Management of Anastomotic Leak

Anuradha R. Bhama, MD, FACS, FASCRS

Anastomotic leak is one of the most, if not the most, worrisome complications in colorectal surgery. The goal of this issue of Clinics in Colon and Rectal Surgery is to provide a comprehensive examination of anastomotic leak. Serving as a timeless guide for maximizing anastomotic outcomes. Each author has thoughtfully compiled an in-depth review of multiple topics related to anastomotic leak an in effort to educate and inform the reader on optimal anastomotic creation and leak management. This edition takes the reader through the journey of anastomotic leak, starting from definitions and risk factors, exploring intraoperative techniques and advancements, treatment of acute and chronic leaks, and finally exploring unique clinical situations such as rectal cancer and J pouch leaks. Unfortunately, despite every best technical effort, excellent training, and perfect planning, all surgeons who perform anastomoses will experience anastomotic leaks at some point in their careers.

One of the main difficulties in discussing anastomotic leak is the lack of a universally accepted definition of this complication. This edition starts with an eloquent discussion of the epidemiology, definition, and implications of anastomotic leak by Drs. Ellis and Maykel. After this fundamental clarification is understood, Dr. Favuzza has identified the risk factors known to contribute to anastomotic leak and continued to then discuss the appropriate utilization of proximal diversion and drains. Drs. Man and Hrabe have done an exceptional job illustrating anastomotic construction. They have meticulously detailed the tried-and-true techniques to create sound anastomoses, one of the most important discussions in this edition. Drs. Uppal and Piggazi have discussed the newer technologies to aid in the creation of an anastomosis. These innovations can be used in conjunction with the tried-and-true traditional techniques to help prevent leak.

Anastomotic troubleshooting, including utilization of the air leak test, correction of stapler misfires, evaluation of incomplete anastomotic doughnuts, and management of bleeding from the staple line is articulately discussed by Drs. Sell and Francone. When these preventive and proactive measures fail, anastomotic leak does occur. The management of acute and chronic anastomotic leaks is addressed in detail. Drs. Kane and Hedrick provide a review of the management of anastomotic leak in the acute setting, while Dr. Maykel and I have described management of a chronic anastomotic leaks presenting well after their index operation.

There are certain exceptional clinical scenarios in which anastomotic leak treatment must consider the underlying disease process. Drs. Jeganathan and Koltun have provided an in-depth review of this complication in the setting of Crohn's disease. Dr. Guyton, Dr. Kearny, and Dr. Holubar have addressed the particular challenges associated with management of anastomotic leak in the setting of an ileal-pouch-anal anastomosis. Drs. Cauley and Kalady have detailed specific anastomotic leak treatments in the setting of rectal cancer, with a particular focus on optimizing oncologic and functional outcomes. Drs. Keller, van Helsdingen, Talboom, and Hompes have provided a brief overview of some specific techniques in the management of anastomotic leak in rectal cancer patients. Finally, the influence of the patient's microbiome on anastomotic leak remains under investigation. The microbiome's effect may counteract all attempts at prevention of anastomotic leak. This theory has been articulated expertly by Drs. Williamson and Alverdy.

It was an honor to bring together this illustrious panel of experts to write what I hope will be an everlasting guide for surgeons in their quest to prevent the daunting complication of anastomotic leak. I would like to personally thank all the authors for their contributions to this edition of the journal. Their expertise and sage advice help shed light on the complexities and intricacies of anastomotic leak.

First and foremost, I would like to thank my late father, Dr. Rajendra K. Bhama – whose vision for me was always greater than my own. I would also like to thank my mentors, Drs. Muneera Kapadia, James Mezhir (dec.), and John Stewart IV, who helped propel me to the field of colorectal surgery and remain an ongoing source of support. Finally, I especially want to thank Dr. Scott Steele, not only for his vision and leadership, but for his enduring mentorship, encouragement, and support to me in my career as an academic surgeon.

Publication History

Article published online:
23 November 2021