandleaksareassociatedwithanincreasedriskofmortalitycomparedwith
patientswithoutaleak(15.8versus2.5percent)[3],aswellasaprolongedhospitalstay,anincreasedrateof
mortality,andanincreaseincancerrecurrencerates[27,37,51].Aretrospectivereviewof1417patientswithan
intraperitonealanastomosisfoundasignificantlylongerlengthofhospitalstayforpatientswithaleakcomparedwith
thosewithoutaleak(28versus10days)aswellasasignificantlyhigherinhospitalmortalityrate(32versus4
percent)[27].
LocalrecurrenceAnanastomoticleakisassociatedwithanincreasedriskforlocalrecurrenceforrectaland
coloncancer.Thefollowingobservationsillustratetherangeoffindings:
Ametaanalysisof11prospectiveandretrospectivestudiesthatincluded9,896patientswithrectalcancerfound
asignificantlyincreasedriskoflocalrecurrencewithananastomoticleakcomparedwithpatientswithnoleak
(OR1.6095%CI1.331.92)[52].
Aprospectivestudyof1,722patientsundergoingcolorectalcancerresectionfoundasignificantlyhigherfiveyear
mortalityrateinpatientswithaleakcomparedwiththosewithoutaleak(56versus36percent)[51].
Inaprospectivestudyof306patientswithresectablecoloncancer,patientswithananastomoticleakhad,at48
monthsfollowup,significantlyhigherratesofbothtumorrecurrence(45versus30percent)andcancerspecific
mortality(53versus31percent)comparedwithpatientswithoutananastomoticleak[37].
Incontrast,ametaanalysisofthreeprospectivestudiesthatincluded1,990patientswithcoloncanceronly,
foundanonsignificantincreasedriskoflocalrecurrencewithananastomoticleakcomparedwithpatientswithno
leak(8.8versus6.6percent,OR2.1695%CI0.885.29)[52].
ChronicpresacralsinusAchronicpresacralsinusisaninfrequentcomplicationofaposteriorleakina
coloanalorilealpouchanalanastomosis.Aretrospectivereviewof100consecutivecasesoftotalmesorectalexcision
withproximaldivertingileostomyidentifiedaparaanastomoticsinusineightpatients[53].Spontaneousclosure
occurredinthreepatients,andlatemalignanttransformationdevelopedintwo.
StricturesTheincidenceofananastomoticstrictureorstenosisafteracolorectalanastomosisrangesfrom0to30
percent[5456].Thiswiderangeisdueatleastinparttoanimprecisedefinitionofstricture.Studieshavedefined
anastomoticstrictureintermsoftheinabilitytopassaproctoscope(12mmdiameter)[57,58]oralargerrigid
sigmoidoscope(19mmdiameter)[56]throughthestenosis.Aclinicallysignificantstricturetypicallypresentswith
signsofapartialorcompletebowelobstruction.Theincidenceofsymptomaticstricturesrangesfrom4to10percent
[31,56,59].
Mostpatientswithananastomoticstricturedonotrequireanintervention.Thisissuewasaddressedinaprospective
studyof179consecutivepatientswithastapledcolorectalanastomosisinwhomabenignstenosisorinabilitytopass
arigidproctosigmoidoscopeoccurredin20percent[56].Onlyeightpatients(4percentofallpatientsand22percentof
thosewithastenosis)presentedwithobstructivesymptomsattributabletothestenosisalleightweretreatedby
endoscopicdilatationalone.
RiskfactorsAnanastomoticstricturemaybetheresultoftissueischemia,inflammation,radiation,anastomotic
leak,orrecurrentdisease[60].Theliteraturesupportingtheroleoftheabovefactorsinthepathophysiologyof
anastomoticstricturesissparse.Bothrandomizedtrialsandprospectiveobservationalstudieshaveidentifiedthe
followingriskfactorsforstrictureformation:
Astapledcolorectalanastomosisbutnotastapledileocolicanastomosisisassociatedwithanincreasedriskof
strictureformationcomparedwithahandsewnanastomosis.Asystematicreviewofsevenrandomizedtrials
with1042patientswithacolorectalanastomosisfoundasignificantlyhigherrateofstrictureformationwith
stapledanastomosis(8versus2percent)[14].Incontrast,ametaanalysisofsixtrialswith955patientswithan
ileocolicanastomosisfoundnodifferenceintherateofstricturebetweenthetwotypesofanastomosis[2].
Inaprospectiveobservationalstudy,theriskofdevelopingastenosisfollowingacolorectalanastomosiswas2.4
timesgreaterinmencomparedwithwomen(25versus14percent)[56].Thismayreflecttheanatomicallynarrow
malepelvisandtheassociatedincreasedtechnicaldifficulty.

