Anastomotic leakage after ileoanal pouch surgery: risk factors and salvage rate

Background Chronic anastomotic leakage (AL) is the most common cause of pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis for Ulcerative Colitis. This study aims to investigate the factors associated with AL and successful salvage of leaking anastomoses after ileoanal pouch surgery. Methods This multicentre retrospective cohort study included patients ≥18 years old with Ulcerative Colitis or unclassified Inflammatory Bowel Disease who underwent ileoanal pouch surgery between 2016 and 2021 in six European centres, with >12 months follow-up. The primary outcome was AL rate. Secondary outcomes included factors associated with the occurrence of AL, diagnosis, management and salvage of AL and stoma-free survival. Results 411 patients were included, of which 13.6% (n=56) had a diagnosed AL with a significantly higher rate in low-volume centres. Of the 56 AL, 44 were diagnosed early and 12 late. Three-stage approach was associated with late diagnosis and treatment. AL were managed using various techniques. The overall AL salvage rate was 85.4%, 92% when diagnosed and treated early and 60% when diagnosed and treated late (p=0.010). Successful AL salvage was associated with long-term stoma-free status (p=0.002). The long-term stoma-free rate was 95.5% in patients with early diagnosed and treated leaks, but only 41.7% when diagnosed and treated late (p<0.001). Conclusion Early diagnosis and treatment of AL diminishes the negative effect of AL after ileoanal pouch surgery. Pro-active anastomotic assessment is mandatory to enable early diagnosis and management especially in patients at increased risk of silent leaks such as three-staged patients.

Objective and Background:Restorative proctocolectomy with ileal pouch-anal anastomosis is the standard surgical procedure for patients with refractory ulcerative colitis. The aim of this study was to evaluate intermediate-term stoma-free rates after ileoanal pouch surgery and current practice in various European centers.Methods:In this multicenter retrospective cohort study, we included patients ≥18 years with ulcerative colitis or unclassified inflammatory bowel disease undergoing primary ileoanal pouch construction between 2016 and 2021 in 4 high-volume (>10 pouch procedures annually) and 2 low-volume European centers. The primary outcome was an intermediate-term stoma-free rate (absence of ileostomy > 1-year postpouch). Secondary outcomes included perioperative practice, predictive factors for intermediate-term stoma-free status, and anastomotic leakage management.Results:In total, 411 patients were included [43% female, median age 40.0 years (IQR, 29.0–52.0)]. Intermediate-term stoma-free rate was 92.2% (378/410 patients), with a variance of 13.0% between centers (P = 0.045). The majority were modified 2-stage (55.5%) or 3-stage (34.5%) procedures. Close rectal dissection (CRD) was performed in 64.6% and transanal minimally invasive surgery proctectomy in 71.8%. Predictive factors for intermediate-term stoma-free status were CRD [odds ratio (OR) = 3.0; 95% confidence interval (CI) = 1.4–6.4; P = 0.01], and high-volume center (OR = 3.7; 95% CI = 1.1–12.5; P = 0.03). In the 56 (13.6%) patients with anastomotic leakage, early diagnosis, and treatment (≤21 days postpouch) were associated with intermediate-term stoma-free status (95.5% vs 41.7%; P < 0.001).Conclusions:This study showed that >90% of ileoanal pouch patients are stoma-free more than 1 year after surgery with substantial variance between centers. Centralization of pouch procedures, implementation of CRD proctectomy, and early diagnosis and treatment of anastomotic leakages could further improve results.

Ileoanal pouch salvage rates with endoluminal vacuum therapy for early vs late anastomotic leaks

The purpose was to examine the clinical characteristics and predisposing factors of late anastomotic leakage following low anterior resection for rectal cancer. We retrospectively evaluated the clinicopathological features of patients who experienced anastomotic leakage after low anterior resection for rectal cancer. Patients were divided into two groups according to the time to leakage: early leakage (within 30 days postoperatively) and late leakage (after 30 days postoperatively). Clinicopathological characteristics were compared between the two groups. Anastomotic leakage occurred in 141 patients. Anastomotic leakage was diagnosed at a median of 17 (range 0-886) days postoperatively; 85 (60.3%) and 56 (39.7%) were categorized as the early and late leakage groups, respectively. Radiotherapy (hazard ratio 5.007; 95% CI 2.208-11.354; P < 0.0001) was the only significant independent predisposing factor for late leakage. Diverting stoma did not protect against late leakage. The late leakage group more frequently had the fistula type (46.4% vs. 10.6%; P < 0.001) and less frequently needed laparotomy (55.4% vs. 78.8%; P = 0.001). The rate of long-term stoma over 1 year was greater in the late leakage than the early leakage group (51.8% vs. 29.4%; P = 0.009). Late anastomotic leakages that develop after 30 days following low anterior resection are not uncommon and may be associated with the use of radiotherapy. Late leakage should be a different entity from early leakage in terms of the type of leakage, methods of management and subsequent sequelae.

