The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis

Abstract

BackgroundIntraoperative testing of colonic anastomoses is routine in assuring anastamotic integrity. We sought to determine the efficacy of the methylene blue enema (MBE) as an intraoperative test for anastomotic leaks.MethodsThis study is a retrospective review of consecutive colonic operations performed from January 2001 to December 2004 in a community hospital setting by a general surgical group that uses the MBE exclusively. All operations featuring a colonic anastomosis and an intraoperative MBE were studied (n = 229). Intraoperative MBE via a rectal tube was used as the diagnostic test. Intraoperative leak (IOL) rate and clinically significant postoperative leak (POL) rate were the outcome measures.ResultsThe IOL rate was 4.5% for proximal anastomoses, 8% for distal anastomoses, and 7% of total anastomoses. The POL rate was 3% of anastomosis. There were no other testing methods employed. There were no POLs in cases where an IOL led to concomitant intraoperative repair. POL rate for proximal anastomosis was 0.8% and for distal 3%, for stapled 1% and hand sewn 5%.ConclusionMBE IOL rate is comparable to published IOL rates for other methods of intraoperative testing. The MBE can be applied to proximal and distal anastomosis. Patients who were found to have an IOL, and underwent immediate repair, did not develop a clinical POL.

Intra-Operative Anastomotic Leak Rates and Testing Methodology in Colorectal Resection Surgery

“…The thirteen reviewed studies included a total of N=3,023 patients (Table 3), [16,17,[19][20][21][22][23][24][25][26][27][28][29]. Study sample size and design was variable.…”

“…Suture repair (74.7%) was the most common method of anastomosis correction used followed by takedown and re-anastomosis (17.3%) and diversion (8.0%). No significant differences in intraoperative leak rates were found were found across anastomosis types (staple: 4.9%, suture: 2.3%, and compression: 0.0%, p=0.066) in the 10 studies that reported leak based on type of anastomosis employed [16,[19][20][21][22][24][25][26][27][28]. Six articles reported on the rate of intraoperative leaks by surgical technique used (laparoscopic v. open) [22,[25][26][27][28][29].…”

“…The study by Chen et al, was excluded from this assessment of post-operative leak rate by study type, as the number of total post-operative leaks were not presented for anastomosis subgroups. Seven articles reported on the rate of post-operative leaks by surgical technique [19,22,[25][26][27][28][29]. In the sample of n=1,589 cases the majority of procedures (55.2%) were performed using laparoscopic techniques.…”

“…Eight studies required the use of intraoperative testing as part of the study protocol. Presence of leak testing across the 13 studies ranged from a rate of 45.2% in Lieto et al, which included a no test control group, to 100% in the eight studies, which required the use of intra-operative leak testing [19,20,22,[26][27][28][29][30]. The rate of intraoperative testing observed in the two studies (Riccardi et al, Leahy et al) where the decision to test was left up to the surgeon was 82.3% (1,243 of 1,023 patients).…”

“…Seven studies required that staple anastomosis be employed [20][21][22][24][25][26][27], while the remaining six studies allowed multiple methods of anastomosis closure. Within these six studies that employed multiple anastomosis methods [16,19,23,[28][29][30], stapled anastomosis was always one of the methods used. Five of these six studies used either staple or suture based anastomosis, while the remaining study (Dauser et Intra-operative anastomotic leak testing was widely used with a total of n=2,598 (85.9%) patients receiving intra-operative testing (Table 4).…”