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ISSN 1405-0099 (Print)

2019, Number 4

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Cir Gen 2019; 41 (4)

Dehiscence of gastrointestinal anastomosis. what to do and what not to do

Campos Campos, Salvador Francisco1; Ureña Álvarez, Jesús Alan2; Fuentes Orozco, Clotilde3,4; Barbosa Camacho, Francisco José4; Barrera López, Francisco Javier4; Jiménez Ley, Vania Brickelia4; González Ojeda, Alejandro3,4

Language: English/Spanish [Versión en español]
References: 63
Page: 243-255
PDF size: 269.62 Kb.


ABSTRACT

The dehiscence of anastomosis is one of the worst complications that can occur after a resection of the digestive tract that increase morbidity, mortality, time of hospital stay and the costs of care in an important way. Anastomotic dehiscence produces nonspecific symptoms and pain that should not be considered as a cardinal symptom because it is very difficult to make a difference between the usual postoperative pain caused by peritonitis secondary to anastomotic leakage; it is also possible to find alterations in vital signs mainly in the respiratory rate and heart rate. The diagnosis requires a high index of suspicion in a patient with an unusual evolution. The differentiation of the concepts of the dehiscence of anastomosis and fistula must be taken into account. The present systematic review integrates contributions in the incidence and risk factors, classification, prevention and treatment.



INTRODUCTION

Anastomotic dehiscence (AD) in the gastrointestinal tract is one of the most feared complications by significantly increasing morbidity, mortality, length of hospital stay, and costs of care. AD produces non-specific symptoms. Pain should not be considered a cardinal symptom. It is difficult to differentiate usual postoperative pain from pain caused by peritonitis secondary to anastomotic leakage. Most of the time, diagnostic suspicion is based on the experience of the surgeon and the unusual evolution of his patient.



DEFINITION

Currently, there is a definition and criteria established for the diagnosis of biliary leakage, pancreatic fistula, and colorectal leakage1 when referring to gastrointestinal tract anastomoses, the conceptual difference between anastomosis dehiscence and gastrointestinal fistula must be clearly stated.

AD is defined as the partial or total loss of continuity in an anastomosis, or very close to the suture line, resulting in a lack of airtightness and communicating the interior of the digestive tract with the extraluminal space,2 which usually generates clinical manifestations in varying degrees that put the patient's life at risk and requires medical intervention consistent with the severity of the case;3 in contrast, fistula refers to communication between adjacent organs or the external environment using an epithelialized pathway whose formation process requires a stabilization time following AD, usually from eight to 30 days. The concepts of fistula and dehiscence are different and ordinarily one could consider that a fistula is the chronic form of AD or that a fistula is always preceded by an AD.



INCIDENCE AND RISK FACTORS

The incidence of anastomotic leakage varies according to the anatomical site and is due to differences in bacterial load, vascular supply, stress on the anastomosis, and patient-specific factors such as a history of radiation therapy, type 2 diabetes, chronic steroid use, and others.4 Table 1 shows the results of the study published by Turrentine et al.5 in which 2,237 patients with anastomotic leakage were included; clinical aspects associated with the sample were studied in terms of prevalence and mortality, and an increase was observed in days of hospital stay in patients with AD (13 versus 5 days), frequency of reoperations (45.8% versus 4%), and greater frequency in men than in women (6.2% versus 3.9%). Kiran and collaborators describe a multivariate analysis of the different factors that could lead to an anastomotic leakage (Table 2).6

Trencheva et al.7 studied 616 patients undergoing colorectal surgical procedures and found AD in 5.7% (35/616) of the cases. The risk factors they identified were: anastomosis less than 10 cm from the anal margin (AM), with 13.9% of AD compared with 3% of anastomosis performed more than 10 cm from the AM, which is explained by the need to section more blood vessels to mobilize the colon to the pelvis. High ligation of the inferior mesenteric artery increased the risk of AD by 3.8 times; the male gender presented greater AD because the pelvis is narrower and makes the procedure more difficult. Other factors that influence prevalence are metabolic complications in the transoperative4 that increase the risk 4.1 times (hemoglobin O2 saturation < 90%, hypotension < 20% of basal, pH < 7.3, bleeding that has required transfusion, acute myocardial infarction, mean blood pressure < 60 mmHg or systolic pressure < 85 mmHg that required the administration of volume or vasoactive drugs). Prevalence also increases in patients with more than three points on the Charlson comorbidities scale (CCS) (Table 3).8



DIAGNOSIS

The medullary aspect of gastrointestinal tract surgery is to avoid denying the possibility of being in the presence of a DA to initiate the diagnostic protocol and treat the patient on time. Karliczek and colleagues have shown that this is an inconvenient situation since when the surgeon was asked to predict AD based on his experience, the sensitivity for predicting leakage in anastomosis performed at < 15 cm from the AM was 62% and the specificity 52%, while for anastomosis performed at > 15 cm from the AM the sensitivity was 38% and the specificity 46%.9



