Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2021 Nov 23;34(6):385-390.
doi: 10.1055/s-0041-1735269. eCollection 2021 Nov.

Anastomotic Troubleshooting

Naomi M Sell  1   2 , Todd D Francone  1   2
Affiliations
Review

Anastomotic Troubleshooting

Naomi M Sell et al. Clin Colon Rectal Surg. .

Abstract

Anastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.

Keywords: air leak test; anastomotic leak; colorectal surgery.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest None declared.

Figures

Fig. 1
Fig. 1
Intraoperative colorectal anastomosis air leak test (ALT). ( A ) Intraabdominal view of pelvis filled with normal saline. The new anastomosis is submerged in the saline and the proximal bowel is gently occluded with a blunt grasper. ( B ) A sigmoidoscope allows direct visualization of the anastomosis and provides air for gentle insufflation to check for bubbles in the ALT.
Fig. 2
Fig. 2
Air leak test (ALT) with use of a 60-cc bulb syringe. Reprinted with permission of Cleveland Clinic Foundation; All Rights Reserved.
Fig. 3
Fig. 3
( A ) Positive air leak test (ALT) of a colorectal anastomosis after sigmoid resection. The bubbles in the saline (Jacuzzi Sign) indicate a defect in the staple line that requires further evaluation. ( B ) Primary repair of the anastomotic defect which was protected by a diverting loop ileostomy.
Fig. 4
Fig. 4
Tissue doughnuts after use of a circular stapler. ( A ) Examples of a complete distal and proximal doughnut with purse string in place. ( B ) Incomplete doughnut.
See this image and copyright information in PMC

References

    1. Krarup P M, Nordholm-Carstensen A, Jorgensen L N, Harling H. Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study. Ann Surg. 2014;259(05):930–938. - PubMed
    1. Study group Qualitätssicherung Kolon/Rektum-Karzinome (Primärtumor) (Quality assurance in primary colorectal carcinoma) . Kube R, Mroczkowski P, Granowski D. Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival. Eur J Surg Oncol. 2010;36(02):120–124. - PubMed
    1. Scarborough J E, Schumacher J, Kent K C, Heise C P, Greenberg C C. Associations of specific postoperative complications with outcomes after elective colon resection: a procedure-targeted approach toward surgical quality improvement. JAMA Surg. 2017;152(02):e164681. - PubMed
    1. Telem D A, Chin E H, Nguyen S Q, Divino C M.Risk factors for anastomotic leak following colorectal surgery: a case-control study Arch Surg 201014504371–376., discussion 376 - PubMed
    1. Bakker I S, Grossmann I, Henneman D, Havenga K, Wiggers T.Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit Br J Surg 201410104424–432., discussion 432 - PubMed