Rectal Anastomotic Leakage Research Articles

Intraluminal negative pressure wound therapy and rectal anastomotic leak management: regular vac sponge and a nasogastric tube.

Intraluminal negative pressure wound therapy and rectal anastomotic leak management: regular vac sponge and a nasogastric tube.

Risk assessment of rectal anastomotic leakage (RAREAL) after DIXON in non-emergency patients with rectal cancer

BackgroundThe routine establishment of a diverting stoma (DS) remains controversial in every patient undergoing Dixon operation. We aimed to establish a model for the risk assessment of rectal anastomotic leak (RAREAL) after Dixon in non-emergency patients with rectal cancer, using routinely available variables, by which surgeons could individualize their approach to DS.Methods323 patients who underwent Dixon operation for rectal cancer from January 2015 to December 2018 were taken as the model group for retrospective study. Univariable and multivariable logistic regression analysis was used to determine the independent risk factors associated with anastomotic leakage. We constructed the RAREAL model. 150 patients who underwent Dixon operation due to rectal cancer from January 2019 to December 2020 were collected according to the uniform criteria as a validation group to validate the RAREAL model.ResultsIn the model group, multivariable analysis identified the following variables as independent risk factors for AL: HbA1c (odds ratio (OR) = 4.107; P = 0.044), Left colic artery (LCA) non preservation (OR = 4.360; P = 0.026), Tumor distance from the anal margin (TD) (OR = 6.373; P = 0.002). In the model group, the area under the curve (AUC) of the receiver operating characteristic (ROC) for evaluating AL with RAREAL was 0.733, and when RAREAL score = 2.5, its sensitivity, specificity and Youden index were 0.385, 0.973, 0.358, respectively. The AUC was 0.722 in the validation group and its sensitivity and specificity were 0.333 and 0.985, respectively, when RAREAL score = 2.5.ConclusionThe RAREAL score can be used to assess the risk of AL after Dixon operation for rectal cancer, and prophylactic DS should be proactively done when the score is greater than 2.5.

A Novel Fluorescence-Based Leak Test Method for Rectal Anastomoses Using Aerosolized Indocyanine Green.

The intraoperative air leak test is commonly performed during rectal surgery to evaluate anastomotic integrity. However, its drawbacks include occasional difficulties in visualizing the exact point of the leak while maintaining the pelvis under saline, the need for repeat testing to identify the leak point, and a lack of continuous visualization of the leak point. To evaluate the feasibility and clinical applicability of using aerosolized indocyanine green, a fluorescent tracer, for detecting rectal anastomotic leakage. Animal preclinical study. Animal laboratory at Kagawa University. Six healthy adult female beagles were included. An anastomotic leakage model with a single air leak point was created in each dog. Indocyanine green was aerosolized using a nebulizer kit with a stream of carbon dioxide flowing at 1.5 to 2.0 L/min. The aerosol was administered into the rectum transanally, and laparoscopic observations were performed. Air leak points were observed using a near-infrared fluorescence laparoscope, after which the presence of corresponding indocyanine green fluorescence was verified. Aerosolized indocyanine green was visualized laparoscopically at all anastomosis sites but not elsewhere. The median time from the administration of the aerosol to its visualization was 4.5 seconds. Pathological examinations were performed 4 weeks postsurgery in all dogs, and no histological abnormalities related to aerosolized indocyanine green administration were observed at the anastomosis sites. The leak points were surgically created and did not occur naturally. Visualization of air leaks at the sites of rectal anastomosis was laparoscopically achievable by administering aerosolized indocyanine green transanally into the rectum in our canine model. This novel fluorescent leak test could be a valid alternative to established methods.

