|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 50-51
Dealing with low rectal anastomotic leaks
Amitabh Yadav, Samiran Nundy
Department of Surgical Gastroenterology and Liver Transplant, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||07-Jul-2020|
|Date of Acceptance||08-Jul-2020|
|Date of Web Publication||11-Aug-2020|
33/13, First Floor, East Patel Nagar, New Delhi - 110 008
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Yadav A, Nundy S. Dealing with low rectal anastomotic leaks. Indian J Colo-Rectal Surg 2019;2:50-1
| Previous Article Information|| |
Sarma DR, Bhattacharya P, Joy H. Endoluminal negative pressure therapy (Endo-SPONGE) for anastomotic leaks following transanal total mesorectal excision: Our experience. Indian J Colo-Rectal Surg 2019;2:12-5.
| Summary|| |
The grading system for anastomotic leaks according to the International Study Group of Rectal Cancer is as follows:
- Grade A results in no change in the patient's management
- Grade B requires active therapeutic intervention but is manageable without re-laparotomy
- Grade C anastomotic requires a re-laparotomy.
Anastomotic leaks after low colorectal anastomoses require interventions, including image-guided placement of percutaneous drains, in only about 7.7% of cases. Their management depends predominantly on personal experience as little literature is available on this subject.
Low rectal anastomoses are prone to leak, but majority of these are localized and heal on their own if there is a diverting ileostomy. Patients with Grade B leaks may be treated and controlled by ileostomy alone. The paper is not clear about the grade of the leaks and collections. For Grade B leaks, various modes of local treatment have been suggested including vacuum-assisted device alone or early transanal suture closure of the leaking anastomosis after EndoVAC therapy.
The principle of treatment, of these localized collections, is to provide continuous drainage by negative suction and thus heal the cavity by obliteration. Continuous drainage of postoperative collections after anastomotic leaks is not achieved by the presence of the anal sphincter, which acts as a physiological barrier. The easiest way to achieve this is by placing a Foley catheter in the rectum across the anastomosis and anal sphincter. The catheter keeps the anal sphincter open and thus provides continuous drainage. The literature supports this maneuver, and, its use has been associated with lower incidence of leaks.
Another important aspect is an antegrade distal colonic wash with normal saline through a catheter placed into the distal limb of the ileostomy, because retained fecal matter in the colon proximal to the anastomosis causes persistent spillage into the leaked area.
After excision of the mesorectum, a potential space is created in the sacral hollow, which is a potential site for a postoperative collection. In the present series, the most common complication after vacuum-assisted device treatment was sacral abscess and anal stenosis. Both these conditions lead to poor reconnection rates and suboptimal reservoir function.
An essential component of the placement of a vacuum drain is the creation of a sealed dressing that creates negative pressure. Unfortunately, such a “sealed” dressing is difficult to achieve in the anal canal.
Another major concern of the treatment is the cost, which is an important consideration in a developing country like India, where the cost of treatment is largely borne by the patients themselves. Anastomotic leaks are reported to increase the cost of treatment by 4.6 times.
Moreover, a change of the vacuum dressing requires general anesthesia on every occasion which adds to the cost and associated risks. The expenditure incurred using this technique is reported to be Rs. 754,000/- (613,500–903,000) per patient.
The average healing time is about 57 days which delays the initiation of adjuvant chemotherapy, an essential component of treatment in these cases. Evidence suggests that the anastomoses healed by the use of VAC and re-suturing in 53% of cases and 34% of cases were not healed even after 12 months postsurgery. Another disadvantage is the low anterior resection syndrome, observed in about 80% of patients which affects their quality of life afterward.
The median duration of follow-up in the current study was short, and therefore, it is difficult to comment upon the long-term incidence of stricture and rate of ileostomy reversal in such a short time. The 5-year overall and disease-free survival rates depend on the initiation of adjuvant chemotherapy, and this has been reported to be an independent risk factor for poor outcomes. The usual time period for starting chemotherapy is 3 weeks after operation. The median time period of stay was 57 days in the current study, which means that chemotherapy was started much later. Would it not have been a better alternative to just place a self-retaining indwelling catheter and leave it in situ?
No pelvic drains were used in this study. Although pelvic drains do not reduce the chances of leaks, they may provide an early indication of the same and postleak clinical course after drain placement is less severe.
In our institution, we manage the majority of leaks of this grade after ultralow anterior resections by keeping the rectal Foley catheter across the anal sphincter. It is kept for 3–5 days routinely and for a longer period in patients with anastomotic leaks, till the discharge and anal discomfort decrease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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