A) CLINICAL MANIFESTATIONS

Semiology in AD cases is imprecise, the usefulness of vital signs in an AD is modest and simplifying the diagnosis of AD to a single element of the clinical picture is inappropriate. Most patients undergoing surgery of the gastrointestinal tract will present some degree of alteration in vital signs (polypnea, fever, tachycardia, hypotension) especially in the early postoperative days; However, in patients with AD these alterations are more accentuated and do not show a tendency towards normalization as in uncomplicated cases; the persistence of tachycardia (> 90 beats per minute) and polypnea (> 20 breaths/minute) can be found in approximately 90-95% of AD cases,10 thus demonstrating its clinical utility.

In the field of bariatric surgery, Arteaga-González and colleagues11 studied 200 patients undergoing bariatric surgery and reported variations in heart rate, white blood cell count and blood pressure, among others (Table 4); they also observed that up to 7.7% of abdominal computed tomography (CT) scans, 28.6% of methylene blue tests and 22.2% of water-soluble contrast tests were falsely negative in patients with confirmed AD at the time of surgery.

Abdominal pain is a symptom that should be taken into account. Its location can be modified according to the site of the anastomosis inside the abdomen. Persistent abdominal pain associated with systemic inflammatory response syndrome (SIRS) may be an enough indication to re-intervene a patient, even if AD has not been confirmed on radiological studies.

It should be mentioned that the patient's functional status and cooperation are elementary to evaluate the evolution, so it is advisable to be extremely cautious in those patients with disabling disorders that hinder communication.



B) LABORATORY

Laboratory studies should be analyzed with caution since biochemical alterations are to be expected because of the physiological inflammatory response triggered by the surgical procedure.

Serum parameters that are clinically useful when studying AD patients are the evolution in the leukocyte count, serum levels of procalcitonin, and C-reactive protein. A study by Singh et al.12 reported that the use of serum C-reactive protein suggesting values above 172 mg/dl on day three of the postoperative period (PO), 124 mg/dl on day four of PO and 144 mg/dl on day five of PO should lead to suspicion of AD with a negative predictive value of 97%; other reports suggest that a maximum C-reactive protein value of 135 mg/dl on day three of PO may be sufficient to discharge the patient with peace of mind (sensitivity 73%, specificity 73%, positive predictive value 95.4%)13 when recommendations for early discharge are followed.

Procalcitonin (PCT) is a soluble calcitonin precursor normally released from the C cells of the thyroid gland in response to severe systemic inflammation. It can be released into other tissues including activated leukocytes. Under normal conditions, it is found at concentrations of approximately 0.05 ng/ml. However, in septic processes it can reach up to 700 ng/ml within two to three hours after the onset of the systemic response, such elevation being measurable even before the elevation of the white blood cell count and the clinical manifestations of SIRS.14 In the clinical context, values below 0.5 ng/ml represent a low risk of severe sepsis, while values above 2 ng/ml represent a very high risk. Its concentration should be assessed with caution in patients with impaired kidney function given it is eliminated by the kidney.15 Unlike C-reactive protein, serum PCT is elevated almost exclusively during bacterial infections, so its usefulness for the diagnosis of AD is the same as for assessing response to antimicrobial therapy.16 An elevation is expected on the first day of the PO due to naturally occurring contamination during intestinal surgery.17 However, its tendency should be of a gradual decrease (> 30% per day) over the course of the following days.

PCT is not elevated in inflammation of non-infectious origin,18 except in liver transplant recipients, severe and prolonged cardiogenic shock, patients with thermal shock, severe pancreatitis, and rhabdomyolysis.

Serum lactate, previously considered a marker for sepsis, severe sepsis, and septic shock, only indicates an alteration in oxidative metabolism and is closely related to criteria for hypoperfusion and multiple organ failure.19

Fouda et al.20 studied the levels of IL6, IL10, tumor necrosis factor in abdominal drainage fluid of patients undergoing colorectal surgery and showed that on day 5 of PO the levels of these cytokines in patients with AD were five times higher than in patients without AD, who showed a gradual decrease in cytokine levels since surgery. The measurement of cytokines is not very specific because the levels can vary greatly without presenting a directly proportional clinical correlation.



