
improved outcomes in colon and rectal surgery
The specific type of fecal diversion, ileostomy versus colostomy,
does not influence anastomotic related outcomes.(25)
MECHANICAL BOWEL PREPARATION
Mechanical bowel preparation before elective resection has been
surgical dogma since Halsted’s description of intestinal anasto-
mosis in 1887. Empiric-based practice relies on mechanical bowel
preparation together with oral antibiotics to reduce the bacterial
load of the bowel and, in theory, to decrease the risks of anas-
tomotic leak and surgical site infection. Bowel preparation, far
from innocuous, is inconvenient and unpleasant for patients and
is associated with potentially harmful metabolic and fluid distur-
bances. For these reasons, and because the purported benefits of
bowel preparation remain unproven, the utility of mechanical
preparation has been questioned.
A Cochrane review evaluating the efficacy of bowel prepara-
tion in its ability to reduce postoperative complications included
1,592 patients from nine randomized, controlled trials stratified
to a colectomy group and a low anterior resection group.(26) The
clinical leak rate in the colectomy group with and without bowel
preparation was 2.9% and 1.6%, respectively (p value not signifi-
cant). The clinical leak rate in the low anterior resection group
with and without bowel preparation was 9.8% and 7.5%, respec-
tively (p value not significant). When the surgical groups were
combined, the 6.2% clinical leak rate in the prepared group was
significantly higher than the 3.2% rate in the unprepared group
(p = 0.003). Meta-analysis of all other infectious complication
rates, including surgical site infection, demonstrated no protec-
tive effect of mechanical bowel preparation.
Despite significant evidence that bowel preparation before

(8, 10, 15, 17, 19, 29) It has also been shown that the size of the
circular stapler does not contribute to the leak rate.(14)
OMENTAL PEDICLE
In an effort to quarantine an anastomosis in the event of a leak and
to mitigate the consequences of a leak, many surgeons utilize an
omental pedicle. To reach a pelvic anastomosis, the omentum is
typically mobilized to survive off the left gastroepiploic artery. The
influence of an omental pedicle on anastomotic outcomes was eval-
uated in a prospective, randomized study of 705 patients undergo-
ing bowel anastomosis and no statistically significant influence on
the rate or severity of leak was observed.(30) Another smaller, ran-
domized, controlled trial of 126 patients demonstrated a protective
effect of an omental pedicle; though, this study could be criticized
for a rather high leak rate (22%) in the group of patients without
an omentoplasty.(31) Both of these studies reported overall leak
rates including clinical and radiologic leaks.
The discrepancy between these two trials is characteristic of
many of the studies investigating anastomotic complications.
Leaks are low frequency events requiring large, homogenous study
populations for accurate evaluation. No firm evidence-based rec-
ommendation can be made with regard to omentoplasty and its
potential effects on colorectal anastomotic outcomes; bringing an
omental pedicle to the pelvis should be done according to the
surgeon’s preference.
RADIATION
Neoadjuvant radiotherapy has been evaluated in terms of poten-
tially increasing the risk of dehiscence of pelvic anastomoses.
The proposed mechanism of increasing the leak rate is that pel-
vic radiation may interfere with healing of the anastomosis due
to toxicity in the pelvis. Radiation changes to the colon side of

