https://doi.org/10.53453/ms.2024.11.3
Non-surgical treatment of anastomotic leakage after rectal
resection: a case report
Silvija Radzevičiūtė
1
, Paulius Lizdenis
2
, Dalius Petrauskas
3
, Algimantas Tamelis
2
1
Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
2
Department of Surgery, Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences,
Kaunas, Lithuania
3
Department of Gastroenterology, Faculty of Medicine, Medical Academy, Lithuanian University of Health
Sciences, Kaunas, Lithuania
Abstract
Background. Colorectal anastomosis leakage remains a significant concern after colorectal surgery. Non-surgical
dealing with anastomotic leak involves making complex decisions based on patient stability and radiographic
findings.
Case presentation. A 59-year-old male patient diagnosed with stage I rectal cancer, which prompted rectal
resection with the formation of a transverso-rectal anastomosis. On 4
th
postoperative day transanal hemorrhage
and wound infection indicated the possible leakage of anastomosis, but no clear leakage was identified
radiologically. The patient responded positively to antibiotic therapy, experiencing an improvement in his overall
condition and was discharged on 14
th
postoperative day. However, 5 days later, the patient's health deteriorated,
marked by symptoms such as high fever, nausea, and hypotension. Computer tomography revealed a substantial
12x3 cm pelvic abscess close to anastomosis and signs of ileus. Additional endoscopy unveiled a 5 mm width
defect in the colorectal anastomosis. To solve this complication, a 7 Fr pig tail drain was strategically placed, and
the patient was initiated on parenteral feeding to ensure proper nutrition. A follow-up colonoscopy in 1 week
identified a confined cavity, prompting the insertion of two additional pig tail drains. With stable vitals and no
signs of peritoneal involvement, the patient was eventually discharged. In following 3 months patient underwent
endoscopic removement of pig tail drains, followed by full recovery.
Conclusions. This comprehensive case report underscores the critical need for physicians to remain vigilant in
recognizing potential risk of colorectal anastomosis. In selected cases endoscopic techniques are suitable to
manage anastomotic leakage.
Keywords: anastomotic leakage, rectal resection, cancer, endoscopic drainage.
Journal of Medical Sciences. 3 Nov, 2024 - Volume 12 | Issue 5. Electronic - ISSN: 2345-0592
Medical Sciences 2024 Vol. 12 (5), p. 32-38, https://doi.org/10.53453/ms.2024.11.3
32
Nechirurginis anastomozės nesandarumo gydymas po tiesiosios
žarnos rezekcijos: atvejo analizė
Silvija Radzevičiūtė
1
, Paulius Lizdenis
2
, Dalius Petrauskas
3
, Algimantas Tamelis
2
1
Lietuvos sveikatos mokslų univesitetas, Medicinos fakultetas, Kaunas, Lietuva
2
Lietuvos sveikatos mokslų univesiteto ligoninė Kauno klinikos, Chirurgijos klinika, Kaunas, Lietuva
3
Lietuvos sveikatos mokslų universiteto ligoninė Kauno klinikos, Gastroenterologijos klinika, Kaunas, Lietuva
Santrauka
Įvadas. Kolorektalinės anastomozės nesandarumas kelia didelį susirūpinimą ir iššūkius po storosios žarnos
rezekcinių operacijų. Sprendimas gydyti anastomozės nesandarumą apima daug faktorių, ypatingai atkreipiant
dėmesį į paciento stabilumą ir radiologinių tyrimų duomenis.