C) RADIOLOGY

Complementing the diagnosis with radiological studies is necessary in cases of suspected AD. CT of the abdomen has displaced plain radiography of the abdomen due to the greater detail provided by the first study. Although the findings seen on a plain radiograph of the abdomen are not very accurate, subdiaphragmatic free air detection after day five of PO should be suspected of AD,21 or even some reports have indicated that disruption of the surgical staple line can be identified.22

A contrasted abdominal CT scan is considered the best diagnostic test for AD. It has been reported to be 94-100% accurate.23 The diagnosis of AD can be confirmed when fluid collections are found around surgical anastomoses,24 and air leakage or leakage of contrast material from inside the intestinal lumen. However, the latter can be observed in only 10% of cases.25

Diagnosis by an enema with contrast media is of little use in evaluating AD within the first five days of PO because of the risk of procedure-related complications, so these types of studies are reserved until after seven or eight days of PO when AD has frequently occurred clinically. Markham and colleagues described the use of barium enemas to assess the integrity of rectal anastomoses before the closure of a protective stoma and reported that up to 41% of patients presented with non-clinical radiological leakage,26 so it has been suggested that closure of the protective stoma be delayed in these patients.27 The introduction of contrast material through the fistulous path is valid for chronic processes.

The use of contrast agents is necessary to improve the diagnostic accuracy of radiological studies; however, these substances can cause adverse events. The most commonly used preparations are barium sulfate suspensions and water-soluble iodine salts; barium should be reserved for cases where the anastomosis is intact because of the risk of developing chemical peritonitis secondary to extravasation of this substance; Iodine-based water-soluble contrast can be safely used orally despite the suspicion of AD because it does not cause chemical injury when leaked from the intestinal lumen; however, its intravenous administration should be avoided in patients with renal failure because it causes contrast-induced nephropathy.



CLASSIFICATION OF THE LEAK

AD was arbitrarily classified as minor defect when the solution of continuity was < 1 cm or less than one third of the anastomosis or major defect with loss of solution of continuity > 1 cm or greater than one third of the anastomosis.

In 2010 the International Rectal Cancer Study Group proposed a system to classify post-anastomosis leakage from the anterior rectal resection into grade A in leakage detected with radiological studies with discrete or absent clinical disturbances that do not require active therapeutic intervention; however, when detected they may delay the closure of the protective stoma, grade B in leakage that requires therapeutic intervention (e.g. medical management, antibiotic treatment or percutaneous drainage), but are manageable without surgical intervention and grade C in anastomotic leaks associated with peritonitis and systemic inflammatory response syndrome (SIRS) that require surgical intervention and commonly involve fecal transit procedures.3 Although this system was described for rectal surgery, it may apply to other viscera.



PREVENTION

The best strategy to decrease complications in our patients is to focus on knowledge and develop prevention strategies in each field. For their application, we can group these strategies into:



A. BACTERIOLOGICAL

The intestinal flora suggests the term intestinal microbiota which is composed of an extensive variety of aerobic and anaerobic germs composed of 90% of Firmicutes (to which the lactobacilli belong) and Bacteroides (to which the bacteroid species belong, these represent 30% of all bacteria); the remaining 10% is represented by actinobacteria and proteobacteria, among which are the known enterobacteria, Escherichia, Klebsiella, Pseudomonas and Salmonella which represent less than 1% of the intestinal flora (Figure 1).

Normal healing processes can be affected in their different phases by variations in the bacterial load and by the bacterial phenotype that can transform from symbiotic to a "tissue destroyer" when there are states of stress in the host. It is characterized by greater virulence and pathogenicity when synthesizing collagenases and matrix remodeling metalloproteases (MMP-remodeling); this means that the same bacteria can behave differently in a healthy host than in one under surgical stress.28 The most studied germs with these behavioral modifications are Pseudomonas aeruginosa29 and Enterococcus faecalis,30 and some research also points to Yersinia enterocolitica, Escherichia coli (E. coli sp.), Salmonella typhi and Campylobacter jejuni.31 These alterations can be detected to some degree in all normal intestinal flora; however, it is common to find a more notorious pathogenic phenotype in the germs that inhabit the site of the anastomosis.

Some studies suggest the possibility of administering probiotics pre and postoperatively to balance the intestinal flora and promote a symbiotic flora, with acceptable effects in reducing days spent in the intensive care unit, mechanical ventilation time, and postoperative infections in critical patients. 32 However, with weak results in terms of reducing the risk of AD. Opponents of such management point out that it is unrealistic that some strains of lactobacilli are enough to normalize the microenvironment of the patient's intestine.

In intestinal surgery, parenteral antimicrobial prophylaxis is recommended including coverage against Gram-positive and anaerobic germs, following international clinical practice guidelines. It has been proven to reduce infections by half. Although the concept of administering enteral antimicrobials before and after surgery was abandoned for some years, more recent microbiological studies revive the need to administer antibiotics with little or no enteral absorption such as neomycin or erythromycin as a complement to parenteral antibiotics. 33 The doses that can be administered enterally are 1 g neomycin + 1 g metronidazole19,18, and nine hours before surgery, or 2 g neomycin + 2 g metronidazole13 and nine hours before surgery.



