Beatričė Lukėnaitė1
1Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
Abstract
Review purpose: The aim is to review historical and prospective studies results of anastomotic leaks (AL) after right hemicolectomy (RH) and ileocolic anastomosis.
Methods: Detailed literature review of articles published in 2002-2019 was performed using PubMed, Cochrane database and Google Scholar search system. Keywords used in the search: right colectomy, right hemicolectomy ileocolic anastomosis, leak, dehiscence, abscess, peritonitis.
Results: The historical studies state, that RH is considered a safe operation with low anastomotic leak rates up to 2-4%. Recent studies suggest AL after RH range from 8% to 9%. Studies have shown a higher chance of AL after stapled anastomosis (5,4 – 8,5%) versus hand sewn anastomosis (2,4 – 7,4%). Other risk factors such as Crohn’s disease, side-to-side versus end-to-end anastomosis, single layer versus double layer anastomosis, intraabdominal versus extra-abdominal anastomosis should be considered. Intraoperative testing reduces the rate of postoperative leakage.
Conclusions: AL rate after RH is high, and this surgery is not as safe as it seemed to be. Patient comorbidities and underlying pathologies should be taken into consideration before performing RH. Intraoperative AL identification should be used to reduce the complication rate.
Keywords: Anastomosis leak, right hemicolectomy, ileocolic anastomosis.
Journal of Medical Sciences. May 25, 2020 - Volume 8 | Issue 17. Electronic-ISSN: 2345-0592
42
Medical Sciences 2020 Vol. 8 (17), p. 42-45
Anastomosis leak rate after right hemicolectomy. Literature
review
Beatričė Lukėnaitė
1
1
Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
Abstract
Review purpose: The aim is to review historical and prospective studies results of anastomotic leaks (AL)
after right hemicolectomy (RH) and ileocolic anastomosis.
Methods: Detailed literature review of articles published in 2002-2019 was performed using PubMed,
Cochrane database and Google Scholar search system. Keywords used in the search: right colectomy, right
hemicolectomy ileocolic anastomosis, leak, dehiscence, abscess, peritonitis.
Results: The historical studies state, that RH is considered a safe operation with low anastomotic leak rates
up to 2-4%. Recent studies suggest AL after RH range from 8% to 9%. Studies have shown a higher chance
of AL after stapled anastomosis (5,4 – 8,5%) versus hand sewn anastomosis (2,4 – 7,4%). Other risk factors
such as Crohn’s disease, side-to-side versus end-to-end anastomosis, single layer versus double-layer
anastomosis, intraabdominal versus extra-abdominal anastomosis should be considered. Intraoperative
testing reduces the rate of postoperative leakage.
Conclusions: AL rate after RH is high, and this surgery is not as safe as it seemed to be. Patient
comorbidities and underlying pathologies should be taken into consideration before performing RH.
Intraoperative AL identification should be used to reduce the complication rate.
Keywords: Anastomosis leak, right hemicolectomy, ileocolic anastomosis.
Journal of Medical Sciences. May 25, 2020 - Volume 8 | Issue 17. Electronic-ISSN: 2345-0592
43
1. Introduction
Right hemicolectomy (RH) (including
ileocaecal resection) is the most common colonic
resection. It is performed in both elective and
emergency settings, and for neoplastic and non-
neoplastic conditions. Postoperative anastomotic
leakage (AL) remains one of the most threating
and potentially lethal complications in
gastrointestinal surgery. Nowadays surgeons
realize that right hemicolectomy is not as safe as
it seemed to be. Our aim is to review historical
and prospective studies results of anastomotic
leaks after right hemicolectomy and ileocolic
anastomosis.
2. Historical anastomosis leak
percentage
We have done a thorough literature
research and found some of the oldest
publications associated with anastomotic leaks.
Studies included anastomotic leaks after elective
ant emergency right hemicolectomy that needed
surgical treatment. Studies from 2003 have
shown, that the percentage of AL after RH was
about 3%. Results suggested that resection and
primary anastomosis can be performed with
acceptable morbidity and mortality in a high
proportion of cases of emergency large bowel
obstructions. (1) Other studies from the same
year have shown that the percentage of AL was
2,5%. This specific study included over 750
patients, which underwent laparoscopic colon or
rectal procedures. The results state, that
laparoscopic colon and rectal surgery in the
hands of well-trained surgeons can be performed
safely with short hospital stay, low analgesic
requirements and acceptable complication rates.
(2) The historical studies state, that RH is
considered a safe operation with low anastomotic
leak rates up to 2-4%.
3. Prospective studies leak percentage
On the other hand, new studies suggest
quite a different result. During recent years many
multicentric retrospective and prospective
studies have been done and the results are quite
worrying. The AL after RH range from 8% to
9%. A study from May 2019 states, that
anastomotic leak occurred in 8,9% of minimal
invasive colectomy (laparoscopic and robotic
surgeries) and in 11,1% of open surgeries. (3)
Even though this study concentrated on
minimally invasive (in specific – robotic surgery)
the AL results are significant. Another
prospective study from 2018 included over 1300
patients undergoing stapled, side-to-side
ileocolic anastomoses. The overall anastomotic
leak rate was 8,3%. (4) The newest studies create
doubt that after all RH is not as safe as it might
seem.