Klinikinio atvejo pristatymas. Aprašomas klinikinis atvejis 59 metų vyriškos lyties paciento, kuriam
diagnozuotas I stadijos tiesiosios žarnos vėžys, dėl kurio buvo atlikta tiesiosios žarnos rezekcija ir susiformuota
pirminė anastomozė. 4-ą pooperacinę dieną transanalinis kraujavimas ir žaizdos infekcija leido įtarti galimą
anastomozės nesandarumą, tačiau radiologiškai nesandarumo nenustatyta. Pacientas teigiamai reagavo į gydymą
antibiotikais, bendra būklė pagerėjo ir buvo išrašytas namo 14-ą pooperacinę parą. Tačiau po 5 dienų paciento
sveikata pablogėjo, atsirado aukšta temperatūra, pykinimas ir hipotenzija. Atlikus kompiuterinę tomografiją
diagnozuotas 12x3 cm dubens abscesas, esantis šalia anastomozės su žarnų nepraeinamumo požymiais.
Endoskopijos metu aptiktas 5 mm pločio kolorektalinės anastomozės defektas. Siekiant nechirurgiškai išgydyti
šią komplikaciją, buvo įvestas 7 Fr „pig-tail“ tipo drenas, o pacientui paskirtas parenterinis maitinimas. Sekančios
kolonoskopijos metu po 1 savaitės į uždarą ertmę buvo įvesti du papildomi tokie drenai. Esant stabiliems
gyvybiniams rodikliams, praėjus dinaminio žarnų nepraeinamumo simptomams, pacientas galiausiai buvo
išrašytas namo. Po 3 mėnesių pacientui buvo atliktas endoskopinis įvestų drenų pašalinimas, po ko jis visiškai
pasveiko.
Išvados. Būtinas maksimalus budrumas atpažįstant galimą kolorektalinės anastomozės nesandarumą ankstyvuoju
pooperaciniu laikotarpiu. Selektyviais atvejais kolorektinės anastomozės nesandarumui gydyti tinka
endoskopiniai metodai.
Raktažodžiai: anastomozės nesandarumas, žarnos rezekcija, vėžys, endoskopinis drenavimas.
Journal of Medical Sciences. 3 Nov, 2024 - Volume 12 | Issue 5. Electronic - ISSN: 2345-0592
33
1. Introduction
Surgical resection of the rectum is a prevailing
therapeutic intervention for rectal cancer, with
colorectal anastomosis often employed to eliminate
the need for a stoma. Despite successful outcomes,
the leakage of the colorectal anastomosis remains a
significant concern due to its potential to increase
postoperative morbidity and mortality rates. Dealing
with anastomotic leak involves making complex
decisions based on patient stability and radiographic
findings. Swift identification of the leak and
intervention are crucial in all cases to reduce the
postoperative morbidity and prevent fatalities.
Surgical management depends on the degree of
intraabdominal contamination and inflammation
which includes pelvic drainage with proximal
diversion, anastomotic resection with end-stoma
creation, or re-anastomosis with proximal diversion.
Latest therapies, including colorectal stenting,
vacuum-assisted rectal drainage, and endoscopic
clipping, have also been described.
We report a surgically treated rectal cancer patient,
who faced leakage of colorectal anastomosis after
the elective surgery. In this case, the identified
anastomotic defect was treated endoscopically by
introducing three endoscopic “pig-tail” drains and
supplementing the patient via parenteral nutrition.
2. Case Report
The subject of this report is a 59-year-old male
patient diagnosed with stage I rectal cancer, which
prompted rectal resection with full splenic flexure
mobilisation and the formation of a transverso-rectal
anastomosis 5 cm from dentate line. On 4
th
postoperative day transanal hemorrhage and wound
infection indicated the possible leakage of
anastomosis, necessitated a relaparotomy involving
revision, but no clear leakage was identified.
Relaparotomy was finished by pelvic lavage and
drainage. The patient responded positively to
antibiotic therapy, experiencing an improvement in
his overall condition and was discharged on 14
th
postoperative day. However, 5 days later, the
patient's health deteriorated, marked by symptoms
such as high fever, nausea, and hypotension.
Diagnostic imaging, specifically computer
tomography, revealed a substantial 12x3 cm pelvic
abscess close to anastomosis and signs of ileus.
