Hyman N et al. (2007) Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 245: 254–258

Patients who suffer an anastomotic leak shortly after colorectal surgery often present with life-threatening symptoms that require fecal diversion and intensive care. Many anastomotic leaks, however, present with subtle symptoms: low-grade fever and failure to thrive. Hyman et al. hypothesized that dramatic variations in anastomotic leak incidence reported in retrospective studies resulted from a failure to capture this subtle presentation. To discover the true incidence and presentation of anastomotic leakage, these authors analyzed data from a comprehensive complications database.

The database included prospectively recorded information on postoperative complications in 1,223 patients who underwent intestinal resection without initial fecal diversion during 1995–2004. Anastomotic leaks occurred in 33 patients (range 27–88 years, 17 male), of whom 15 underwent fecal diversion. The overall incidence of anastomotic leak (2.7%) was consistent across all but one surgical site—a markedly high leak incidence after ileorectal anastomosis (23.3%) prompted the authors to review the stapling technique used.

In total,12 leaks were diagnosed clinically at a mean of 7.0 days postoperatively, and the remainder were diagnosed by imaging, at a mean of 16.0 days postoperatively; CT performed better than contrast enema to diagnose the leaks. Many (14) leaks were only diagnosed after the patient was readmitted to hospital, and 4 leaks were diagnosed >30 days postoperatively (well after the typical hospital discharge time). In the light of these results, the authors stress the need for prospective recording of complications data and adequate patient follow-up, to ensure timely diagnosis and treatment of anastomotic leaks.