4. Anastomosis leakage risk factors
Many factors are known to be
associated with anastomotic leak including
patient comorbidity, underlying pathology and
anastomotic technique. Studies have shown a
higher chance of AL after stapled anastomosis
versus hand sewn anastomosis. A prospective
study from 2017 included 3208 patients whom
underwent colorectal surgery. The overall
anastomotic leak rate was 8,1%, which was
similar following hand sewn (7,4%) and stapled
(8,5%) techniques. The study found that stapled
anastomosis was associated with an increased
AL rate comparing it with hand sewn
anastomosis. (5) Another retrospective cohort
study from 2019, which included 1414 patients,
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44
found out that AL is also higher in stapled (5,4%)
versus hand sewn (2,4%) anastomosis. (6)
Another risk factor for AL is Crohn’s
disease. In 2019 a prospective study was
published which has shown, that AL after RH in
patients with Crohn’s disease is 8,8%. (7) Also,
in other studies we see, that the AL rate is also
higher in reoperated patients with Cohn’s disease
(5% of AL detected in patients with no previous
intestinal resection and 17% detected in patients
with a history of previous intestinal resection).
(8)
There are also other risk factors that
should be considered: side-to-side versus end-to-
end anastomosis, single layer versus double layer
anastomosis, intraabdominal versus
extraabdominal anastomosis.
5. Anastomosis testing
Many intraoperative tests to assess the
gastrointestinal anastomoses exist. Yet, there is
still a lack of standardization which of these tests
should be chosen in a routine clinical practice.
Tests that evaluate the integrity of anastomosis
consists of 1) Air-leak test; 2) Intraluminal saline
test; 3) Methylene blue dye tests; 4)
Intraoperative endoscopy test. Tests that are used
to evaluate the perfusion of the anastomosis: 1)
Doppler ultrasound; 2) Laser Doppler
flowmetry; 3) Scanning laser Doppler
flowmetry; 4) Tissue oxygen tension; 5) Near-
infrared spectroscopy; 6) VLS; 7) Transanal
narrow band imaging (NBI); 8) ICG fluorescence
angiography; 9) Sidestream darkfield imaging
(SDFI); 10) Laser speckle contrast imaging
(LSCI). Despite the lack of well-designed studies
with properly selected control there are sufficient
amount of data showing that intraoperative
testing reduces the rate of postoperative leakage.
In our opinion, these tests should be standardized
and used in everyday practice.
6. Conclusions
ALs remain a huge challenge despite
many surgical and technological advances. As
the studies show, AL rate after RH is high, and
this surgery is not as safe as it seemed to be.
Patient comorbidities and underlying pathologies
should be taken into consideration before
performing RH. Also, improved early
intraoperative AL identification is essential for
the successful management of this threating
complication.
7. Declarations
The author declares no conflict of interest. This
research received no external funding
8. Literature
1. Martino A, La Rocca F, Romagnuolo G, Di
Muria A, Festa P, Napolitano G, et al.
[Primary anastomosis in the neoplastic
colonic obstruction]. Ann Ital Chir. 2002
Dec;73(6):599–602; discussion 602-603.
2. Schlachta CM, Mamazza J, Gregoire R,
Burpee SE, Poulin EC. Could laparoscopic
colon and rectal surgery become the
standard of care? A review and experience
with 750 procedures. Can J Surg J Can Chir.
2003 Dec;46(6):432–40.
3. Wei D, Johnston S, Goldstein L, Nagle D.
Minimally invasive colectomy is associated
with reduced risk of anastomotic leak and
other major perioperative complications and
reduced hospital resource utilization as
compared with open surgery: a retrospective
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45
population-based study of comparative
effectiveness and trends of surgical
approach. Surg Endosc. 2019 May 14;
4. 2015 European Society of Coloproctology
Collaborating Group. The impact of stapling
technique and surgeon specialism on
anastomotic failure after right-sided
colorectal resection: an international
multicentre, prospective audit. Colorectal
Dis Off J Assoc Coloproctology G B Irel.
2018 Nov;20(11):1028–40.
5. 2015 European Society of Coloproctology
collaborating group. The relationship
between method of anastomosis and
anastomotic failure after right
hemicolectomy and ileo-caecal resection: an
international snapshot audit. Colorectal Dis
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6. Nordholm-Carstensen A, Schnack
Rasmussen M, Krarup P-M. Increased Leak
Rates Following Stapled Versus Handsewn
Ileocolic Anastomosis in Patients with
Right-Sided Colon Cancer: A Nationwide
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2019;62(5):542–8.
7. 2015 European Society of Coloproctology
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right hemicolectomy or ileocaecal resection
An international audit by ESCP and S-
ECCO. Colorectal Dis Off J Assoc
Coloproctology G B Irel. 2017 Sep 15;
8. Johnston WF, Stafford C, Francone TD,
Read TE, Marcello PW, Roberts PL, et al.
What Is the Risk of Anastomotic Leak After
Repeat Intestinal Resection in Patients With
Crohn’s Disease? Dis Colon Rectum. 2017
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