Anastomotic leakage remains a major complication after surgery for colorectal carcinoma, but its origin is still unknown. Our hypothesis was that early anastomotic leakage is mostly related to technical failure of the anastomosis, and that late anastomotic leakage is mostly related to healing deficiencies. The aim of this study was to assess differences in risk factors for early and late anastomotic leakage. This was a retrospective cohort study. The Dutch ColoRectal Audit is a nationwide project that collects information on all Dutch patients undergoing surgery for colorectal cancer. All patients undergoing surgical resection for colorectal cancer in the Netherlands between 2011 and 2015 were included. Late anastomotic leakage was defined as anastomotic leakage leading to reintervention later than 6 days postoperatively. In total, 36,929 patients were included; early anastomotic leakage occurred in 863 (2.3%) patients, and late anastomotic leakage occurred in 674 (1.8%) patients. From a multivariable multinomial logistic regression model, independent predictors of early anastomotic leakage relative to no anastomotic leakage and late anastomotic leakage relative to no anastomotic leakage included male sex (OR, 1.8; p < 0.001 and OR, 1.2; p = 0.013) and rectal cancer (OR, 2.1; p < 0.001 and OR, 1.6; p = 0.046). Additional independent predictors of early anastomotic leakage relative to no anastomotic leakage included BMI (OR, 1.1; p = 0.001), laparoscopy (OR, 1.2; p = 0.019), emergency surgery (OR, 1.8; p < 0.001), and no diverting ileostomy (OR, 0.3; p < 0.001). Independent predictors of late anastomotic leakage relative to no anastomotic leakage were Charlson Comorbidity Index of ≥II (OR, 1.3; p = 0.003), ASA score III to V (OR, 1.2; p = 0.030), preoperative tumor complications (OR, 1.1; p = 0.048), extensive additional resection because of tumor growth (OR, 1.7; p = 0.003), and preoperative radiation (OR, 2.0; p = 0.010). This was an observational cohort study. Most risk factors for early anastomotic leakage were surgery-related factors, representing surgical difficulty, which might lead to technical failure of the anastomosis. Most risk factors for late anastomotic leakage were patient-related factors, representing the frailty of patients and tissues, which might imply healing deficiencies. See Video Abstract at http://links.lww.com/DCR/A730.

The aim of the study was to compare patients with symptomatic anastomotic leakage following low anterior resection of the rectum (LAR) for cancer diagnosed during the initial hospital stay with those in whom leakage was diagnosed after hospital discharge. Forty-five patients undergoing LAR (n = 234) entered into a randomized multicentre trial (NCT 00636948), who developed symptomatic anastomotic leakage, were identified. A comparison was made between patients diagnosed during the initial hospital stay on median postoperative day 8 (early leakage, EL; n = 27) and patients diagnosed after hospital discharge at median postoperative day 22 (late leakage, LL; n = 18). Patient characteristics, operative details, postoperative course and anatomical localization of the leakage were analysed. Leakage from the circular stapler line of an end-to-end anastomosis was more common in EL, while leakage from the stapler line of the efferent limb of the J-pouch or side-to-end anastomosis tended to be more frequent in LL (P = 0.057). Intra-operative blood loss (P = 0.006) and operation time (P = 0.071) were increased in EL compared with LL. On postoperative day 5, EL performed worse than LL with regard to temperature (P = 0.021), oral intake (P = 0.006) and recovery of bowel activity (P = 0.054). Anastomotic leakage was diagnosed most often by a rectal contrast study in EL and by CT scan in LL. The median initial hospital stay was 28 days for EL and 10 days for LL (P < 0.001). The present study has demonstrated that symptomatic anastomotic leakage can present before and after hospital discharge and raises the question of whether early and late leakage after LAR may be different entities.

