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Anastomotic leaks occur in roughly 6 to 12 percent of colectomies that include an end-to-end anastomosis (EEA) in the distal colon.1 The integrity of these anastomoses is affected by many factors including vascularity of the tissue, condition of the staple line, and tension of the anastomosis.2 Given the difficulty in evaluating each of these components, four means of assessment are currently being used by surgeons to assess the integrity of the anastomoses including colonic submersion followed by perianal air insufflation (air leak test), dyed enemas (povidone-iodine test), rigid sigmoidoscopies, and evaluation of doughnut integrity.2, 3
Air leak tests and doughnut integrity have been shown to be helpful in predicting contrast radiological leaks when both tests show signs of leakage, but not clinically significant leaks.2 Dyed enemas and sigmoidoscopies have also demonstrated benefit in locating leaks intraoperatively.3 This is the first case-control study to evaluate all four intraoperative maneuvers to determine which is most effective.
After approval by Mount Sinai Medical Center (MSMC) Investigational Review Board, 196 patients were retrospectively studied. Forty-nine patients underwent colectomies with colorectal anastomoses performed with an EEA stapler that resulted in subsequent anastomotic leaks. The following procedures were evaluated: low anterior resections, left hemicolectomies, sigmoid resections, and ileoanal pull-throughs.
Doughnut integrity was measured on a dichotomous scale, a positive test indicating damage to either the proximal or distal doughnut. Any intraoperative diversions were excluded because it lessens the risk of anastomotic leak and reduces severity of clinical presentation.
The 49 patients were obtained from a prospectively maintained database from the Department of Surgery at MSMC that defines an anastomotic leak as a disruption in an enteric anastomosis as defined by radiographic studies by computed tomography scan, endoscopy, contrast study, or clinical presentation supported by laboratory data, vital signs, and clinical symptoms (sepsis, abdominal pain, shortness of breath, pain, etc.).
This cohort was compared to a matched control group of 147 patients. All control patients underwent the same procedures but with no postoperative...