sate. The possible mechanism whereby pelvic drains, theoreti-
cally, may protect against colorectal anastomotic leak relies on the
characteristics of the extra-peritoneal low pelvis in that the peri-
toneum is absent. Violation of the presacral space during proctec-
tomy leaves a significant raw surface and without the absorptive
abilities of the peritoneum fluid can collect in the dependent dead
space created by total excision of the mesorectum. Further com-
plicating the matter is the potential for negative pressure in the
low pelvis that promotes the accumulation of fluid that can possi-
bly disrupt the anastomosis. A pelvic drain can, possibly, prevent
accumulation of fluid behind the anastomosis. These theoretical
benefits of pelvic drainage together with results of statistically
under-powered trials may explain why many surgeons continue
to drain pelvic anastomoses.
Routine pelvic drainage has been evaluated in retrospective
fashion as well as with randomized, controlled trials with regard
to a possible influence on the occurrence and diagnosis of col-
orectal anastomotic leak. For example, the data collected in the
prospective, randomized Dutch TME trial was studied after-the-
fact in retrospective fashion to determine the utility of pelvic
drainage during low anterior resection.(19) Patients in this trial
were randomly assigned whether or not to receive neoadjuvant
radiation therapy before TME. At the time of operation, place-
ment of pelvic drains was decided at the discretion of the oper-
ating surgeon. Multiple regression analysis demonstrated that
pelvic drainage was strongly associated with a lower clinical leak
rate (leaks occurred in 9.6% of patients with drains compared
with 23.5% of patients without drains, p < 0.001). Moreover, the
need for re-operation in leaking patients was significantly more
likely in patients without preexisting pelvic drainage (97% of

difficult or impossible to influence. Due to the large numbers
of patients required to study anastomotic complications, many
variables may never be studied sufficiently in terms of possibly
contributing to anastomotic leak (Table 7.1).
Total mesorectal excision, as it was originally described, left a
relatively ischemic distal rectum after resection for proximal rec-
tal cancer. Tumor specific mesorectal excision for proximal rectal
cancer has become popular as it preserves the distal mesorectum
without compromising oncologic adequacy and decreases the
risk of leak compared with total mesorectal excision.(10, 15, 33,
38) The height of an anastomosis can influence tension across
the tissues and, together with prolonged operating time, is likely
a surrogate marker for more difficult operations especially in the
narrow, male pelvis. It is also postulated that, in low pelvic anas-
tomoses, the proximate anal sphincter increases the intraluminal
pressure across the anastomosis jeopardizing its integrity.
In terms of the surgical approach, the Clinical Outcomes of
Surgical Therapy (COST) trial and others have not demonstrated
an increased anastomotic failure rate with regard to laparoscopic
versus conventional open colectomy.(39–41) Trials evaluating
laparoscopic versus open rectal cancer resection with colorectal
anastomosis are underway.
CLINICAL PRESENTATION
The clinical manifestations of anastomotic dehiscence vary
depending on the location of the leaking anastomosis, the
severity of the leak and whether or not the leak is contained or
walled-off. For these reasons, while many patients with anasto-
motic dehiscence present acutely with signs and symptoms of
sepsis and an abdominal catastrophe, a subset of patients have
Table 7.1 Factors with conflicting evidence in the literature that

rapid progression to multisystem organ dysfunction. Meanwhile,
in a considerable number of patients, recognition of an anasto-
motic leak may be difficult due to the significant overlap between
the signs and symptoms of a leaking patient and those of a typi-
cal patient recovering from major abdominal surgery. Patients
may present with any combination of fever, tachycardia, varying
degrees of abdominal pain and distension, ileus, diarrhea, mal-
aise, failure to thrive, bowel obstruction, and septic shock. Some
patients present with symptoms mimicking cardiac complications
such as respiratory failure and chest pain. Leaking patients may
also fail to clinically progress or recover within a usual timeframe,
have increasing narcotic demands, or have decreased urine output
requiring fluid boluses. The physical exam of a leaking patient may
include focal or diffuse abdominal tenderness, rigidity, guarding,
abdominal distension, and evidence of varying degrees of hemo-
dynamic collapse. Patients may have leukocytosis, typically with a
left shift, leukopenia, metabolic acidosis, or thrombocytopenia.
After any intestinal anastomosis, the surgeon must maintain a
high index of suspicion when evaluating patients with unusual
signs of sepsis or patients who fail to meet the clinical milestones
of normal recovery within a typical timeframe. The potential for
delay in diagnosis is significant; delays may impact patient out-
comes and have medicolegal ramifications.
DIAGNOSIS
Patients with generalized peritonitis consistent with a leak require
urgent return to the operating room with concomitant intrave-
nous fluid resuscitation and broad-spectrum antibiotics. In this
setting, the time to re-operation is critical and a diagnostic jour-
ney with imaging studies will only delay potentially life-saving
abdominal exploration. Meanwhile, patients with a more subtle

