Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer.

AIM Anastomotic leakage is a feared complication of colorectal surgery and can be devastating in low pelvic anastomosis. With the advent of nonoperative treatments for leakage, the question of management of persistent low colorectal and coloanal anastomosis arises. A review of patients who have undergone transanal repair of anastomotic leakage is presented. METHOD A review of all anastomoses performed in the Division of Colorectal surgery at two institutions, from January 2000 to June 2008, was performed. Anastomotic leakage was defined as the finding at reoperation of a dehiscence, or radiographic findings of extravasation from the anastomosis, or the identification of intra-abdominal abscess formation at the site of the anastomosis, enterocutaneous fistula or rectovaginal fistula. Patients who underwent transanal repair of the leakage were identified. RESULTS There were 663 low anterior resections performed during the study period. Of these, 36 experienced leakage of a low colorectal or coloanal anastomosis. Of these 36 patients, five underwent transanal repair of the anastomotic leak. All had had a low anterior resection for rectal cancer (coloanal=4; low colorectal anastomosis=1). Four had had prior chemoradiation and ileostomy defunctioning at the initial operation. The fifth had an ileostomy created to treat a leak. Six transanal repairs were performed, including endorectal advancement flap (n=3), dermal flap (n=1), direct suture repair (n=1) and debridement of an infected cavity (n=1). At the time of the present assessment, four patients had undergone reversal of ileostomy after radiographic evidence of complete healing and the fifth patient has a persistent leak. CONCLUSION Transanal repair of a persistent low colorectal or coloanal anastomotic leakage is feasible in selected cases, even when chemoradiation has been performed.