Little Consensus in Either Definition or Diagnosis of a Lower Gastro-intestinal Anastomotic Leak Amongst Colorectal Surgeons

Purpose: The purposes of this study were to assess the working definition of a colorectal anastomotic leak among colorectal surgeons and to survey the current approach to investigation and management of a patient with a suspected anastomotic leak.

Methods: Online survey consisting of nine questions regarding the definition, assessment and investigation of anastomotic leaks was conducted. Of the 738 eligible ACP members contacted, 210 responded (28.4%).

Results: Results demonstrated that 94.2% of surgeons agreed 'extravasation of contrast on enema' and 91.8% agreed 'faecal material seen in drains/from the wound' constituted a clinical leak. Only 69.2% agreed that a leak was 'intra-abdominal sepsis requiring a laparotomy', and about half agreed that radiological collections constituted a leak when either treated with antibiotics (46.6%) or with percutaneous drainage (51.4%). Serial clinical examination was the perceived most sensitive clinical feature for a leak, with 75% of surgeons ranking this in their top three choices. Surgeons radiologically confirm a leak on average in 80.2% of cases. A CT with rectal contrast for a left-sided leak was selected by 42.9% of respondents. For a right-sided/small bowel anastomosis, 44.5% selected a CT with oral contrast and 43.4% a CT with IV contrast.

Conclusions: There is still significant heterogeneity between surgeons in what they define as an anastomotic leak. Most surgeons valued clinical examination as the most sensitive initial tool for leak detection; however, radiology has a major role in the confirmation of clinical leaks in colorectal patients. There is an increasing need to be able to classify and grade anastomotic leaks, both to improve the care of patients and for audit purposes.