anastomotic leak outright as well as after a CT scan fails to dem-
onstrate a leak.(9, 45) Extravasation or pooling of rectal contrast
outside of the bowel lumen during an enema study is pathogno-
monic of leak (Figures 7.1 and 7.2). Water-soluble contrast must
be used when evaluating for a possible anastomotic dehiscence as
extravasated barium increases the severity of a leak by adding to
the inflammatory response in the abdomen. In reality, the choice
of imaging study in a particular patient is influenced by the clini-
cal presentation, institutional expertise, and available resources.
MANAGEMENT
The management of anastomotic dehiscence in a particular
patient depends on the clinical manifestations of the leak and
the condition of the patient (Figure 7.3). Common manifesta-
tions of a leak from a colorectal anastomosis are asymptomatic,
leak without abscess, leak with associated abscess, peritonitis, and
colocutaneous fistula.
Asymptomatic
Early in the experience with circular staplers, routine water-
soluble contrast enemas demonstrated that as many as half of
patients with pelvic anastomoses demonstrated a radiologic leak
during the first postoperative week. Often these are short, sim-
ple sinus tracts originating from the anastomosis. In otherwise
Table 7.2 The time interval between colorectal anastomosis and
diagnosis of a leak.
Post Op Day
Study N of Diagnosis
a
Range (days)
Rullier 1998 (8) 32 11 2–41
Carlsen 1998 (16) 11 8 4–15

arrows) from colorectal anastomosis (lateral view).
No abscess
No peritonitis
Antibiotics
Bowel rest
No resolution
or
Patient worsens
Anastomotic Leak
Peritonitis
Colocutaneous
Fistula
Abscess
Laparotomy
Antibiotics
Resuscitation
Address any
collections
Drainage
Antibiotics
Leak resolves
Laparotomy
No further
treatment
Worsens
Fistula
Antibiotics
Bowel rest
Nutrition
No resolution

and must be treated in urgent fashion. As reviewed earlier, in these
situations, there is no benefit to pursuing diagnostic studies as the
consequences of delaying operative intervention may be dire.
Colocutaneous fistula
Fistulization to the skin, typically through a drain site or skin
incision, may be a late manifestation of anastomotic leak. Once
a fistula is observed clinically, a CT scan is helpful to evaluate for
any undrained collection which would need to be addressed. In
general, once the local sepsis has been controlled, most anasto-
motic fistulae will close with bowel rest. Optimizing nutritional
status and attention to wound care are important in these patients.
Specific circumstances that may preclude spontaneous resolution
of a fistula are distal obstruction, associated anastomotic stric-
ture, radiation, and steroid therapy. Patients who fail nonopera-
tive treatment may benefit from operative intervention.
OPERATIVE INTERVENTION
The goals of re-operation for anastomotic leak are to control the
source of sepsis, remove any purulence or contamination and
prevent ongoing leak. While preservation of function is impor-
tant, it must be emphasized that these are life-saving operations.
There are a number of options available to the surgeon returning
a patient to the operating room to address a leaking anastomosis
and the particular procedure performed is decided at the time of
exploration based on clinical judgment and the unique presenta-
tion of the patient on the table.
As most patients undergoing reoperation for suspected leak
require some form of fecal diversion that may be permanent,
potential sites for stoma formation should be marked preopera-
tively. In the operating room, it is helpful to have the patient in
either split leg position or in lithotomy stirrups to facilitate access

