Anastomotic leaks are defined as ‘a leak of luminal contents from a surgical join between two hollow viscera’. They are the most important complication to recognise following gastrointestinal surgery.
Early diagnosis, resuscitation and treatment of an anastomotic leak is key. Delay leads to prolonged contamination of the abdomen or chest by the luminal contents, leading to the development of severe sepsis and progression to multi organ failure and death.
In this article, we shall look at the risk factors, clinical features and management of an anastomotic leak.
There are several factors that increase the risk of an anastomotic leak developing:
- Emergency surgery or longer intra-operative time
- Peritoneal contamination
- Oesophageal-gastric or rectal anastomosis
- Medication (see Table 1)
- Smoking and alcohol excess
- Diabetes or obesity / malnutrition
|Medication||Type||Evidence & Recommendations|
|Corticosteroids||Steroid||Prolonged use may increase AL|
|Infliximab||Anti-TNF∝ monoclonal antibody||Slows wound monoclonal healing but no impact of AL rate|
|Mycophenolate mofetil, cyclosporin A, tacrolimus and everolimus||Immunosuppressant||Mycophenolate AL risk based in clinical observational study.
For other drugs, experimental evidence suggests increased AL risk
|Azathioprine||Purine analogue immunosuppressant||Contradictory evidence|
|Bevacizumab||VEGF inhibitor||Bevacizumab Should be stopped and not restarted for at least 28 days either side of surgery|
Table 1 – Medications that influence the rate of anastomotic leak (AL), adapted from ASGBI guidelines on prevention, diagnosis and management of colorectal anastomotic leakage.
The most common clinical features of an anastomotic leak are abdominal pain and fever. They usually present between five and seven days post-operatively.
On examination, patients will be pyrexial, tachycardic, with signs of peritonism or prolonged ileus. It is important to check for feculent / purulent material or bile in the wound drain (or bile in the chest drain for oesophageal anastomoses)
Note: Any patient with systemic sepsis or is not improving as expected (“failing to progress”) after a GI resection should be considered to have an anastomotic leak until proven otherwise.
The most appropriate initial investigation for a suspected anastomotic leak is a range of blood tests – FBC and CRP (raised WCC and CRP), U&Es, LFTs (low albumin), and a clotting screen.
A venous blood gas (raised lactate) will assess degree of tissue perfusion. A repeat Group and Save will be needed for possible surgery or radiological drainage.
The definitive diagnosis of anastomotic leak is made by a CT scan (Abdomen Pelvis) with contrast.
Once an anastomotic leak has been diagnosed, the key immediate principles in management relate to the treatment of the potential contamination and resultant sepsis.
Ensure the patient is nil by mouth (NBM) and start broad spectrum antibiotic cover (as per local guidelines). Gain IV access and start IV fluids, and insert a urinary catheter to enable monitoring of fluid balance.
Any suspected anastomotic leak requires urgent senior review.
Any minor leaks will require simply observation and bowel rest, with potential for percutaneous drainage if needed.
For a major leak, exploratory laparotomy is required, whereby subsequent surgical intervention may involve stoma formation or diversion / stenting, with an abdominal washout.