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ManagementManagementofananastomoticstricturedependsuponitsetiologyandanatomiclocation.
MalignantstricturesWhentheinitialresectionisperformedformalignancy,itisimperativetoruleoutlocal
recurrence.Theevaluationincludeslaboratorytests(CEA),radiographicimaging(CTscan,MRI,endoscopic
ultrasound,orPETscan),andendoscopicbiopsyofthestricture.
Malignantrecurrenceisreportedtoberareinearlystrictures(uptosixmonths)buttheriskoflocalmalignant
recurrenceincreaseswithtime[54].Intheabsenceofdistantmetastaticdisease,surgicalresectionofamalignant
anastomoticstrictureshouldbeperformed,withrestorationofgastrointestinalcontinuityiftechnicallyfeasible.Inthe
presenceofdistantmetastaticdiseaseorunresectablelocoregionaldisease,proximalfecaldiversionmaybe
warrantedforpalliation.
Aretrospectivereviewof68patientsundergoingacolorectalresectionformalignantdiseasefoundthattumor
recurrencewasresponsibleforseven(10percent)anastomoticstrictures[58].Theinitialmanagementwasendoscopic
dilatationforall68patients,withasuccessrateof59percent(40patients).Forallsevenpatientswithastenosis
secondarytorecurrenttumor,theinitialbiopsywasnegativeformalignancy.Persistenceorrecurrenceofstenosis
followingendoscopicdilatationledtoasubsequentbiopsyandthediagnosisofmalignancy.Fourofthesevenpatients
weretreatedbyasurgicalresection,theotherthreereceivedapalliativecolostomy.
BenignstricturesBenignlowcolorectal,coloanal,andileoanalstricturesareusuallyeffectivelytreatedwith
repeateddilatationusinganexaminingfingerorrubberdilators.Highercolorectal,colocolic,orileocolicstricturesmay
bemanagedendoscopically.Endoscopicballoondilatationissuccessfulin88to100percentofbenigncases
[56,58,61].Endoscopicalternativesemployingtheuseofselfexpandingmetallicstentsorendoscopictransanal
resectionofstricturesareeffectiveintreatingsevereanastomoticstrictures[62].Inrefractorycases,surgicalrevision
mayberequiredand,occasionally,permanentfecaldiversioniswarranted.
OutcomesEndoscopicdilatationismoresuccessfulandcarriesalowercomplicationrateinpatientswhowere
operateduponforbenignratherthanmalignantdisease.
Inaretrospectivereviewof94patients,endoscopicdilatationwassignificantlymoreeffectivewithabenign
stricturecomparedwithamalignantstricture(88versus59percent)[58].Thecomplicationratewassignificantly
higherinpatientswhohadprevioussurgeryforcancer(23versus4percent).Complicationsofendoscopic
dilatationincludedbenignrestenosis(11percent),perforation(5percent),andabscessformation(2percent).
Aretrospectivestudyof27patientswithcolorectalanastomoticstricturesrefractorytoendoscopicmanagement
underwentsurgicalrevisionwitheitheracolorectalorcoloanalanastomosiswithoutamortalityandnoevidence
ofrestenosisinanypatientatamedianfollowupof28months[54]
FistulasTheriskofafistulaoccurringafteracolorectal,coloanal,oranileocolicanastomosisrangesbetween1to
10percent[29,6368].Rectourinary(rectovesical,rectourethral)fistulasfollowingcolorectalsurgeryarerare[69,70].
Dataarelimitedonthefrequencywithwhichrectourinaryfistulasaremalignant.Inthelargestseriesofpatientswith
anacquiredrectourinaryfistula,only3of15fistulaswererelatedtorectalcancer[69].
Fistulascandevelopbetweentheanastomosisandtheskin,vagina,genitourinarysystem,andpresacralspace.
Enterocutaneous(colocutaneous)fistulasthatdevelopbetweenthecolorectalanastomosisandtheskinareusuallya
latemanifestationofanunrecognizedanastomoticleak.(See"Rectovaginalandanovaginalfistulas"and"Overviewof
entericfistulas".)
RiskfactorsRiskfactorsforthedevelopmentofafistulaincludeananastomoticdehiscenceandleak,an
anastomosis5cmfromtheanalverge,preoperativeradiationtherapy,advancedcancer,resectionforcancer,
abscess,doublestapledanastomosis,andinadvertentinclusionofthevaginalwallinastapledanastomosis
[29,64,65,71,72].
Thefollowingfindingshavebeennotedindifferentstudies:
Inaretrospectivereviewofthreecohortstotalling390womenundergoingalowanteriorresectionforrectal
cancer,20(5.1percent)developedasymptomaticanastomoticvaginalfistula(AVF)and32(8.2percent)
developedaconventionalanastomoticleak[29].TheAVFwasdiagnosedclinicallyasanevidentcommunication
betweenthevaginaandtheanastomosis.
