Intra‐operative assessment of left‐sided colorectal anastomotic integrity: a systematic review of available techniques

Abstract

Aim Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer‐related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought. Method A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990–2020. Additional papers were detected by scanning references of relevant papers. Results A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air‐leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra‐operatively provides the opportunity for either suture reinforcement or formal takedown with or without re‐do of the anastomosis and consideration of diversion. Suture repair alone of a positive air‐leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future. Conclusion Although over reliance on any assessment tool should be avoided, intra‐operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra‐operatively for mechanical failure, particularly distal anastomoses.

Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left‐sided Colorectal Resections

“…No definitive conclusions can yet be drawn from the current literature regarding the most effective modality of assessing anastomotic integrity [ 4 ]. A recent systematic review evaluating different approaches to colorectal anastomotic assessment could not find any superiority of one method over another, although advising to test anastomoses through basic air-leak tests to exclude mere mechanical failure [ 1 ].…”

“…The current colorectal anastomotic leak rate persists to be relatively high, broadly ranging between 5 and 15% [ 1 ]. The pathogenesis of anastomotic colorectal leaks is by all means multifactorial [ 2 , 3 ].…”

“…The pathogenesis of anastomotic colorectal leaks is by all means multifactorial [ 2 , 3 ]. Although the surgeon may have no power over the modification of tumor and patient-specific variables, surgical technique of anastomotic construction—encompassing lack of tension, adequate vascularity and appropriate application of basic principles of anastomosis creation—is instead directly controllable by the surgeon [ 1 ].…”

The Colorectal Anastomosis: A Timeless Challenge

“…Evidence suggests the latter is superior. 134 Although routine air leak test has not consistently shown reduction in anastomotic leak, [135][136][137] it provides the opportunity for immediate intervention.…”

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

“…Although these intra-operative techniques are well established, there are no standard guidelines as to which should be used. As a result of this, there is considerable variation between surgeons and hospitals [141]. To begin to address this, the European Society of Coloproctology Safe-anastomosis Programme in Colorectal Surgery (EAGLE) has been set up.…”