We performed 2,083 colon resections (CR) and 573 rectal resections (RR) in the from 2008 to 2020. ALs were detected in 123 cases by using clinical examinations as well as laboratory values and imaging techniques like abdominal ultrasound or CT scan. ALs were detected in 92 cases of the CR (4.4%) with a median time of occurrence of 5 days postoperatively (min. 1 day; max. 27 days) whereas 31 cases with AL following RR (6.3%) were detected 6 days postoperatively (min. 1 day; max. 49 days). 72.8% of the AL cases following colon resections were present in male patients (n = 67). The median age of these patients on the day of the operation was 67 years (min. 26 years; max. 89 years). 48.4% of the AL cases following rectal resections were present in male patients (n = 15). The median age of these patients on the day of the operation was 65 years (min. 40 years; max. 87 years).
ALs occurred in 81 patients (65.9%) with the primary diagnosis of a colorectal cancer, whereas the other 42 patients (34.1%) underwent CS due to a benign diagnosis such as diverticulitis, chronic inflammatory bowel disease, or mesenteric ischemia. The primary operations of all cases in this study included:
38 patients underwent a right sided colon resection
54 patients underwent a left sided colon resection
14 patients underwent a high anterior rectal resection
17 patients underwent a low anterior rectal resection
Depending on the difference in the perioperative approach between colon and rectal surgery, the management of a possible AL differs. Therefore, we studied both groups separately. The general results of this study are summarized in Table 1.
Table 1
General results of the study
Colorectal resections with AL
|
Colon resections
|
Rectal resections
|
Gender
|
25 female patients
67 male patients
|
16 female patients
15 male patients
|
Age
|
67 (median)
|
65 (median)
|
Diagnosis
|
50 (malignant)
|
31 (malignant)
|
ASA Score
|
I– II ◊ 33.7%
III– IV ◊ 66.3%
|
I– II ◊ 47.2%
III– IV ◊ 52.8%
|
Initial surgical procedure
|
38 right-sided colon resection
54 left-sided colon resections
|
14 anterior rectal resections
17 low-anterior rectal resections
|
Laparoscopic vs open surgery
|
Laparoscopic assisted CR in 51%
|
Laparoscopic assisted RR 55.5%
|
AL cases
|
92 cases
|
31 cases
|
Median time of AL detection
|
5 days postop.
|
6 days postop.
|
Length of hospital stay
|
23 days (median)
|
27 days (median)
|
Colon resections
In eight cases, the AL had been simply over-sewn (8.7%). In 18 cases, the AL had been over-sewn and a protective ileostomy had been constructed (19.6%). In 14 cases, the anastomosis was resected and reconstructed (15.2%). Preservation of the anastomosis was not possible in 52 cases (56.5%), and therefore, the anastomosis had been taken down and an end stoma had been constructed.
In the further course, some of the interventions were insufficient leading to the necessity of a re-intervention. By simply over-sewing the AL, three patients did not need a surgical re-intervention whereas five underwent an average of 2.4 surgical re-interventions (min. one + max. eight re-interventions). The anastomosis was preserved in 37.5% of the cases (three of eight cases), with a median length of hospital stay of 26 d (min. 10 d + max. 51 d) and a mortality rate of 1 (12.5%).
In case of over-sewing the AL with the construction of a protective ileostomy, 14 patients did not need surgical intervention whereas four underwent an average of 1.5 surgical re-interventions (min. one + max. three re-interventions). We observed preservation of the anastomosis in 77.8% of the cases (14 of 18 cases), a median length of hospital stay of 26 d (min. 11 d + max. 66 d), and mortality rate of 1 (5.9%).
Resection and reconstruction of the anastomosis was sufficient in eight cases, whereas six patients underwent an average of 1.6 surgical re-interventions (min. one + max. four re-interventions). Preservation of the anastomosis was possible in 57.1% of the cases (eight of 14 cases). The median length of hospital stay was 24 d (min. 7 d + max. 71 d), with a mortality rate of 4 (28.6%).
In case of taking the anastomosis down with the construction of an end stoma, 44 patients did not need a surgical re-intervention, whereas eight underwent an average of 1.3 re-interventions per patient (min. one + max. three re-interventions). The median length of hospital stay was at 19 d (min. 5 d + max. 71 d) with a mortality rate of 8 (18.2%).
