Anastomotic leakage after low rectal stapler anastomosis: significance of intraoperative anastomotic testing

Aims: One of the most significant surgical complications following rectal resection with primary anastomosis is anastomotic leakage. The aim of this study was to evaluate the benefit of intraoperative anastomotic testing of stapled anastomoses and the impact on leakage rate. Methods: Between 1987 and 2000, 1360 consecutive rectal resections for carcinoma were performed. In 933 operations rectal resection was completed with either stapled (n=788), handsewn (n=80) or coloanal (n=65) anastomosis. Since 1995 we introduced intraoperative anastomotic testing, routinely. Between 1995 and 2000, 296 patients were treated with stapled anastomosis following rectal resection. Different variables influencing anastomotic leakage were evaluated. Results: Between 1987 and 2000, 68 of 933 patients treated by resection and anastomosis developed a clinically significant anastomotic leak (7.3%) where as between 1995 and 2000 the leakage rate was 9.8% of all patients with stapled anastomosis. There was an increase in resection rate from 62 to 72%. Since 1995 we demonstrated either intraluminal bleeding or leakage in 18.1% of all stapled anastomoses by intraoperative anastomotic testing. The postoperative anastomotic leakage rate was equal in those patients with normal and abnormal findings of anastomotic testing even though 74% of all patients with irregular findings were treated by performing a protective stoma simultaneously. We found no significant risk factor for the development of anastomotic leakage. Conclusion: We recommend a protective stoma with any anastomosis within the lower third of the rectum. Anastomoses within the middle and upper third of the rectum demonstrate a lower risk of anastomotic insufficiency and do not need a protective stoma, routinely.