B. TECHNICAL CONSIDERATIONS

In general terms, when an anastomotic failure occurs within the first few days, from the first to the fourth, it is considered due to technical errors, while failures that occur five to seven days after the procedure are suggested to be caused by ischemia at the anastomotic site.34

  • 1. Anastomosis preparation: when performing the anastomosis, care should be taken to ensure it is tension-free, since axial traction may increase the space between sutures and increase the possibility of leakage, and in other cases ischemia in the suture area.35
  • 2. Perfusion and microcirculation: preserving the vascularization of the intestinal segment is cardinal to success. Special attention and meticulousness must be given when manipulating the vascular arches and avoiding distension, torsion, or unnecessary section of the vessels during surgery. The intraoperative use of dyes such as indocyanine green,36 conventional Doppler ultrasound,37 or laser Doppler ultrasound38 have been described as aids to identify the best irrigation site and guide during the preparation of the anastomosis; however, the availability of these tools persists as a problem for their daily application.
  • 3. Manual suture vs. mechanical suture: Scientific evidence between performing the anastomosis with staplers or manually has delineated that in inexperienced surgeons mechanical suturing offers reduced surgical time with more homogeneous results as long as the proper staple height is selected and no more than two mechanical suture lines are spliced; when experienced surgeons perform manual anastomosis the result is practically the same when compared to mechanical suture in terms of incidence of anastomotic leakage regardless of the gastrointestinal tract segment, reporting only an increase in surgical time.39,40
  • The shape and closing height of the surgical staples must be considered as one of the important technical factors. Each manufacturer has designed its color codes on its staple cartridges, so they must be properly selected according to the type of procedure. It is common for more than one staple shot to be required; however, splicing more than three mechanical suture lines in the same place increases the risk of leakage by more than twice.
  • Sutureless anastomosis by compression rings of nitinol41 has been described as allowing scar tissue to heal between the edges of the ring at the anastomosis and then be expelled as the surgical edges slough off eight to 10 days after the procedure;42 supporters of this method argue that not piercing the tissue to place the suture or staples decreases bleeding, generates less tissue damage, less inflammatory reaction, and less risk of anastomotic failure.43 Nitinol is a nickel-titanium alloy whose memory characteristics keep it in a shape that allows constant pressure to be exerted on the anastomosis site and, compared to stainless steel, is less toxic, carcinogenic and immunogenic due to its lower nickel content and the stability that the alloy confers on titanium.44
  • 4. Drainages: the use of surgical drains was based on considering them as a sentinel for the integrity of the anastomosis; unlike esophageal surgery where there is a general acceptance of using surgical drains (grade 5 evidence),45 in abdominal surgery the discussion remains because closed drains are considered to be obstructed and lose that watchdog function, while open drains contaminate the wounds.
  • In colorectal surgery, the evidence recommends the use of drains in procedures performed below the sacral promontory, while in intra-abdominal surgery the utility is little or non-existent.46 In the field of bariatric surgery, similarly, the evidence is not strong enough to recommend their routine use,47 since the patient's general conditions and the presence of SIDS or tachycardia may be sufficient indications for reoperation despite the lack of clinical confirmation of anastomotic leakage.
  • 5. Leakage test: the underwater tightness test ("rim test") should not be a rule for all procedures, since manipulation of the newly created anastomosis can unravel the tissues and increase the risk of AD. In selected cases, this test is useful to demonstrate the site where the technical error occurred during the surgical procedure; however, it is preferable to perform the test endoscopically to evaluate the integrity of the anastomosis and the hemostasis of the surgical site.11,21



C. CONTROL OF FACTORS RELATED TO THE PATIENT

When addressing this field, we must consider that we can influence some risk factors, which will be described later; however, there are non-modifiable factors that increase the risk of AD. Some of the factors that directly increase the risk of AD are a medical history of chemotherapy or radiotherapy, hypotension in the transplant, poorly controlled type 2 diabetes, chronic steroid use, smoking, and atherosclerosis, use of large diameter staplers (31-34 mm) to make the ileal reservoir in the ileoanal anastomosis, the male gender in the case of colorectal surgery due to the technical difficulty because of the narrower male pelvis4 and to perform anastomosis below the peritoneal fold.48