Background: An anastomotic leak (AL) after a restorative proctocolectomy and an ileal J-pouch increases morbidity and the risk of pouch failure. Thus, a perfusion assessment during J-pouch formation is crucial. While indocyanine green near-infrared fluorescence (ICG-NIRF) has shown potential to reduce ALs, its suitability in a restorative proctocolectomy remains unclear. We aimed to develop a standardized approach for investigating ICG-NIRF and ALs in pouch surgery. Methods: Patients undergoing a restorative proctocolectomy with an ileal J-pouch for ulcerative colitis at an IBD-referral-center were included in a prospective study in which an AL within 30 postoperative days was the primary outcome. Intraoperatively, standardized perfusion visualization with ICG-NIRF was performed and video recorded for postoperative analysis at three time points. Quantitative clinical and technical variables (secondary outcome) were correlated with the primary outcome by descriptive analysis and logistic regression. A novel definition and grading of AL of the J-pouch was applied. A postoperative pouchoscopy was routinely performed to screen for AL. Results: Intraoperative ICG-NIRF-visualization and its postoperative visual analysis in 25 patients did not indicate an AL. The anastomotic site after pouch formation appeared completely fluorescent with a strong fluorescence signal (category 2) in all cases of ALs (4 of 25). Anastomotic site was not changed. ICG-NIRF visualization was reproducible and standardized. Logistic regression identified a two-stage approach vs. a three-stage approach (Odds ratio (OR) = 20.00, 95% confidence interval [CI] = 1.37–580.18, p = 0.029) as a risk factor for ALs. Conclusion: We present a standardized, comparable approach of ICG-NIRF visualization in pouch surgery. Our data indicate that the visual interpretation of ICG-NIRF alone may not detect ALs of the pouch in all cases—quantifiable, objective methods of interpretation may be required in the future.

We analyzed literature data and our results of treatment of 37 patients with cancer of the middle and lower rectal ampulla (Т2-4аN0-2М0) who underwent low anterior resection of the rectum with colorectal anastomosis. The purpose of the study was to reveal characteristics of late colorectal anastomotic leakage. The results demonstrated differences in the clinical course of early and late colorectal anastomotic leakage, the site of anastomotic defect, anastomosis characteristics and the need for repeat surgery. There were some pathogenetic aspects distinguishing early and late anastomotic leakage, such as technical problems in early leakage and association with preoperative radiotherapy in late anastomotic leakage. Conclusions: timely diagnostics of microleakage of colorectal anastomosis will allow changing the further tactics of the patient management and avoiding the manifestation of late anastomotic leakage.

&lt;b&gt;Introduction:&lt;/b&gt; The complications of surgical treatment for rectal cancer, particularly anastomotic leaks after anterior resection, are a significant clinical problem. We retrospectively analysed preoperative factors that may affect the occurrence of complications. &lt;br&gt;&lt;b&gt;Meterial and Methods:&lt;/b&gt; A total of 392 rectal cancer patients were included in a retrospective analysis. A total of 257 anterior resections (AR) and 135 abdominoperineal resections (APR) were performed. The risk factors for early postoperative complications were analysed by logistic regression and receiver operating characteristic curves. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; The significant risk factors for severe complications (grade 3B and higher on the Clavien-Dindo scale) in the multivariate analysis were neutrophil to lymphocyte ratio &gt; 5 (P = 0.047) in the AR group, age of the patients (P = 0.031) in the APR group, and coronary artery disease in both groups (P = 0.03, P = 0.011, respectively). There were no risk factors for anastomotic leaks in the AR group before the analysis was divided into early and late leaks. In the univariate analysis, the statistically significant risk factors for early leaks were preoperative neutrophil to lymphocyte ratio &gt; 5 and peripheral blood platelet count, while late leaks were associated with coronary artery disease; however, in the multivariate analysis, these factors were not statistically significant. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The risk factors for severe postoperative complications were neutrophil to lymphocyte ratio &gt; 5, advanced age of the patients and coronary artery disease. The different risk factors for early and late anastomotic leaks after anterior resection may indicate their different aetiologies.

