1. Anastomotic Leak (lower GI)
T R Wilson
Doncaster Royal Infirmary

2. Incidence 1-2 % of small bowel anastomoses
5% of right colonic anastomoses
10-15% of low rectal anastomoses 

3. Aetiology Patient factors Technical factors Poor nutritional state
Anaemia
Uraemia
Diabetes
Steroids
Old age
Technical factors
Tension
Poor blood supply
Local infection
Hypoxia
Hypotension (number and duration of episodes)
Excess fluid → oedema

4. Presentation May occur at any time in the first 3 weeks
Spectrum of presentation depending on
Site and severity of leak
Patients response to inflammation
Whether the stoma was defunctioned
Insidious: Failure to progress
Mild: Low grade temperature, malaise, tachycardia, vague pain, nausea
Severe: faeculent peritonitis

5. Investigation Bloods: ↑ WCC usually raised
CXR: May show significant free gas
Careful digital rectal examination
CT is often investigation of choice
Contrast enema useful adjunct
Negative examination may not exclude a leak
May show a leak that is of no clinical importance

6. Management - Localised leak
Gut rest (NG tube)
Parentral nutrition if prolonged ileus
Antibiotics
Drainage of significant collection
Per rectal
Use of endosponge
Percutaneous (abdominal vs transgluteal)

7. Management - Generalised leak
Optimise for theatre (antibiotics)
Options
Take down anastomosis and exteriorise ends or close rectum
Defunctioning ileostomy if leak from a low colo-anal anastomosis
If small hole (<1 cm) with good blood supply can consider re-suturing +/- covering stoma
Insert catheter → controlled fistula

8. Defunctioning stoma Loop ileostomy versus loop colostomy
Colostomy preferred prior to pre-adjuvant radiotherapy if no subsequent anastomosis
Otherwise surgeons preference
Factors to consider
Ileostomy easier to fashion and close
Colostomy easier to manage
Ileostomy has higher risks of dehydration
Both stomas have high rates of complications associated with fashioning and reversal

9. Anastomotic Bleed - rectum
Incidence – 0.5 – 1 %
Usually presents in first 24 hours
Most settle with conservative management
Persistent bleed
Suture per rectum
Tightly pack rectum (?adrenaline soaked gauze)
If higher join may need refashioning

10. Question 1
What is the approximate incidence of a colonic (not rectal) anastomotic leak
1 in 10
1 in 20
1 in 50
1 in 100

11. Question 2
Which of the following is not a risk factor for anastomotic leak
Renal failure
Extensive adhesiolysis prior to anastomosis
The anastomosis subjectively rated as unsatisfactory by the operating surgeon
Continuation of IV fluids until 3rd postoperative day

12. Question 3
Which of the following is least suggestive of anastomotic leak after laparoscopic right hemi
NG aspirate of >400 mls / 24 hours at day 5
Swinging fever with right pleural effusion on CXR at day 7
Development of sudden onset of sepsis and generalised peritonitis at day 2
Worsening central abdominal pain over 24 hours and marked tenderness in centre of abdomen at day 3

13. Question 4
Which is the least useful test to detect a leak from a coloanal anastomosis after laparoscopic surgery
Digital rectal examination
Contrast enema
CT scan
Laparoscopy

14. Question 5
A 47 year old woman has a coloanal anastomotic leak at day 5 associated with a 3cm fluid/gas collection in pelvis. He has a low grade fever and heart rate of 110, but is otherwise well. He has a defunctioning anastomosis. Which is the least desirable first line management option
Trial of antibiotics
Drainage of collection through anastomosis under anaesthetic
Pelvic washout and suture
Take down of anastomosis and end colostomy

15. Question 6
A defunctioning colostomy is more preferable than a defunctioning ileostomy
Prior to radiotherapy for a mid rectal cancer
To protect a pouch anal anastomosis
Prior to radiotherapy for an anal cancer
To protect a colorectal anastomosis in an unprepared colon

16. Question 7
Which of the following is an advantage of an ileostomy over a colostomy
Easier to close
Easier to manage
Less dehydration
Does not require closure with subsequent protectomy