  • 1. Intestinal preparation of the colon: Since 1971 Nichols and Condon49 have described the usefulness of mechanical bowel preparation (MBP) and its effects on intestinal bacterial load. In their report, they analyzed the modifications in intestinal flora by taking cultures in the ileum, cecum, and transverse colon of patients undergoing cholecystectomy. For their study, they divided patients into six groups: no MBP and no antibiotic, MBP without antibiotic, MBP + kanamycin, MBP + neomycin, MBP + sulfonamides (phthalylsulfathiazole) + neomycin, MBP + erythromycin + neomycin. In this study, they demonstrated that MBP alone helped remove only visible matter without causing changes in the intestinal flora; the MBP + kanamycin, MBP + neomycin, and MBP + neomycin + sulfonamides groups had no noticeable changes in the number of aerobes and anaerobes; while the MBP + erythromycin + neomycin treated group greatly reduced the number of aerobes and anaerobes.49
  • Kiran and colleagues6 studied 8,442 patients retrospectively, dividing them into groups: no MIC without antibiotic (27.2%; 2,296); MIC without antibiotic (45.3%; 3,822) and MIC with antibiotic (27.5%; 2,324) and reported differences in surgical site infection (14.7% versus 12.1% versus 6.2%), postoperative ileus (15.1% versus 12.3% versus 9.2%), bowel leakage (4.6% versus 3.5% versus 2.1%), sepsis (4.4% versus 2.8% versus 2.3%) and 30-day mortality (1.6% versus 0.6% versus 0.3%). Although this study does not specify which drug or which dose was used, it is clear that MBP is useful only if performed in conjunction with oral antibiotics (Table 5).
  • New literature is included in the latest guidelines of the American Society of Colon and Rectal Surgeons published in 2019, which recommends the use of MBP with oral antibiotics for colorectal resection as a grade 1B evidence. On the other hand, the use of IPM without antibiotics in elective colorectal surgery with a grade of evidence 1A, as well as the use of only oral antibiotics without IPM (grade of evidence 2C) or the use of enemas without IPM or the use of oral antibiotic therapy (grade of evidence 2B) are not recommended.50
  • 2. Protective stomas: controlled clinical trials confirm the safety of performing protective stomas in patients at high risk of AD to prevent anastomotic leakage in high-risk anastomoses, such as those performed very close to the anal margin. This behavior results in fewer septic complications and fewer re-operations, with the disadvantage of negatively impacting the quality of life and increasing associated morbidity while the stoma is being held, without eliminating the possibility of remaining with the stoma permanently.51-53



TREATMENT

The clinical presentation of an AD can manifest in different ways. Treatment should be according to the needs of the patient. Group B AD cases can be managed medically, while group C cases, although the anastomotic disruption is not confirmed radiologically, should be managed with urgent surgery, because the progression from peritonitis to septic shock is rapid and catastrophic, and it requires management in the intensive care unit with hemodynamic support. In all patients with severe generalized peritonitis, attempts at medical treatment are insufficient until the septic focus has been controlled.54

Once the condition of the abdomen has been evaluated, surgical treatment should be individualized for each patient, and the decision made in the operating room. In cases of severe inflammation and induration, it is prudent not to further injure the tissues and to limit washing, draining, and if possible, performing a proximal stoma. In cases where dehiscence affects two thirds of the circumference or more, the anastomosis can be dismantled, a stoma made and closed distally (or the two orifices externalized), although if the patient is hemodynamically stable and resources are available, a resection of the affected segment can be decided and the anastomosis redone, albeit with a greater risk of DA once the inflammation in the intestine subsides and the tension in the sutures loosens.17,55 In patients without systemic manifestations of infection, conservative management with antibiotics, analgesia, fasting, intestinal decompression, and parenteral nutrition may ensue. Treatment for collections around anastomoses detected by tomographic studies can be divided according to their size; those under 3 cm can be managed with medical treatment, and those over 3 cm can be drained percutaneously,56 with a success rate of 81% and mortality of 3%.57

Endoscopic therapies can be used as a resource to avoid re-intervention of the AD patient. Disruptions may be treated by placing stents in the esophagus58 or colon59 as a bridge to the defect to contain the leakage and allow healing. Some fistulas can be closed from within the intestinal lumen by placing conventional endoscopic clips or special bear-trap clips that are placed over the tip of the endoscope also called OVESCO (over-the-scope)60 and allow the closure of larger defects. To assist in the drainage and obliteration of the para-anastomotic spaces, suction-assisted endoscopic drainage therapies have been described, in which the same principles of suction-assisted closure (VAC) therapy are followed; for application, a sponge is introduced into the para-anastomotic sinus and the system is connected to a suction hose, either transorally or transanally, as needed61 (Figure 2). Although some studies showed encouraging results with up to 97% success rates,62 a multicenter study of transanal drainage for chronic presacral sinuses conducted in the Netherlands 63 demonstrated a success rate of up to 75%; this study included 16 patients with low anterior colon resection and AD, requiring an average of 13 suction system replacements (eight to 17), and found that those patients who started treatment within six weeks of the AD diagnosis were 75% successful, while those who started after six weeks of the diagnosis were 38% successful.



