International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study

Abstract

Purpose Little is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide. Methods In this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases). Results In total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy. Conclusion This TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.

Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers

“…The endoscopic or conventional trans-anal anastomotic repair were important methods used within the study centers to preserve a leaking anastomosis, which is in consensus with the study of Talboom et al [15]. Altogether, this emphasizes the efforts within the present study centers to salvage a leaking anastomosis and thus to avoid a permanent ostomy, which is in accordance to other studies [15].…”

“…In the present study, 40 centers, members of CHIR-Net and affiliated centers, were anonymously interviewed via an online survey. The response rate was similar to other studies [14,15]. Remarkably, 77% of the answering study centers agreed that a standardized algorithm will help to better manage a leakage but only half of them use the definition and grading of CAL proposed in 2010 by ISREC [10].…”

“…The preference changes in the case of elderly and/or frail patients when more than half of the study centers prefer to perform surgery (grade B vs. C: 31.8 vs. 59.1%). Similar to other studies, poor vascularization was in most of the centers (86.4%), a criterion to manage CAL as grade C in all patients [11,15]. Considering a grade C leakage with good bowel vascularization, all centers would try to salvage the anastomosis and form a protective ostomy in young and fit patients.…”

“…Although the grading has been validated in former studies, its application in the routine clinical work-up remains unclear [8,11,12]. Other studies reported a more patient-tailored algorithm, the decision-making being frequently influenced by the surgeon or hospital experience [13][14][15].…”

SEVTAR—A multicenter randomized controlled trial to investigate the impact of prophylactic endoluminal placed vacuum sponge for prevention of anastomotic leakage after low rectal resections

“…In many hospitals in Germany and other countries, EVT for treating AL is considered the gold standard and the results are satisfying ( 7 , 8 ). However, the treatment is costly and time-consuming.…”