Endoscopic closure of a postoperative rectal anastomotic leakage with hemoclips: A case report

Management of Low Colorectal/Coloanal Anastomotic Leak: Results of a French National Intergroups Practice Survey (FRENCH-GRECCAR-SFCD)

AIMS

Anastomotic leakage (AL) impacts short-term and long-term outcomes after colorectal surgery, yet no consensus exists regarding its diagnosis and management. The aim was to establish a proactive consensus-based approach for diagnosing and treating AL following rectal cancer surgery through a national survey.

METHODS

A questionnaire was designed to assess 24 clinical scenarios related to the diagnosis and management of fistulas in low colorectal (LCA) or coloanal anastomosis (CAA) with a diverting ileostomy.

RESULTS

A total of 203 surgeons from three surgical societies participated. Consensus was reached on four key indicators warranting further investigation of AL: CRP > 250 mg/L, fever ≥ 38.5°C, tachycardia > 100 bpm, and diffuse abdominal pain. In the presence of any warning sign, 87% recommended an urgent contrast-enhanced abdominopelvic CT scan without routine rectal contrast as the first-line diagnostic tool. Isolated extra-digestive air bubbles or uncollected effusions without air bubbles were managed with antibiotics (61%-78%). A perianastomotic collection required an anal examination under general anesthesia (70%). For treatment, transanal drainage (56%) was preferred over image-guided percutaneous drainage, combined with endoluminal vacuum therapy and at least 7 days of antibiotics (97%). Drain removal was recommended (64%) when imaging confirmed the absence of residual collection.

CONCLUSIONS

This national survey established a consensus-driven proactive management algorithm for LCA/CAA fistulas. Further validation controlled trial is needed to confirm the effectiveness in reducing AL-related complications.

Achieving a cure for anastomotic leakage following laparoscopic low anterior resection for rectal cancer using an endoscopic closure device, a MANTIS clip

Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a major complication. While most reports focus on the closure of AL using over-the-scope clip (OTSC), few reports are available on the use of through-the-scope clip (TTSC). This is because TTSC is not typically designed for full-thickness closure, unlike OTSC. However, a MANTIS clip, categorized as TTSC, is indicated for full-thickness closure. A 73-year-old man diagnosed with AL 7 days postoperatively following laparoscopic LAR underwent laparoscopic drainage and ileostomy the next day. Although the drainage led to the shrinkage of the fistula, it persisted even after 2 months. Consequently, the fistula orifice was closed using a MANTIS clip under colonoscopy and radiography. Two days later, the patient was discharged. The drain was withdrawn cautiously to prevent residual fistula and removed completely on day 29. This report highlights our experience in using a MANTIS clip for AL following LAR.

Computer tomography-guided negative pressure drainage treatment of intrathoracic esophagojejunal anastomotic leakage: A case report

BACKGROUND

Esophagojejunal anastomotic leakage (EJAL) is a serious and potentially crucial complication of total gastrectomy and represents the major cause of postoperative death, with a mortality rate of up to 50%. However, treatment remains challenging and controversial. We report here the case of a patient whose intrathoracic EJAL was successfully treated with computer tomography (CT)-guided negative pressure drainage treatment.

CASE SUMMARY

A 69-year-old male patient complained of difficulty swallowing within the last six months. He was diagnosed with esophagogastric junction carcinoma, Siewert II, cT3N0M0 stage II. Total gastrectomy and Roux-en-Y esophagojejunostomy were performed. High fever, left chest pain and dyspnea appeared on postoperative day 5, and EJAL was confirmed by CT, gastroscopy and oral blue-dimethylene tests. Conservative treatment measures were applied immediately, including antibiotics, nasojejunal tubes, and repeated thoracic puncture and drainage under ultrasound guidance. However, without sufficient and effective drainage, the thoracic infection and systemic condition continued to deteriorate. With the cooperation of multiple departments, percutaneous CT-guided drainage (24 Fr 7 mm) in the thoracic cavity was successfully placed near the anastomotic leakage. Because of continuous negative pressure suction, the infection symptoms were effectively controlled and the general situation gradually recovered. Subsequent follow-up examination showed that the patient was in good condition.

CONCLUSION

Negative pressure drainage via CT may represent an effective minimally invasive approach to treating intrathoracic EJAL.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.