We routinely drain this anastomosis with 2 presacral perineal drains and peritonize the pelvic floor. So when a anastomotic leak happens- and it happens often in low RRA -the drains are put on lavage with diluted Braunol for the one drain and the other is on mild aspiration. Very few patients require reoperation- only those with signs of peritonitis. 

peritonization at the end of the procedure is the keypoint for conservative treatment in case of anastomotic leaks. This can be hard in case of laparoscopic approach. A good option in case of the presence of a sinus is to use in the early phases a suction "VAC like" system as Endosponge, if it fits

If the anastamosis has completely disrupted and the end of colon lies a few centimeters from the top of anal canal, are there any interventions possible to ensure healing?

I believe the most complete analysis of this problem can be seen here:

J Am Coll Surg. 2014 May;218(5):940-9. doi: 10.1016/j.jamcollsurg.2014.01.051. Epub 2014 Feb 18.

Management of anastomotic leakage in a nationwide cohort of colonic cancer patients.

Krarup PM1, Jorgensen LN2, Harling H2; Danish Colorectal Cancer Group.

Best regards

Thank you Kristian but this paper does not answer the specific question

Dear Surendra,

2 problems to solve, first is the sepsis from the desunion but I assume that the patient has an ileostomy and local drainage will get over this.

The second problem is to found a plan to avoid a permanent stoma.

Before going to this solution we need to be clear about the term we use. Was this a low colorectal stapeled anastomosis or was it a real coloanal sawn on the dentate line?

My experinece is that most people do low colorectal anastomosis with a rectal cuff always a bit longer then what was expected.

The only way to fix this is to redo a complete abdominal approach with a few steps to go through.

1) Are you sure that the cancer is well under control, has the patient received radiation? HOw far are we from the initial operation?

2)How much of the colon was removed at the first operation, was the inferior mesenteric vein divided was the midle colic preserved?

3)After a large midle line laparotomy, complete adhesiolysis is necessary from DJ flexure to IC valve.

4)Mobilising the colon going to the pelvis is one of the difficult times because dissection has to go between the left uretere and the meso of the descendidng colon lost of hard adhesions if surgery was just a few months ago. If necessary obviously the colon has to be compromised.

5)there is usualy a lot of fibrosis closing the pelvis access due to the local sepsis and often it looks totaly impossible to recreat space for a new reconstruction, you have to have seen that once before but it is possible without too much danger to recreate space by pulling hard on bladder/prostate or bladder /vagina to crack the pelvic fibrosis helping with 2 fingers in the anal canal. Carefull with ureteres and internal iliac vessels.

6) mobilising enough colon to reach the anus, often a Deloyer's procedure is required because the descnding colon can be traumatised during the redo pelvic dissection.

7)through a transanal approach with a lone star, mucosectomy from dentate line to the top of the rectal stump, avoiding to remove this rectal stump oftne very close to uretra or vaguina .

8) Soave trans ana hand sown coloanal anastomosis between idealy a colonic 7 cm J-Pouch or sometime just a straight coloanal if the colon is large enough or too short.

9) Loop ileostomy for 6 weeks, opacification through it before reversal.

This is 6 to 10 hours operation but works very well and gived a very good functional outcome.

Regards

Bertrand Jauffret

Immediate endoanal pull-through will be my choice. As long the redo procedure is delayed the functional outcome is more compromised.

I understand you are talking about an acute complication in the early postoperative period (few days after previous resection), and there is not difuse peritonitis. In this situation, I would dissect proximal colon free and extensivelly clean and wash pelvic area; after these maneuvers I will proceed to new reconstruction as illustrated by Dr Jauffrett. Important key points:

1 - Re-operation should be made immediately after soon diagnosis of disruption . It makes no sense to reconstruct into a deeply infected pelvis.

2 - Assure complete freeing of left  angle of the colon: it should be completely mobilized till midtransverse colon. No tension is admitted on the suture line.

3 - Use an omental flap to protect the anastomotic area and to replenish the pelvic space at the same time making possible closure of the pelvis.