ComparedwithwomenwhodidnotdevelopanAVForconventionalanastomoticleak,womenwithanAVF
weresignificantlymorelikelytohaveananastomosis5cmfromtheanalverge(65versus19percent),
havereceivedpreoperativeradiationtherapy(85versus38percent),andhaveUnionforInternational
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CancerControl(UICC)cancerstageIV(30versus8percent).
Comparedwithwomenwhodiddevelopaconventionalanastomoticleak,womenwithanAVFwere
significantlymorelikelytohaveananastomosis5cmfromtheanalverge(4.3versus5.0percent),alower
bodymassindex(22versus25kg/m2),andadiagnosisafterhospitaldischarge(70versus41percent).An
AVFpresentedlaterthanaconventionalleak(25versus11days).
Intraoperativevaginalperforation,salpingooophorectomy,concomitanthysterectomy,andaprevious
hysterectomywerenotassociatedwiththeformationofanAVForaconventionalleak.
AquestionnairesenttomembersoftheAmericanSocietyofColonandRectalSurgeonsregardingtheincidence
andtreatmentofrectovaginalfistulas(RVF)followingalowanteriorresection(LAR)oranabdominalperineal
resection(APR)reportedonresultsofapproximately6300LARand2100APRprocedures[64].Fiftyseven
patientsdevelopedanRVF.ThehypothesizedcausesoftheRVFincludedinadvertentlyincludingthevaginal
wallwithastapledanastomosis,spontaneousdrainageofapelvicabscess,orrecurrenttumor.Fiftyfourfistulas
wereclinicallyevident,53occurredinastapledanastomosis,and48weredirectlyadjacenttotheanastomotic
siteonclinicalexamination.
Inaretrospectivereviewof161patientsundergoingalowanteriorresection(LAR)foraprimaryrectalcancer,16
(10percent)developedarectovaginalfistula(RVF)[65].TheriskofaRVFwasgreatestforpatientstreatedwith
anintersphinctericresection(49percent),averylowLAR(18percent),LAR(7percent),andthosewithadouble
stapledanastomosiscomparedwithasinglestapledanastomosis(15versus5percent).Nopatienttreatedwith
ahighanteriorresectionproceduredevelopedaRVF.
ManagementFistulasarebestmanagedbyaddressingthesitesthatareinvolved.Optionsincludeconservative
management,divertingcolostomy,orendoanalorendovaginaladvancementflapreconstruction[65].Therearenohigh
qualitydataavailablefromprospectivetrials.
RectovaginalandcolovaginalfistulasSpontaneousclosureisunlikelyforpatientswithcolovaginalor
rectovaginalfistulas,andproximalfecaldiversionmaybenecessarytoalleviatesymptoms.Theoptimaltimefor
surgicalexcisionandrepairofthefistulaiscontroversial.Highanastomoticvaginalfistulasmayrequirea
colorectalresectionwhilelowfistulasmaybeamenabletotransvaginalortransanalexcisionandrepair[66].(See
"Rectovaginalandanovaginalfistulas",sectionon'Surgicalprinciples'.)
ColocutaneousfistulasConservativeandsupportivemanagementistheinitialapproachforpatientswitha
colocutaneousfistula,sinceapproximatelyonehalfwillclosespontaneouslyatameanof30days(range10to
180days)[73].Ifthefistulapersistslongerthansixweeksorisahighoutputfistula,itislesslikelytoclose
spontaneously.Definitiveoperativeinterventionshouldbedelayedforapproximatelythreetosixmonthstoallow
forresolutionofsepsisand/ortorestorenutritionalstatus.Themanagementofentericfistulas,includinglocal
controlandnutritionalsupport,isdiscussedelsewhere.(See"Overviewofentericfistulas".)
RectourinaryfistulasDataarelimitedonthemanagementofrectourinaryfistulas.Inaseriesoffivepatients
witharectourinaryfistularelatedtoarectalcancer,surgicalmanagementincludedexcisionandrepairor
reconstructioninthree,apermanentcolostomyandapermanenturinarydiversioninone,andapermanent
colostomywithtemporaryurinarydiversioninone[70].Allpatientsexperiencedreliefofsymptoms.Theoptimal
surgicalmanagementofarectourinaryfistulaforpatientswithlocallycurativediseaseisanexcisionandwith
reconstructiveprocedures.Forpatientswithadvancedorunresectabledisease,apermanentfecaland/orurinary
diversionprocedureisnecessary.
OutcomesMorbidityandmortalitywithfistulasvarieswiththelocationofthefistula.