Introduction: Anastomotic leakage (AL) is a feared complication of gastrointestinal surgery and has a high morbidity and mortality. Although several studies have investigated risk factors for AL and its diagnosis, little is known about treatment strategies for AL and the relationship between mortality and the time interval between the diagnosis of the AL and its treatment. The aims of this study were to gain insight into the influence of the time between diagnosis and treatment of AL and to investigate what interventions are used. Methods: Retrospective study of patients surgically treated for AL between January 2008 and December 2012 in our hospital in the Netherlands. Results: In total 2095 abdominal gastrointestinal surgeries were performed, 120 patients were included in our study (5.7%). Non-survivors were significantly older, had a higher CRP level on the day of reoperation, and had to wait longer for surgery after the diagnostic CT scan. A probit model described mortality risk as a function of age and time to corrective surgery. Conclusion: Older age and longer delay between diagnostic CT and surgery for AL were associated with an increased mortality. This emphasizes the fact that urgent corrective surgery is necessary to decrease AL mortality, especially in the older patient. We advise to standardize the treatment of AL; this prevents delay and increases chances of survival.

To review the outcome after restorative proctocolectomy among children and adolescents with ulcerative colitis at a pediatric inflammatory bowel disease center. The records of all patients with ulcerative colitis undergoing colectomy and ileoanal anastomosis at The Hospital for Sick Children, Toronto, Canada, were reviewed. Questionnaires concerning functional results were sent to patients with restored transanal defecation. Seventy three patients (mean age, 13.2 years; range, 2.6-18.8 years) underwent ileoanal anastomosis (19 straight ileoanal anastomosis, 41 J pouch, 13 S pouch) between January 1980 and June 1995 and were observed 5.8+/-3.3 years. The ileoanal anastomosis is nonfunctional in 19 (26%) patients. Excision rates according to type of restorative procedure were J pouch, 7% (3 of 41); S pouch, 32% (4 of 13); and straight ileoanal anastomosis, 32% (6 of 19). Failure was usually attributable to intractable diarrhea among patients with straight ileoanal anastomosis but was caused by anastomotic leak or pelvic-perianal sepsis among patients with pouch procedures. Failure rates did not vary with age at ileoanal anastomosis. Among patients retaining ileoanal continuity, continence problems reported in the questionnaire were frequent and tended to be more extreme among younger patients. Overall, 90% of respondents reported satisfaction with the functional outcome of the restorative operation. The success rate of the ileoanal anastomosis/J-pouch procedure is comparable to that in adult series. The ileoanal anastomosis/J-pouch procedure is the operation of choice for children and adolescents who want ileoanal continuity restored after colectomy for ulcerative colitis.

Late anastomotic leakage is reported to account for half of all anastomotic leakages after low anterior resection of the rectum. An important clinical question is whether late and early anastomotic leakages are different entities. We retrospectively reviewed the medical records of patients who experienced anastomotic leakage after low anterior resection in two Japanese hospitals. The clinical characteristics were extracted and analyzed. During the study period, 179 patients underwent low anterior resection. A pelvic drainage tube was routinely utilized in all cases and was generally removed 4 to 6 days after the operation. Twenty-six patients had anastomotic leakage; the diagnosis was based on fecal contamination of the drainage in 24 cases. The median interval between operation and detection of anastomotic leakage was 3.5 days. Anastomotic leakage was diagnosed within 7 days of the operation in 25 cases and on postoperative day 20 (after hospital discharge) in one case. There was no instance of anastomotic leakage diagnosed more than 30 days after the operation. There was no relationship between clinical variables and days of leakage diagnosis. The rarity of late anastomotic leakage in our study, compared with previous studies, may relate to the relatively extended period of pelvic drainage tube usage in our institutes, which likely shortens the interval before leakage diagnosis. Our results suggest that late anastomotic leakage is a delayed symptom of subtle early anastomotic leakage rather than a separate entity.

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP). Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2weeks postoperatively. This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

Improved diagnosis and treatment of anastomotic leakage after colorectal surgery

The endo-sponge was used in two patients in the treatment of anastomotic leakage following ileo-anal J-pouch reconstruction. Recently, local vacuum sponge treatment has shown to be effective to treat contained anastomotic leakage after low anterior anastomosis in rectal cancer patients. Two patients (male, 18 years; female, 40 years) who underwent restorative proctocolectomy for ulcerative colitis developed localized anastomotic leakage without general peritonitis. This was endoscopically managed by transanal placement of an endo-sponge (B. Braun Medical B.V., Melsungen, Germany) after a diverting ileostomy was performed. The sponge was frequently replaced until resolution of the sinus was achieved in 35 and 56 days. Vacuum endo-sponge treatment can help anastomotic leakage after ileo-anal pouch surgery.