4 - Loop ileostomy for protection is mandatory

Best regards

usually leaks occur on 4th or 5th day and noticed on the following day.By that time area is already contaminated deep in the pelvis.Reconstruction may not be successful.Since

we all mostly do a defunctioning ileostomy,two drains in the pelvis and ?closure of pelvic peritoneum,supportive non interventional treatment is safer and at appropriate time re evaluate and redo the anastamosis.I am a strong beleaver in doing a loop ileostomy,however good anastamosis is, in cases of colo anal or ultra colorectal anastamosis.I give a small anticlock wise twist to the loop ileostomy, so that contents of proximal bowel will not spill in to the distal defunctioned segment.In our scenario these pts are sick mostly  for a second intervention.

Thanks for the interesting question and discussions.

Thank you all for your valuable responses.

Let us give it a twist

If the patient is well with no collections in the pelvis. Patient has an ileostomy and no signs of pelvic sepsis and is in 3rd or 4th weeks after surgery . What will you do to

1. keep the distal end of colon patent and not allow it to stenose

2. ensure healing and bridging of gap between distal end of colon and top of anal canal.

When such reoperations are planned, in order to minimize the left ureter damage during the full left colon mobilization, we try to stent pre-operatively the left ureter by cistoscopic approach; the stent is tied to the Foley catheter.The ureter can be easily felt and recognized during re-operation. At the end of procedure the stent is remouved by retracting the Foley catheter. 

usually anastamotic dehiscense of colorectal or coloanal is due to technical or ischemic

I am sure most of us if not all do a defunctioning loop ileostomy and test for the integrity of anastamosis.so if a leak due to technical ,it is noticed immidiately or if it is ischemic it usually happens 3rd or4 th day and clinical recognition follows the next day in most of the centres.So the area is contaminated and difficult to do anstamosis at that time,and invariably dehicense occurs again.Since there is a loop ileostomy which I routinely twist anticlockwise to prevent proximal loop contents spilling in to the dital defunctioned loop,and the pt has two pelvic drains and probably pelvic peritonium is closed and the pt many a times sick due to sepsis,why can not we wait and do it as an elective procedure after initial conservative management.

Suturing of pelvic peritoneum is life saving to avoid peritonitis in case of likage.

Usually we pu two drains. In case of leakage with stable patient, Iirrigation with betadine ghrough one drain and 

Hi Surendra,

If continuity between colon and anal canal is not reestablished a stricture will develop with or without a pre sacral collection.

It is possible to dilate the stricture regularly but it could be for ever, the functional outcome will be disappointing with a lot of time spent on or close the toilets and very poor continence due to the lake of compliance of the neo rectum.

Presacral collection can persists for years with little symptoms but can also generate significant scary PR bleeding.

It depends on how much is missing, if the disruption is only partial and more then 80% of circumference is preserved after a few dilatations it may stabilizes to something comfortable. If the colon is completely separated from the anal canal it is difficult to imagine a healing process bridging the disunion without a severe and permanent stricture.

Have you done a pouch or was this a straight coloanal, sometime it is only the pouch leaking this is repairable.

It is too early to go back anyway so why not waiting a few months and see what is happening?

If the patient has received radiation it is very unlikely that any healing will come from the surrounding structure except the colon which is the only tissue able to generate a healing process.

It is exactly the same problem HPB surgeons get with biliary anastomosis, no mucosal contact = stricture.

Regards

Bertrand Jauffret.

if there is leak of the coloanal anastomosis , with pelvic peritonium being sutured intra-operatively and no signs of peritonitis, then nothing much needs to be done.

the problem of stricture can be addressed at a later date.

I agree Jauffret with your excellent answer and at this point of time wait and watch as suggested by others could be possibly the best option.

In case of leakage of a coloanal anastomosis a defunctioning ileostomy or diverting colostomy with distal loop buried to avoid communication of fecal content is mandatory. Whether to chose a colostomy (Hartmann-like) or a ileostomy depends on the type of previous surgery. After a 3 to 6-months recovery a combination of barium x-ray, endoscopy and MRI can help to guide stoma closure. Anyway, one should always keep in mind that a residual ghost fistula can still be there but you can deal with it later on with a VAAFT approach.

Re-explore, Total diverting ilesotomy and drainage of pelvis

usually we perform diverting ileostomy sincronus with  colo-anal anastomosis , so if a leakeage occurr the patient is not septic,don't close the ileostomy and treat the deiscense( vacuum sponge) 

 Total diverting ilesotomy and drainage of pelvis and treat the patient as acase of peritonitis (fluid/antibiotics)