RectovaginalfistulasOutcomesrelatedtothemanagementofrectovaginalfistulasfollowingcolorectalsurgery
aredifficulttoquantitatebecauseofthesmallnumberofreportedcases.Thefollowingfindingsareillustrative:
Aretrospectivereviewincluded16patientswithrectovaginalfistulasfollowinglowanteriorresectionforrectal
cancer[65].Spontaneousclosureofthefistulaoccurredinsixpatients,reconstructivesurgerybyvarious
methodsresultedincompletehealingineightpatients,anddeathduetometastaticdiseaseoccurredintwo
patients.
Inaseriesofninepatientswithrectovaginalfistulasfollowingcolorectalsurgery,fourrequiredpermanentfecal
diversiontomanagetheirfistula[66].
ColocutaneousfistulasColocutaneousfistulasaregenerallylowoutputfistulasandhaveanalmost50percent
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chanceofspontaneouslyclosing.Incontrast,highoutputfistulasareassociatedwithmortalityratesbetween5
to20percent[73,74]andfistulasthatdonotspontaneouslycloseareassociatedwithahighmorbidityrate[74].
Aretrospectivereviewof61patientsreferredtoaspecializedcenterreportedthecomplicationandmortalityrates
followingsurgicalrepairofanenterocutaneousfistulawithanopenabdominalwound[74].Initialmanagement
includedtreatmentofsepsisandrestorationofnutritionalstatus,whichwasthenfollowedbyanoperative
resectionofthefistulaandclosureoftheabdominalwound.Therewerethreepostoperativedeaths,seven
recurrentfistulas,and52patientswithpostoperativerespiratoryandsurgicalsiteinfections.Recurrentfistulas
occurredonlyinthepatientswithreconstructionoftheabdominalwallwithprostheticmeshcomparedwithsuture
closure(7of29versus0of34patients).
RectourinaryfistulasTherearefewreportedcasesofarectourinaryfistula[70]andnohighqualitydatafrom
prospectivetrialsorlargeretrospectivereviewsreportingoutcomesfollowingacolorectalresection.
SUMMARYANDRECOMMENDATIONSThesafetyofcolorectalsurgery,asperformedinpatientswithcolorectal
cancerandinflammatoryboweldisease,hasimproveddramaticallyovertheyearsduetoimprovementsin
preoperativepreparation,antibioticprophylaxis,surgicaltechnique,andpostoperativemanagement.Anastomotic
complicationsfollowingcolorectalsurgeryincludebleeding,dehiscenceandleakage,strictures,andfistulas.
Formanagementofmajoranastomoticbleeding,theinitialmanagementshouldbeconservativewithsupportive
care,includingbloodtransfusionsandcorrectionofanyunderlyingcoagulopathy.Endoscopicand/orsurgical
interventionshouldbereservedforunstablepatientsorthosewithpersistentbleeding,despiteconservative
measures.(See'Majorbleeding'above.)
Themanagementofanextraperitonealdehiscenceincludespercutaneousdrainageforalowpelvicabscessthat
isincontinuitywithanastomoticleak.Forpatientswithalowpelvicabscessincontinuitywiththeanastomotic
leakthatarenotamenabletopercutaneousdrainage,anexaminationunderanaesthesiawithtransrectalortrans
anastomoticdrainageshouldbeperformed.Considerationofproximalfecaldiversioniswarrantedinsymptomatic
patients.(See'Extraperitonealanastomoticleak'above.)
Optionsformanagementofanintraperitonealdehiscenceincludeconservativemanagementwithbroadspectrum
antibioticsandbowelrest,imageguidedpercutaneousdrainageofabscesses,temporaryfecaldiversionand/or
drainage,orresectionoftheanastomosis.Earlyoperativeinterventioniswarrantedforpatientswithgeneralized
peritonitisandsepsisorpatientswithafreeintraperitonealleakonradiographicimaging.(See'Intraperitoneal
anastomoticleak'above.)
Theinitialmanagementforanastomoticstricturesincludesfingerdilatationforlowanastomosesandendoscopic
balloondilatationforhigheranastomosis.Itisimperativetoruleoutlocalrecurrenceiftheinitialresectionwas
performedformalignancy.Inrefractorycases,surgicalrevisionmayberequiredand,occasionally,permanent
fecaldiversioniswarranted.(See'Strictures'above.)
Colocutaneousfistulascanbemanagedconservativelyasmostwillclosewithoutoperativeintervention.(See
'Fistulas'above.)
Anastomoticvaginalfistulasshouldbemanagedinitiallybyproximalfecaldiversion.Definitivesurgicalrepair
shouldfollow.(See'Fistulas'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic15687Version16.0

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RobinBoushey,MDNothingtodisclose.LaraJWilliams,MD,MSc,FRCSCNothingtodisclose.MartinWeiser,
MDNothingtodisclose.WenliangChen,MD,PhDNothingtodisclose.
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