Leaving the leaking anastomosis in place
An alternative to end stoma creation in many instances consists of
abdominal washout, proximal fecal diversion via loop stoma, and
drainage of the anastomotic leak.(19, 23, 45, 46) The benefits of this
approach are that it effectively controls the septic source and allows
the majority of patients to undergo stoma reversal in the future.(4,
6, 17) The main criticism of leaving a leaking anastomosis in place is
that luminal contents proximal to the anastomosis may provide an
ongoing source of contamination and that the anastomosis may stric-
ture or fistulize.(23) Review of the literature does not substantiate the
concern of ongoing contamination and demonstrates that proximal
diversion is safe and has a high rate of anastomotic salvage.
The use of a colostomy versus ileostomy for diversion does not
impact anastomotic outcomes but meta-analysis of 1,204 patients
demonstrated significantly fewer stoma related complications and
postreversal hernias with loop ileostomy.(25) Some advocate lavage
of the proximal colon to eliminate whatever stool is proximal to the
anastomosis and some surgeons describe suturing closed the anas-
tomotic defect in an effort to contain the leak; the utility of these
maneuvers remains empiric. Deciding whether or not to resect or
preserve a leaking anastomosis depends on the surgeon’s experience,
the size of the anastomotic defect, and the viability of the colon.
Repeat anastomosis after resection of the leaking anastomosis
In certain situations, it may be possible to resect a leaking anasto-
mosis and perform a new anastomosis with or without proximal
diversion. This may be technically possible when dealing with a
leak from an ileocolic anastomosis. Colorectal anastomoses are
unlikely to be amenable to immediate reconstruction given the
limitations of reach, especially in a hostile abdomen.
Exteriorization of the leaking anastomosis

sion after a leak and bowel function after experiencing a leak are
significantly impaired.(49) In comparison with patients who did
not leak, patients who undergo stoma reversal after resolution of a
leak have decreased rectal capacity and compliance and more diffi-
culties evacuating.(7) In addition, in a review of nearly 1,400 surgi-
cal patients treated for rectal cancer, patients who leaked were less
likely to receive adjuvant chemotherapy and when they did receive
chemotherapy, it was more likely after a substantial delay.(6)
In a multicenter Scottish study of 2,235 patients who under-
went curative resection for colorectal cancer, the 5-year overall
survival rate, excluding mortalities within 30-days of operation,
for patients who leaked compared with patients who did not
leak was 42% and 55%, respectively (p < 0.01) (3). The 5-year
cancer-specific survival rate, also excluding postoperative deaths,
for patients who leaked compared with patients who did not leak
was 50% and 68%, respectively (p < 0.001). The increased risk of
cancer-specific death in patients with an anastomotic leak was
most apparent between 2 and 4 years after surgery. Similarly,
other studies have demonstrated increased local recurrence rates
(5) as well as decreased overall and cancer-specific survival (50)
after anastomotic leak. The etiology of these inferior long-term
outcomes in patients who suffer a leak remains speculative.
ANASTOMOTIC STRICTURE
Colorectal anastomotic stricture may occur in up to 10% of patients
depending on how a stricture is defined.(51, 52) From a clinical
standpoint, stricture may be defined as a symptomatic narrowing
of the anastomosis that obstructs the flow of intestinal contents.
(53) Alternatively, a stricture may be defined by the inability to pass
a particular size of proctoscope through an anastomotic narrow-
ing. The vast majority of anastomotic strictures tend to be short

Stoma reversal in the face of a stricture risks anastomotic disrup-
tion at the site of the stoma takedown and should be avoided.
The majority of colorectal anastomotic strictures that require
intervention are readily salvaged using endoluminal dilating
techniques.(55) Typically, dilation is postponed until the anas-
tomosis has healed and become more pliable; waiting over 4–6
(a) (b)
(c)
(d)