CONCLUSIONS

It is clear that despite a better knowledge of the etiology, prevention, diagnosis, and management of intestinal anastomosis, leaks occur. We must take great care in the prevention and timely diagnosis and take action on the factors that influence the presentation of the problem as they are:

  • • Microbioma of the patient.
  • • Preoperative preventive measures and their indications.
  • • Preparation of the colon.
  • • Purified surgical technique.
  • • Use of perioperative antibiotics, both oral and intravenous.
  • • Perfect anastomosis.
  • • Consider proximal stoma in high-risk anastomosis.


REFERENCES

  1. Welsch T, von Frankenberg M, Schmidt J, Büchler MW. Diagnosis and definition of anastomotic leakage from the surgeon's perspective. Chirurg. 2011; 82: 48-55. doi: 10.1007/s00104-010-1916-4.

  2. Fuentes-Orozco C, Rendón-Félix J, González-Ojeda A. ¿Dehiscencia de anastomosis o fístula entérica? Necesidad de definiciones precisas en la descripción de complicaciones quirúrgicas, aun en cirugía pediátrica. Gac Med Mex 2015; 151: 700-702.

  3. Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery. 2010; 147: 339-351.

  4. Chadi SA, Fingerhut A, Berho M, DeMeester SR, Fleshman JW, Hyman NH, et al. Emerging trends in the etiology, prevention, and treatment of gastrointestinal anastomotic leakage. J Gastrointest Surg. 2016; 20: 2035-2051.

  5. Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg. 2015; 220: 195-206.

  6. Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015; 262: 416-425; discussion 423-425. doi: 10.1097/SLA.0000000000001416.

  7. Trencheva K, Morrissey KP, Wells M, Mancuso CA, Lee SW, Sonoda T, et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg. 2013; 257: 108-113. doi: 10.1097/SLA.0b013e318262a6cd.

  8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40: 373-383.

  9. Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis. 2009; 24: 569-576. doi: 10.1007/s00384-009-0658-6.

  10. Erb L, Hyman NH, Osler T. Abnormal vital signs are common after bowel resection and do not predict anastomotic leak. J Am Coll Surg. 2014; 218: 1195-1199. doi: 10.1016/j.jamcollsurg.2013.12.059.

  11. Arteaga-González I, Martín-Malagón A, Martín-Pérez J, Carrillo-Pallarés A. Usefulness of clinical signs and diagnostic tests for suspected leaks in bariatric surgery. Obes Surg. 2015; 25: 1680-1684. doi: 10.1007/s11695-015-1589-7.

  12. Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg. 2014; 101: 339-346. doi: 10.1002/bjs.9354.

  13. Scepanovic MS, Kovacevic B, Cijan V, Antic A, Petrovic Z, Asceric R, et al. C-reactive protein as an early predictor for anastomotic leakage in elective abdominal surgery. Tech Coloproctol. 2013; 17: 541-547. doi: 10.1007/s10151-013-1013-z.

  14. Giaccaglia V, Salvi PF, Antonelli MS, Nigri G, Pirozzi F, Casagranda B, et al. Procalcitonin reveals early dehiscence in colorectal surgery: the PREDICS study. Ann Surg. 2016; 263: 967-972. doi: 10.1097/SLA.0000000000001365.

  15. Meisner M, Lohs T, Huettemann E, Schmidt J, Hueller M, Reinhart K. The plasma elimination rate and urinary secretion of procalcitonin in patients with normal and impaired renal function. Eur J Anaesthesiol. 2001; 18:79-87.

  16. Meisner M. Update on procalcitonin measurements. Ann Lab Med. 2014; 34: 263-273. doi: 10.3343/alm.2014.34.4.263.

  17. Meisner M, Tschaikowsky K, Hutzler A, Schick C, Schüttler J. Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med. 1998; 24: 680-684.

  18. Meisner M, Tschaikowsky K, Palmaers T, Schmidt J. Comparison of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations at different SOFA scores during the course of sepsis and MODS. Crit Care. 1999; 3: 45-50.

  19. Clec'h C, Ferriere F, Karoubi P, Fosse JP, Cupa M, Hoang P, et al. Diagnostic and prognostic value of procalcitonin in patients with septic shock. Crit Care Med. 2004; 32: 1166-1169.

  20. Fouda E, El Nakeeb A, Magdy A, Hammad EA, Othman G, Farid M. Early detection of anastomotic leakage after elective low anterior resection. J Gastrointest Surg. 2011; 15: 137-144.

  21. Tang CL, Yeong KY, Nyam DC, Eu KW, Ho YH, Leong AF, et al. Postoperative intra-abdominal free gas after open colorectal resection. Dis Colon Rectum. 2000; 43: 1116-1120.