Additional endoscopy unveiled a 5 mm width defect
in the colorectal anastomosis (Fig. 1). Contrast
rentgenoscopy through catheter inserted into the
defect revealed 5x6 cm size abscess cavity close to
anastomosis (Fig. 2). To solve this complication, a 7
Fr pig tail drain was strategically placed, and the
patient was initiated on parenteral feeding to ensure
proper nutrition (Fig. 3). Even though the patient's
symptoms subsided, a follow-up colonoscopy in 1
week identified a confined cavity, prompting the
insertion of two additional pig tail drains (Fig. 4).
With stable vitals and no signs of peritoneal
involvement, the patient underwent rehabilitation
and was eventually discharged, with a structured
follow-up plan in place. In following 3 months
patient underwent endoscopic removement of pig
tail drains, followed by full recovery.
Fig. 1. Endoscopy unveiled a 5 mm width defect in
the colorectal anastomosis.
Journal of Medical Sciences. 3 Nov, 2024 - Volume 12 | Issue 5. Electronic - ISSN: 2345-0592
34
Fig. 2. Contrast rentgenoscopy through catheter
inserted into the defect revealed 5x6 cm size abscess
cavity close to anastomosis.
Fig. 3. 7 Fr pig tail drain was strategically placed
through the defect into the cavity.
Fig.
4. Follow-up colonoscopy in 1 week identified a
confined cavity, prompting the insertion of two
additional pig tail drains.
3. Discussion
Despite tremendous developments in surgical
procedures, diagnostics, and postoperative
monitoring, anastomotic leak (AL) remains a major
concern that has a significant impact on
postoperative morbidity and death rates, as well as
the overall cost of therapy. According to several
research, the general prevalence ranges from 1 % to
39 %, while clinically severe AL occurs in 3-6 % of
patients [1]. For a decade, various studies attempted
to define the risk factors, early diagnosis, and
treatment.
Even though many risk factors have been
established, multicentric prospective research on
anastomotic leak following colon resection are
lacking [2]. Male gender, comorbidities, distance of
tumor from anal verge, blood transfusions, ASA
score, obesity, malnutrition, preoperative chemo-
radiotheraphy are well known independent risk
factors for AL [3]. In several studies individual
surgeon was identified as a significant risk factor for
anastomotic leakage therefore strategies should be
made to limit performance variability among
surgeons [4]. Gut microbiota dysbiosis has been
identified as a contributing factor to AL throughout
the last decade, but the precise implications remain
unknown [5]. More research is needed to determine
the risk factors of anastomotic leakage.
Anastomotic leaking has an impact on the surgery's
success, increases hospitalisation time and
expenditures, and affects short- and long-term
outcomes. AL encompasses a wide spectrum of
clinical manifestations, from a radiological finding
to peritonitis and sepsis with multiorgan failure [6].
Clinical signs include fever, discomfort, purulent
discharge, indications of peritonitis, and
cardiovascular symptoms [7]. Anastomotic leaks
often develop after 5 to 8 days of surgery but may
occur as late as the 13th postoperative day [8]. After
being released from the hospital, several patients
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35
(42 %) received AL diagnosis, while 12 % received
one after the 30-day mark following surgery [7].
Anastomotic leakage has no early distinct clinical
symptoms, and any alterations in the patient’s
hemodynamic should be looked at accurately.
An abdominal-pelvic computed tomography scan is
still the gold standard for diagnosing anastomotic
leakage, however C-reactive protein and
procalcitonin have been found to be early predictors
beginning from postoperative day 2-3 [6].
According to the researchers, acute pain on the first
postoperative day should bring attention when it
comes to the possible development of AL.
