Proceedings of the First International Summit on Intestinal Anastomotic Leak, Chicago, Illinois, October 4–5, 2012

Abstract

Objective: The first international summit on anastomotic leak was held in Chicago in October, 2012 to assess current knowledge in the field and develop novel lines of inquiry. The following report is a summary of the proceedings with commentaries and future prospects for clinical trials and laboratory investigations. Background: Anastomotic leakage remains a devastating problem for the patient, and a continuing challenge to the surgeon operating on high-risk areas of the gastrointestinal tract such as the esophagus and rectum. Despite the traditional wisdom that anastomotic leak is because of technique, evidence to support this is weak-to-non-existent.Outcome data continue to demonstrate that expert high-volume surgeons working in high-volume centers continue to experience anastomotic leaks and that surgeons cannot predict reliably which patients will leak. Methods: A one and one-half day summit was held and a small working group assembled to review current practices, opinions, scientific evidence, and potential paths forward to understand and decrease the incidence of anastomotic leak. Results: Results of a survey of the opinions of the group demonstrated that the majority of participants believe that anastomotic leak is a complicated biologic problem whose pathogenesis remains ill-defined. The group opined that anastomotic leak is underreported clinically, it is not because of technique except when there is gross inattention to it, and that results from animal models are mostly irrelevant to the human condition. Conclusions: A fresh and unbiased examination of the causes and strategies for prevention of anastomotic leak needs to be addressed by a continuous working group of surgeons, basic scientists, and clinical trialists to realize a real and significant reduction in its incidence and morbidity. Such a path forward is discussed.

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

“…One powerful modality contributing to major alterations in composition and virulence of the gastrointestinal microflora is radiation. The susceptibility to RTinduced diarrhea could be linked to differential initial microbial colonization [106] . In a rat model of LAR, Olivas et al [107] demonstra ted that the combination of preoperative RT and intestinal inoculation with Pseudomonas aeruginosa resulted in a higher rate of AL, whereas radiation alone or Pseudomonas aeruginosa alone did not cause AL.…”

Are gut bacteria associated with the development of anastomotic leaks?

“…Substantial experimental and clinical evidence from the past 60 years demonstrates the role of bacteria in the pathogenesis of anastomotic leak (AL) and the prevention of AL with topical antibiotics, eveninthe presence ofischemia [26]. The fact that this knowledge has not found its way into clinical practice might have to do with the fact that most surgeons are convinced that AL is caused by poor surgical technique either leaving gaps, traumatizing intestinal tissue, causing poor blood supply or tension on the suture line [27].…”

Colorectal anastomotic healing: why the biological processes that lead to anastomotic leakage should be revealed prior to conducting intervention studies

“…Besides, many studies focus on the effect of a certain intervention on the AL rate, without studying the biochemical process of anastomotic healing first. An international summit on intestinal AL concluded that research into the pathogenesis of AL could be advanced markedly by performing additional analyses in human anastomotic tissues during and after surgery [ 56 ]. The use of human tissue (or microbiota) will lead to a reduced demand of experimental research, thereby reducing the numbers of animals that are being used nowadays.…”