  22. Williams CE, Makin CA, Reeve RG, Ellenbogen SB. Over-utilisation of radiography in the assessment of stapled colonic anastomoses. Eur J Radiol. 1991; 12: 35-37.

  23. Daams F, Wu Z, Lahaye MJ, Jeekel J, Lange JF. Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature. World J Gastrointest Surg. 2014; 6: 14-26.

  24. Power N, Atri M, Ryan S, Haddad R, Smith A. CT assessment of anastomotic bowel leak. Clin Radiol. 2007; 62: 37-42.

  25. Doeksen A, Tanis PJ, Wüst AF, Vrouenraets BC, van Lanschot JJ, van Tets WF. Radiological evaluation of colorectal anastomoses. Int J Colorectal Dis. 2008; 23: 863-868.

  26. Markham N, Greatorex RA, Everett WG. The value and significance of the limited barium enema examination following restorative resection for carcinoma of the rectum. Ann R Coll Surg Engl. 1987; 69: 116-118.

  27. Kalady MF, Mantyh CR, Petrofski J, Ludwig KA. Routine contrast imaging of low pelvic anastomosis prior to closure of defunctioning ileostomy: is it necessary? J Gastrointest Surg. 2008; 12: 1227-1231.

  28. Swank GM, Deitch EA. Role of the gut in multiple organ failure: bacterial translocation and permeability changes. World J Surg. 1996; 20: 411-417.

  29. Engel J, Balachandran P. Role of Pseudomonas aeruginosa type III effectors in disease. Curr Opin Microbiol. 2009; 12: 61-66.

  30. Shogan BD, Belogortseva N, Luong PM, Zaborin A, Lax S, Bethel C, et al. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med. 2015; 7: 286ra68. doi: 10.1126/scitranslmed.3010658.

  31. Sandrini S, Alghofaili F, Freestone P, Yesilkaya H. Host stress hormone norepinephrine stimulates pneumococcal growth, biofilm formation and virulence gene expression. BMC Microbiol. 2014; 14: 180. doi: 10.1186/1471-2180-14-180.

  32. Stavrou G, Giamarellos-Bourboulis EJ, Kotzampassi K. The role of probiotics in the prevention of severe infections following abdominal surgery. Int J Antimicrob Agents. 2015; 46 Suppl 1: S2-S4.

  33. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195-283.

  34. Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M. The science of stapling and leaks. Obes Surg. 2004; 14: 1290-1298.

  35. Valverde A. Anastomosis digestivas: principios y técnica (cirugía abierta y laparoscópica). Apar Dig. 2015; 31: 1-20. doi: 10.1016/s1282-9129(15)72442-6.

  36. Alander JT, Kaartinen I, Laakso A, Pätilä T, Spillmann T, Tuchin VV, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012; 2012: 940585.

  37. Ambrosetti P, Robert J, Mathey P, Rohner A. Left-sided colon and colorectal anastomoses: Doppler ultrasound as an aid to assess bowel vascularization. A prospective evaluation of 200 consecutive elective cases. Int J Colorectal Dis. 1994; 9: 211-214.

  38. Vignali A, Gianotti L, Braga M, Radaelli G, Malvezzi L, Di Carlo V. Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum. 2000; 43: 76-82.

  39. Honda M, Kuriyama A, Noma H, Nunobe S, Furukawa TA. Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg. 2013; 257: 238-248.

  40. Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2012; CD003144. doi: 10.1002/14651858.CD003144.pub2.

  41. Zbar AP, Nir Y, Weizman A, Rabau M, Senagore A. Compression anastomoses in colorectal surgery: a review. Tech Coloproctol. 2012; 16: 187-199. doi: 10.1007/s10151-012-0825-6.

  42. Berho M, Wexner SD, Botero-Anug AM, Pelled D, Fleshman JW. Histopathologic advantages of compression ring anastomosis healing as compared with stapled anastomosis in a porcine model: a blinded comparative study. Dis Colon Rectum. 2014; 57: 506-513. doi: 10.1097/DCR.0000000000000009.

  43. D'Hoore A, Albert MR, Cohen SM, Herbst F, Matter I, Van Der Speeten K, et al. COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™). Colorectal Dis. 2015; 17: 522-529.

  44. Es-Souni M, Es-Souni M, Fischer-Brandies H. Assessing the biocompatibility of NiTi shape memory alloys used for medical applications. Anal Bioanal Chem. 2005; 381: 557-567.

  45. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg. 2004; 240: 1074-1084; discussion 1084-1085.

  46. Kingham TP, Pachter HL. Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg. 2009; 208: 269-278. doi: 10.1016/j.jamcollsurg.2008.10.015.