431P Neoadjuvant treatment with regorafenib and capecitabine combined with radiotherapy in locally advanced rectal cancer: A multicenter phase Ib trial (RECAP) SAKK 41/16

Currently high risk locally advanced rectal cancer (LARC) patients (pts) are treated with intensified neoadjuvant chemotherapy and radiation (TNT). The previous study SAKK 41/08 showed that adding Sorafenib to long course chemoradiation (LcCRT) is highly active. This potential improvement in clinical outcome by adding a multi-TKI as Regorafenib (R) to LcCRT was investigated in the SAKK 41/16 trial. Pts with T3-4 and/or N+ M0 rectal cancer were included. Neoadjuvant LcRCT was given with Capecitabine 825mg/m2d1-d38 and 28 fractions of 1.8Gy (50.4Gy). R was added d1-14 and d22-35. The phase I part was done in a 3+3 dose escalation (DE) scheme for R. The recommended dose (RD) was used for the cohort expansion (CE). The primary endpoints included dose limiting toxicity (DLT) and pathological response (defined as near complete regression [npCR] or complete regression [pCR] according to Dworak) for the CE. 19 pts were required based on a one-sided type I error 20% and a power 80% for assuming a npCR/pCR rate of ≥ 40% for H1 compared to npCR/pCR rate of ≤ 20% for H0.. 25 pts were included. Two DLT occurred with R 120mg, ending in a RD of 80mg daily. 19 pts were treated with the RD, 8 pts (42.1%; one-sided 80% CI (lower bound): 30.7%; 95% CI: 20.3%-66.5%) reached the primary endpoint (5 pts [26.3%] had npCR and 3 pts [15.8%] had pCR). One additional patient received no surgery due to clinical CR. Downstaging of T and/or N was seen in 15 of 18 operated pts (83.3%). All pts had R0 resection and clear circumferential margin. Postoperative complications occurred in 6 pts (35.3%), one anastomotic leak grade G4, 3 pts with local infections. The most common treatment related adverse events ≥ G3 in the CE were diarrhea and rectal anastomotic leak in 2 pts each. Adding Regorafenib in RD 80 mg to LcCRT in LARC reached both primary endpoints and showed high activity. This regimen did not prolong the neoadjuvant treatment time in contrast to TNT. Toxicity was manageable, and postoperative complications were as expected. This regimen deserves further investigation especially in efficacy comparision to TNT regimens.

TU2.2 Endo-Sponge Carries Good Outcome for Low Rectal Anastomotic Leak; Case Series study

Abstract Introduction Rate of anastomotic leak is considered rare, and the low rectal ones are approximately 10% of all leaks. Management of anastomotic leak is variable and could be challenging. ENDO-SPONGE is advised by experts to be considered given some criteria to be met but in general, ENDO-SPONGE is thought to improve patients’ life quality and maintains the possibility of stoma reversal after resolution of the leak. Objective To assess the management of anastomotic leak using ENDO-SPONGE in our hospital and to compare our practice with the international published data. Methods Case study of patients diagnosed with anastomotic leak and treated with ENDO-SPONGE. All cases from 2016 to 2021 were included. Concordance with the NICE briefing and recommendation which was published in 2019 was studied. All data were collected in a Microsoft forms then transcribed into an Excel sheet. Results 13 patients treated with ENDO-SPONGE were identified – median age is 66. Guidelines suggest that ENDO-SPONGE changes should occur within 24–72 hours and the compliance from the trust was only 25%. However the compliance with the number of changes, place of insertion, and the outcome was 100%. 99% of the ENDO-SPONGE replacement took place in the theatre, only one patient's ENDO-SPONGE was replaced in endoscopy department. Complete resolution of the leak occurred in 11 of the 13 patients and only 2 required open drainage. 5/13 were eventually reversed. Conclusions More Compliance with timing of replacement of ENDO_SPONGE should be improved but overall ENDO_SPONGE carried a good outcome with complete resolution in nearly 85% of patients.

Application of Transurethral Prostate Resection Instrumentation for Treating Low Rectal Anastomotic Leakage: A Pilot Study.