postoperative anastomotic complications
weeks is prudent. Simple methods used to dilate a low anastomo-
sis include gentle digital rectal exam or sequentially sized dilators
(i.e., bougie, Hegar, etc.).
Strictures out of reach for these modalities or that require con-
trolled dilation under direct observation are usually treated with
commercially available through-the-scope (TTS) hydrostatic bal-
loon dilators that control radial expansion using a pressure gauge
(Figure 7.7). Sequential dilation to a diameter >20 mm is usually
accomplished under conscious sedation with or without empiric
antibiotic coverage and has a low complication rate.(56) Balloon
dilation is successful in the majority of cases although repeat dila-
tions may be required. Injecting triamcinolone, a long-acting
corticosteroid, into the stricture or releasing the stricture using
electrocautery or laser in combination with balloon dilation may
decrease the need for repeat dilations without significantly increas-
ing the complication rate.(57) Larger diameter, over-the-wire bal-
loons may require fewer repeat dilations than TTS devices.(55)
The few patients with short anastomotic strictures who do not
respond to repeated dilation and patients with long, irregular

curative resection for colorectal cancer. Br J Surg 2005; 92:
1150–4.
4. Hedrick TL, Sawyer RG, Foley EF et al. Anastomotic leak and
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5. Branagan G, Finnis D. Prognosis after anastomotic leakage in
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
8
General postoperative complications
Scott R Steele and Clifford L Simmang
Financial Disclosure: No outside financial support or provision
of supplies was solicited or received in connection with this work.
Disclosure and Proprietary Statement: This is an original work
by the above author. The opinions expressed are the author’s and
author’s alone. They do not necessarily reflect the opinion of the
U.S. Government, the U.S. Department of Defense, or Madigan
Army Medical Center.
CHALLENGING CASE
A 72-year-old female is scheduled to undergo a low anterior
resection for T3N0M0 rectal cancer. She has been confined to a
wheelchair for the last month due to a fibular fracture. Her co-
morbidities include diabetes, hypertension, hyperlipidemia, and
she has a 50 pack-year smoking history. Describe the optimal
management for deep venous thrombosis prophylaxis.
CASE MANAGEMENT
The patient falls into a high risk classification as evidenced by
her older age, recent immobility, smoking history, comorbidi-
ties, malignancy, and need for pelvic surgery. In addition to the
mechanical measures (e.g., graduated compression stockings or
intermittent pneumatic compression devices and early ambula-
tion) this patient should receive either subcutaneous unfraction-
ated heparin (typically 5,000 IU two or three times per day) or
low molecular weight heparin (~0.5 IU/kg), with higher doses

Although it may seem intuitive that adequate control of postop-
erative pain is a mandatory and rather easy standard to achieve,
in practice this oftentimes remains a far more difficult objective
to attain. In part, this may be secondary to the lack of having an
accurate way to predict those patients that will have difficulty with
postoperative pain control. In addition, we frequently use primi-
tive measures to quantify pain, relying heavily on devices such as
visual analogue scales and verbal pain scales commonly employed
in the recovery phase, which, due to language and cultural barri-
ers, often do not have adequate correlation amongst patients. This
is especially evident when trying to accurately detect and record
changes in pain level over time, evaluate which pain dimension
the patient is being asked to report (i.e., intensity versus relief), or
to which interval does the pain level correspond (i.e., current level
versus average over a time period).(2) Despite these difficulties,
adequate pain control remains such an important component to
the overall care of the postoperative patient, it is often referred to
as the fifth vital sign. Optimal control of pain continues to be pur-
sued through a multifactorial and multifaceted approach.
Emphasis in recent years has been toward adequate preoperative
and thus preemptive pain control. Medications such as ketorolac,
COX-2 inhibitors, and local anesthesia before the incision have all
been used in attempt to lessen postoperative pain, as well as decrease
reliance on more traditional methods such as narcotics. Sim and
colleagues in a prospective randomized blinded study of 40 patients
undergoing elective colorectal surgery found the perioperative use
of COX-2 inhibitors, which included a single dose 1 hour before
surgery, was associated with a significant decrease in both postop-
erative narcotic use as well as shorter recovery of bowel function
and earlier discharge.(3) Lack of widespread use of these agents has,