The main results of AL treatment, following colon resections are summarized in Table 2
Table 2
Results of the short-term outcome parameters following colon resections
First intervention
|
n = cases
|
Preservation rate
|
Definitive intervention
|
No. of re-interventions per patient
(mean value)
|
Length of stay (median)
|
Mortality
|
Simply over-sewing the AL
|
8 (8.7%)
|
37.5%
|
3 / 8 Simply over-sewing the
AL
4 / 8 Taking the anastomosis
down + end stoma
1 / 8 Over-sewing the AL +
protective ileostomy
|
2.4 (min. 1 + max. 8)
|
26 d (min. 10 + max. 51)
|
n = 1 (12.5%)
|
Over-sewing the AL + protective ileostomy
|
18 (19.6%)
|
77.8%
|
14 / 18 Over-sewing the AL
+ protective ileostomy
4 / 18 Taking the anastomosis
down + end stoma
|
1.5 (min. 1 + max. 8)
|
26 d (min. 11 + max. 66)
|
n = 1 (5.9%)
|
Resection and reconstruction of the anastomosis
|
14 (15.2%)
|
57.1%
|
8 / 14 Resection and
reconstruction of the
anastomosis
6 / 14 Taking the anastomosis
down + end stoma
|
1.6 (min. 1 + max. 4)
|
24 d (min. 7 + max. 71)
|
n = 4 (286%)
|
Taking the anastomosis down + end stoma
|
52 (56.5%)
|
0%
|
52 / 52 Taking the anastomosis
down + end stoma
|
1.3 (min. 1 + max. 8)
|
19 d (min. 5 + max. 71)
|
n = 8 (18.2%)
|
|
|
|
|
p-value = 0.155
|
p-value = 0.717
|
p-value = 0.514
|
Rectal resections
573 RR have been analyzed. ALs were detected in 31 cases in a median time of 6 days after surgery. In nine cases, the AL had been over-sewn and a protective ileostomy had been constructed (all these cases initially underwent a high anterior rectal resection). In five cases (13.9%), the primary treatment of the ALs following RR was a combination of a peritoneal lavage with a transanal drainage (all these cases initially underwent a low anterior rectal resection). However, preservation of the anastomosis had not been possible in 17 cases so that the anastomosis had been taken down and an end colostomy was constructed (47.2%).
In case of over-sewing the ALs with the construction of a protective ileostomy, seven patients did not need a re-intervention, whereas two patients underwent an average of 1.5 surgical re-interventions (min. one + max. two re-interventions). Preservation of the anastomosis was possible in 77.8% of the cases (seven of nine cases). The median length of hospital stay in these cases was at 28 d (min. 13 d + max. 57 d). None of these patients died in course of time.
By the combination of a peritoneal lavage with a transanal drainage, two patients did not need a re-intervention whereas three patients underwent an average of 1.6 surgical re-interventions (min. one + max. three re-interventions). In 60% of the cases, this intervention proved to be sufficient (three of five cases). The median length of hospital stay in these cases was at 13 d (min. 8 d + max. 31 d) with an overall mortality rate of one patient (20%).
In case of taking the anastomosis down with the construction of an end stoma, 10 patients did not need a surgical re-intervention whereas seven patients underwent an average of 1.1 surgical re-intervention (min. one + max. two re-interventions). The median length of hospital stay was at 29 d (min. 9 d + max. 40 d) with a mortality rate of one patient (5.9%).
The main results of AL treatment following rectal resections are summarized in Table 3.
Table 3
Results of the short-term outcome parameters following rectal resections
First-Intervention
|
n = cases
|
Preservation rate
|
Definitive-Intervention
|
No. of re-interventions per patient (mean value)
|
Length of stay
(median)
|
Mortality
|
Over-sewing the AL + protective ileostomy
|
9 (29.0%)
|
77.8%
|
7 / 9 Over-sewing the AL +
protective ileostomy
2 / 9 Taking the anastomosis
down + end colostomy
|
1.5
|
28 d (min. 13 + max. 57)
|
-
|
Lavage + Drainage
|
5 (16.2%)
|
60%
|
3 / 5 Lavage + Drainage
1 / 5 EndoVAC therapy
1 / 5 Simply over-sewing the
AL
|
1.6
|
13 d (min. 8 + max. 31)
|
n = 1 (20%)
|
Taking the anastomosis down + end colostomy
|
17 (54.8%)
|
-
|
17 / 17 Taking the anastomosis
down + end colostomy
|
1.1
|
29 d (min. 9 + max. 40)
|
n = 1 (5.9%)
|