PurposeTo determine an accurate method of inspecting low anastomotic leakages and application of transurethral prostate resection instrumentation for treating low rectal anastomotic leakage.Patients and MethodsClinical data of eight patients treated for anastomotic leakage after rectal cancer surgery at Zhangye People’s Hospital (affiliated to Hexi University), from August 2019 to November 2021, were retrospectively analyzed. Transanal prostate resection instrumentation was used to assess the leakage and surrounding conditions. Using prostate resection instrumentation, the presacral and perirectal residual cavities were washed and removed, and indwelling suprapubic presacral, transanal presacral, and rectal drainage tubes were placed. Continuous presacral saline irrigation and drainage and open negative-pressure suction in the rectal cavity were performed until the patients’ fistula healed.ResultsOf the eight patients with anastomotic leakages, one had grade B and seven had grade C International Study Group of Rectal Cancer anastomotic leakage classifications following Dixon operation. Transanal prostate resection instrumentation showed that the leakage of the one patient with grade B was less than a third of the circumference of the anastomosis. Among the seven patients with grade C, one leakage was less than a third of the anastomotic circumference. One patient had complete separation of the anastomosis and one distal colon necrosis, which necessitated immediate descending colostomy. Conservative treatment was successful in six patients; the conservative overall cure rate was 75%, and the median healing time was 43 (21–68) days.ConclusionTransanal examination of rectal anastomotic leakage using prostate resection instrumentation is comprehensive, easy to perform, provides clear visualization, accurately guides catheter placement, and can be combined with continuous open negative-pressure drainage, which is a safe, convenient, and effective method for treating low rectal leakage.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis.

Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.

Diagnosis and treatment of anastomotic leak after low anterior resection for rectal cancer: current status and future prospect

Anastomotic leak is one of inevitable postoperative complications of rectal cancer. With the improvement of surgical techniques, the enhancement of the cognization of rectal cancer, and the development of surgical instruments, surgical procedures of rectal cancer are getting more sophisticated. The anastomosis is performed lower and lower, however the incidence of anastomotic leak is not significantly decreased. In addition, different from intraperitoneal anastomotic leak, the low rectal anastomotic leak after low anterior resection has many special issues in the diagnosis and treatment in clinic. The incidence of peritonitis caused by low anastomotic leak is low, the onset time is late, and symptoms of peritonitis are mild. So most low anastomotic leak is treated conservatively, second surgical repair or resection of anastomotic site is rarely performed, and proximal intestinal diversion is commonly performed. In the prevention of low anastomotic leak, some techniques and precautions during the perioperative period and identification of high risk factors might play important roles. Combined our clinical experiences, we introduced the diagnosis, treatment, prevention and research progression of low anastomotic leak after anterior resection of low rectal cancer, we hope it would be helpful.

Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy?

IntroductionLiterature on rectal anastomosis and diverting ileostomy in patients treated with hyperthermic intraperitoneal chemotherapy (HIPEC) is limited. This study assesses the safety of rectal anastomoses during cytoreductive surgery (CRS) and HIPEC, with and without fecal diversion, and its morbidity when performed. Materials and methodsFrom January 2012 to January 2020, patients with peritoneal metastases who underwent CRS and HIPEC that required a rectal anastomosis were included in this single-hospital retrospective chart review. Results84 patients were included, of which 29 had a diverting loop ileostomy. The rectal anastomotic leak (AL) rate for the series was 8.3%. Factors associated with AL were male gender (p = 0.031) and increased BMI (p < 0.0005). Diverting loop ileostomy was associated with a significant decrease of clinically significant rectal AL (0% vs 12.7%, p = 0.045). However, the 90-day readmission rate was higher in this group (37.9% vs 10.9%, p = 0.003). Stoma reversal surgery was performed for all patients, but 3 patients experienced AL (10.7%). ConclusionsThis study suggests that creation of a diverting loop ileostomy may be an effective strategy to prevent symptomatic rectal AL following CRS with HIPEC. However, it is also associated with an increased readmission rate and increased risk of AL following reversal surgery.

A comment on “The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery” by Arezzo A et al

A comment on “The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery” by Arezzo A et al

A trinity technique for prevention of low rectal anastomotic leakage in the robotic era