  47. Liscia G, Scaringi S, Facchiano E, Quartararo G, Lucchese M. The role of drainage after Roux-en-Y gastric bypass for morbid obesity: a systematic review. Surg Obes Relat Dis Off J Am Soc Bariatr Surg 2014; 10: 171-176. doi: 10.1016/j.soard.2013.09.008.

  48. Bannura CG, Cumsille GMA, Barrera EA, Contreras PJ, Melo LC, Soto CD, et al. Factores asociados a la dehiscencia clínica de una anastomosis intestinal grapada: análisis multivariado de 610 pacientes consecutivos. Rev Chil Cir. 2006; 58: 341-346.

  49. Nichols RL, Condon RE, Gorbach SL, Nyhus LM. Efficacy of preoperative antimicrobial preparation of the bowel. Ann Surg. 1972; 176: 227-232.

  50. Migaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the use of bowel preparation in elective colon and rectal surgery. Dis Colon Rectum. 2019; 62: 3-8.

  51. Chude GG, Rayate NV, Patris V, Koshariya M, Jagad R, Kawamoto J, et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology. 2008; 55: 1562-1567.

  52. Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008; 248: 52-60.

  53. Montedori A, Cirocchi R, Farinella E, Sciannameo F, Abraha I. Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev. 2010; CD006878. doi: 10.1002/14651858.CD006878.pub2.

  54. Weledji EP, Ngowe MN. The challenge of intra-abdominal sepsis. Int J Surg. 2013; 11: 290-295. doi: 10.1016/j.ijsu.2013.02.021.

  55. Phitayakorn R, Delaney CP, Reynolds HL, Champagne BJ, Heriot AG, Neary P, et al. Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J Surg. 2008; 32: 1147-1156. doi: 10.1007/s00268-008-9468-1.

  56. Johnson WC, Gerzof SG, Robbins AH, Nabseth DC. Treatment of abdominal abscesses: comparative evaluation of operative drainage versus percutaneous catheter drainage guided by computed tomography or ultrasound. Ann Surg. 1981; 194: 510-520.

  57. Elagili F, Stocchi L, Ozuner G, Dietz DW, Kiran RP. Outcomes of percutaneous drainage without surgery for patients with diverticular abscess. Dis Colon Rectum. 2014; 57: 331-336.

  58. van den Berg MW, Kerbert AC, van Soest EJ, Schwartz MP, Bakker CM, Gilissen LP, et al. Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula. Dis Esophagus. 2016; 29: 572-579.

  59. Lamazza A, Fiori E, Schillaci A, Sterpetti AV, Lezoche E. Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal stents. Am J Surg. 2014; 208: 465-469. doi: 10.1016/j.amjsurg.2013.09.032.

  60. Mangiavillano B, Caruso A, Manta R, Di Mitri R, Arezzo A, Pagano N, et al. Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: A multicenter retrospective study and a classification of gastrointestinal tract perforations. World J Gastrointest Surg. 2016; 8: 315-320. doi: 10.4240/wjgs.v8.i4.315.

  61. Nerup N, Johansen JL, Alkhefagie GA, Maina P, Jensen KH. Promising results after endoscopic vacuum treatment of anastomotic leakage following resection of rectal cancer with ileostomy. Dan Med J. 2013; 60: A4604.

  62. Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc. 2008; 22: 1818-1825.

  63. van Koperen PJ, van Berge Henegouwen MI, Rosman C, Bakker CM, Heres P, Slors JF, et al. The Dutch multicenter experience of the endo-sponge treatment for anastomotic leakage after colorectal surgery. Surg Endosc. 2009; 23: 1379-1383. doi: 10.1007/s00464-008-0186-4.



AFFILIATIONS

1 Department of General Surgery. Hospital de Especialidades del Centro Médico Nacional "La Raza" (1984-2013). Ex-President, Asociación Mexicana de Cirugía General. Academia Mexicana de Cirugía.

2 Servicio de Cirugía General en el Hospital de Especialidades del Centro Médico Nacional "La Raza" (2012-2016). Member of the Asociación Mexicana de Cirugía General.

3 Unidad de Investigación Biomédica 02. Hospital de Especialidades. Centro Médico Nacional de Occidente del Instituto Mexicano del Seguro Social.

4 Departamento de Cirugía General. Hospital de Especialidades. Centro Médico Nacional de Occidente del Instituto Mexicano del Seguro Social.



Ethical considerations and responsibility: Data privacy. According to the protocols established in the authors\' workplace, they declare that they have followed the protocols on the privacy of patients\' data while preserving their anonymity.

The informed consent of the patient referred to in the article is held by the author.

Funding: No financial support was received for this work.

Conflict of interest: The authors declare that there is no conflict of interest in the carrying out of this paper.



CORRESPONDENCE

Dr. Alejandro González Ojeda. E-mail: avygail5@gmail.com




Received: 17/12/2018. Accepted: 16/06/2019

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