Abdominal CT scan diagnosis accuracy is
significantly impacted by a number of important
parameters, including the time of postoperative
imaging, the quality of the CT image, and the
radiologists' experience. However, the use of a
water-soluble contrast enema can greatly enhance
the diagnostic value of this evaluation. With the use
of such techniques, postoperative ALs may be
detected with 100 % sensitivity, marking the
occurrence of this serious complication. Rectal
contrast has a far higher chance of reaching the
anastomotic location as compared to oral contrast
[7]. In addition to being able to identify AL, CT can
be utilised therapeutically to empty an abscess
percutaneously [9]. Early detection of AL is crucial
and postoperative care should include C-reactive
protein tests and CT imaging despite clinical
symptoms.
The optimum way to handle anastomotic leakage
following colonic surgery is still up for debate;
approaches vary depending on the clinical state of
the patient, the viability of the intestine, the
preference, experience, and expertise of the surgeon
[10]. Patients with indications of peritonitis or septic
shock is treated with emergent surgery. Those with
an abscess on CT would be drained if it was possible.
Additionally, antibiotics alone were given to other
patients who had moderate symptoms or a simple
pelvic collection [11]. To effectively control an
abscess larger than 3 cm, drainage, medications, and
bowel rest are necessary. Percutaneous drainage
under computed tomography or ultrasound guidance
is a viable alternative, with success rates of up to
86 %. It is critical to completely drain the abscess
cavity, as partial drainage is associated with a high
failure rate [12]. Traditionally, the preferred therapy
for a damaged colorectal or coloanal anastomosis
was anastomosis excision with proximal limb
exteriorization as an end colostomy (Hartmann's
surgery). This removes the cause of sepsis, but in
most cases, the patient is left with a permanent
stoma, with less than half of patients ever having it
reversed. Hartmann's method may be required in the
patient with generalised ischemia or necrosis or
extensive dehiscence of the anastomosis during
reoperation. However, the tendency continues to
avoid resecting the extraperitoneal anastomosis
[13]. To reduce the incidence of AL following
anterior resection of rectal cancer, clinical practice
has been using diverting loop ileostomy more
frequently in recent years. A diverting stoma can
lessen or even prevent fatal abdominal and pelvic
infections, abscesses, and septic shock caused by
anastomotic leaking, as well as the need for
additional surgery. The effectiveness of diverting
ileostomy in lowering anastomotic leakage rates and
its use as a standard surgical procedure for rectal
cancer treatment are still up for debate and are not
recommended as a routine modality [14].
Endoluminal vacuum-assisted therapy (EVT) was
recently established as a treatment for colorectal
anastomotic leaks. EVT encounters a high rate of
complete recovery of anastomotic leakage and
stoma reversal. EVT is a potentially effective,
minimally invasive treatment. There could be a
considerable decrease in the requirement for
subsequent surgery with a mean success rate of 85%
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36
[15]. The main factor influencing the medical care
of AL is the patient's clinical stability. To conclude,
non-surgical treatment remains the best course of
action for clinically stable patients, in the other hand
for clinically unstable patients with pelvic sepsis,
Hartmann’s procedure still remains widely used in
clinical practice.
Preoperative management of inflammatory
variables and nutritional state must be coordinated
to prevent anastomotic leaks following surgery [16].
Finding all these risk variables that influence the
occurrence of postoperative ALs has been the
attention of various researches. Indeed, improving
one's knowledge and comprehension of particular
preoperative, intraoperative, and perioperative
aspects may aid surgeons to come to better
intraoperative decisions. Numerous biomarkers and
prediction models for ALs have produced
encouraging findings so far. To learn more about
creating precise models or biomarkers for
anticipating this serious consequence, more research
is still needed [7].
4. Conclusions
This comprehensive case report underscores the
critical need for physicians to remain vigilant in
recognizing potential risk of colorectal anastomosis.
Latest endoscopic therapy reported in this case
expands the field of minimally invasive treatment in
selected cases of colorectal anastomosis leakage.
The changing range of available treatments
emphasizes the continuous attempts to enhance the
handling of anastomotic leaks after rectal surgery.
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