BackgroundAnastomotic leakage (AL) is a severe complication of low anterior resection (LAR) for rectal cancer, and effectiveprevention is urgently needed. In the robotic era, this study aimed to explore the role of innovative techniques in preventing AL in rectal cancer patients undergoing robotic LAR. MethodsFrom May 2012 to May 2017, a total of 601 patients underwent robotic LAR, with 191 patients participated as control subjects (non-PST group) and 410 patients are subjected to a trinity technique (PST group). The AL rate, short-term and long-term outcomes are analyzed and compared. ResultsThe overall rate of AL was 6.8% out of 601 patients, with Grade B at 5.7% and Grade C at 1.1%, using the ISREC grading system. The PST group presented lower incidence of both overall AL (5.1% vs 10.5%, P = 0.015) and major AL (0.2% vs 3.2%, P = 0.005), when compared with the non-PST group, respectively. Furthermore, the PST group had similar surgical complications (17.3% vs 20.9%, P = 0.286), while with lower re-hospitalization rate (2.7% vs 6.3%, P = 0.038) and reoperation rate (0.2% vs 4.2%, P = 0.001), compared with the non-PST group, respectively. Short-term recovery and long-term oncological outcomes were not significant in the two groups. By multivariate logistic regression models, the risk factors of AL of robotic LAR are confirmed as non-PST technique, estimated blood loss ≥100 mL, anastomosis from anal verge <5 cm, and distal resection margin from tumor <2 cm. ConclusionsThe innovative PST technique may shed light on an effective method for preventing occurrence of AL in robotic LAR.

Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients. A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors. Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30days and 100days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6-31.5, p = 0.011, and OR = 16.4, 95% CI: 3-88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7-53, p < 0.0001, and OR = 17.2, 95% CI: 3.8-78.6, p < 0.0001). Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.

The use of Endo-SPONGE® in rectal anastomotic leaks: a systematic review.

The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. Endo-SPONGE®seems to bea useful method of rectal anastomotic leak treatment inselected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.

Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors.

In patients with a previous history of rectal anastomotic leakage (AL), the surgical indications and timing for closure of a diverting stoma have to be carefully judged. Even if AL has apparently healed before stoma closure, re-leakage may occur after closure. The aim of this study was to determine the incidence and risk factors for recurrent AL following stoma closure. We also examined the treatment strategies aiming to minimize the risk of recurrent AL. From January 2009 to December 2016, 1008 patients underwent sphincter-saving surgery [low anterior resection, all-sphincter-preserving rectal resection with hand-sewn coloanal anastomosis (CAA) and intersphincteric resection (ISR)] for primary rectal cancer with curative intent at our hospital. A total of 69 patients with AL with a Clavien-Dindo Grade III or more who subsequently underwent closure of a diverting stoma were retrospectively reviewed for this study. The incidence of recurrent leakage after stoma closure in this series was 13% overall with an incidence of 25% in the CAA/ISR group and 5% in the low anterior resection group. Significant risk factors included hand-sewn anastomosis (P=0.0257) compared to stapled anastomosis, ischaemia at the anastomotic site as the cause of initial AL (P<0.001) and a shorter interval between confirmation of healing and stoma closure (P=0.00952). Ischaemia at the anastomotic site was the main risk factor for recurrent leakage, particularly after CAA/ISR. Additional treatment options before stoma closure should be considered to avoid re-leakage in such cases.

Neoadjuvant radio-chemotherapy prolongs healing of anastomotic leakage after rectal resection treated with endoscopic vacuum therapy.

Background:Neoadjuvant radiochemotherapy (nRCT) is an important component in the treatment of advanced rectal cancer. Endoscopic vacuum therapy (EVT) has become the treatment of choice for anastomotic leakage after rectal resection in many institutions in Germany. Published case series report on average success and stoma reversal rates of more than 80%. However, so far, there is no distinct report on the potential influence of nRCT on EVT.Methods:A total of 11 patients treated with EVT for anastomotic leakage after nRCT and rectal resection were retrospectively compared with a cohort of eight patients with rectal anastomotic leakage without neoadjuvant treatment. Primary endpoints were death, treatment success, and long-term preservation of intestinal continuity. Secondary endpoint was the duration of treatment. Statistical analysis was performed using Statistical Package for Social Science (SPSS) version 23.0.Results:There was no difference in mortality (0%), success rate (90.9% versus 100%, p = 0.381), or long-term preservation of continuity (63.6% versus 62.5%, p = 0.960). After nRCT, patients showed a significant longer duration of EVT (31.1 days versus 15.9 days, p = 0.040) which was associated with a significantly higher number of sponge applications (9.6 versus 5.0, p = 0.042).Conclusions:In our analysis, EVT showed success in over 90% of patients with anastomotic leakage after rectal resection for colorectal cancer, regardless of neoadjuvant treatment. However, in case of anastomotic leakage, nRCT seems to be associated with the need for a significant longer duration of EVT.

