2008 Annual Meeting Abstracts
What is the Evidence for Anastomotic Leak Testing in Colorectal Anastomoses
Rocco Ricciardi, MD, MPH, Patricia L. Roberts, MD, Peter W. Marcello, MD, David J. Schoetz, MD, Lawrence C. Rusin, MD.
Lahey Clinic, Burlington, MA, USA.
Objective: We examined our experience with anastomotic leak testing (ALT) for left-sided colorectal anastomoses.
Design: Cohort analysis
Setting: Subspecialty practice
Patients: Consecutive subjects were selected from a database of 2,627 patients treated from 1/2001 through 12/2007.
Interventions: Patients underwent left-sided colorectal anastomoses and ALT as per surgeon preference.
Main Outcome Measures: Anastomosis type, method (hand-sewn vs. stapled), performance of ALT, repair method for positive ALT, and development of postoperative clinical leak.
Results: A total of 998 (38%) left-sided colorectal anastomoses were performed: 899 (90.1%) stapled and 99 (9.9%) hand-sewn. Of these, 825 (82.7%) underwent ALT: 804 (89.4%) stapled but only 21 (21.2%) hand-sewn anastomoses. An intraoperative air leak was noted in 65 (7.9%) tested anastomoses: 63/804 (7.8%) stapled and 2/21 (9.5%) hand-sewn. A clinical leak developed in 48 (4.8%) patients: 4.4% of all stapled and 8.1% of all hand-sewn anastomoses (p=0.13). Clinical leaks were noted in 7.7% of all positive ALTs as compared to 3.8% of all negative ALTs and 8.1% of all untested anastomoses (p<0.03). Clinical leaks were particularly high 6/28 (21.4%) in the absence of ALT for circular stapled anastomoses. If ALT was positive, then suture repair alone (n=41) had the highest rate of postoperative clinical leak as compared to diversion or reanastomosis (n=24), 12.2% vs. 0%, respectively (p=0.19).
Conclusions: Our data reveal a high rate of air leaks with ALT in left-sided colorectal anastomoses. In addition, the high rate of clinical leaks in untested anastomoses leads us to recommend ALT for all left-sided anastomoses, both stapled and hand-sewn. While commonly practiced, suture repair of a positive ALT was associated with a higher rate of clinical leak compared to diversion or reanastomosis.