Dealing with low rectal anastomotic leaks

Dealing with low rectal anastomotic leaks

Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage.

BackgroundEndoluminal vacuum‐assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure.MethodsA systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta‐analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random‐effects meta‐regression model.ResultsOf 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40–105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty‐five patients (9·1 per cent) required additional interventions after EVT. Thirty‐eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex.ConclusionEVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.

89P - Prevention and management of low rectal anastomotic leakage in the robotic era: A propensity score matched study

Background: Anastomotic leakage (AL) is a severe complication of robotic low anterior resection (LAR) for rectal cancer, and effective prevention is urgently needed. In the robotic era, to evaluate the role of innovative techniques that prevented AL in rectal cancer patients undergoing robotic LAR. Methods: From September 2012 to September 2017, a total of 581 patients underwent robotic LAR, with 131 patients participated as control subjects (non-PST group) and 450 patients were subjected to PST techniques. After propensity scores adjusted for potential bias, the AL rate, short-term and long-term outcomes were compared between the two groups. Results: The overall rate of AL was 7.1% out of 581 patients, with Grade B at 6.2% and Grade C at 0.9%, using the ISREC grading system. After matching propensity scores, the PST group presented improvement in both overall AL (5.0% vs 10.7%, P = 0.034) and major AL (0.4% vs 3.1%, P = 0.044) compared with the non-PST group, respectively. Furthermore, the PST group had lower surgical complications (13.6% vs 21.6%, P = 0.014) and reoperation rates (0.8% vs 4.6%, P = 0.019) compared with the non-PST group, respectively. Long-term oncological outcomes were not significant in the two groups. By multivariate regression models, we demonstrated that distance of anastomosis from anal verge <5cm, distance of distal resection margin from tumor <2cm, estimated blood loss ≥100mL and non-PST technique were risk factors of AL in robotic LAR. Conclusions: Avoiding routine diverting stoma, the innovative PST techniques may shed light on an effective method for preventing occurrence of AL in robotic LAR. Legal entity responsible for the study: Zhongshan Hospital, Fudan University. Funding: Supported by The National Natural Science Foundation of China (81602035, 81472228); The Shanghai Municipal Commission of Health and Family Planning: Shanghai Outstanding Youth Specialist Training Program (Q2017-059); Clinical Science and Technology Innovation Project of Shanghai (SHDC12016104). Disclosure: All authors have declared no conflicts of interest.

Different approaches for Endo-SPONGE® insertion to treat rectal anastomotic leaks.

Different approaches for Endo-SPONGE® insertion to treat rectal anastomotic leaks.

Neopterin, kynurenine and tryptophan as new biomarkers for early detection of rectal anastomotic leakage.

IntroductionAt present, there are no strong predictors, nor a useful scoring system, that clearly identifies patients at risk for anastomotic leakage.AimThis study aimed to investigate a new method that assesses this risk by monitoring levels of neopterin, tryptophan, and kynurenine, in bodily fluids.Material and methodsThis prospective study included patients who underwent elective rectal resection for carcinoma. The basic condition for inclusion was rectal anastomosis using the double-stapling technique. Preoperative levels of neopterin, tryptophan, kynurenine, and their ratios, were assessed with blood and urine samples. These levels were then monitored for 6 postoperative days in venous blood, urine, and abdominal drainage fluid.ResultsA total of 42 patients were enrolled in the study. Thirty-six patients underwent a laparoscopic resection and 6 patients had an open procedure. No differences were found among neopterin, tryptophan, and kynurenine serum levels. However, the groups were observed to have significant differences in the urinary neopterin/creatinine ratio: the preoperative neopterin/creatinine ratio was 139.5 μmol/mol in the group with leakage, vs 114.8 μmol/mol in the group without complications, p = 0.037. The same results were observed during the postoperative period, p = 0.012. Additionally, the group with complications had a higher mean value of neopterin in drainage fluid, p = 0.048.ConclusionsOur study demonstrated that high preoperative levels of urinary neopterin could be interpreted as a risk for anastomotic leakage. Moreover, pathological levels of neopterin in urine and abdominal drainage fluid could be useful for early identification of anastomotic leakage during the postoperative period prior to its clinical development.