Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Nov 27, 2015; 7(11): 289-292
Published online Nov 27, 2015. doi: 10.4240/wjgs.v7.i11.289
Anastomotic leakage in rectal cancer surgery: The role of blood perfusion
Martin Rutegård, Jörgen Rutegård
Martin Rutegård, Jörgen Rutegård, Department of Surgical and Perioperative Sciences, Umeå University, S-90187 Umeå, Sweden
Author contributions: Rutegård M conceived and wrote the article; Rutegård J edited and revised the manuscript for important intellectual content.
Conflict-of-interest statement: The authors have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Martin Rutegård, MD, PhD, Department of Surgical and Perioperative Sciences, Umeå University, SE-901-87, S-90187 Umeå, Sweden. martin.rutegard@surgery.umu.se
Telephone: +46-90-7858628 Fax: +46-90-7851156
Received: May 20, 2015
Peer-review started: May 20, 2015
First decision: July 10, 2015
Revised: July 12, 2015
Accepted: September 29, 2015
Article in press: September 30, 2015
Published online: November 27, 2015

Anastomotic leakage after anterior resection for rectal cancer remains a common and often devastating complication. Preoperative risk factors for anastomotic leakage have been studied extensively and are used for patient selection, especially whether to perform a diverting stoma or not. From the current literature, data suggest that perfusion in the rectal stump rather than in the colonic limb may be more important for the integrity of the colorectal anastomosis. Moreover, available research suggests that the mid and upper rectum is considerably more vascularized than the lower part, in which the posterior compartment seems most vulnerable. These data fit neatly with the observation that anastomotic leaks are far more frequent in patients undergoing total compared to partial mesorectal excision, and also that most leaks occur dorsally. Clinical judgment has been shown to ineffectively assess anastomotic viability, while promising methods to measure blood perfusion are evolving. Much interest has recently been turned to near-infrared light technology, enhanced with fluorescent agents, which enables intraoperative perfusion assessment. Preliminary data are promising, but large-scale controlled trials are lacking. With maturation of such technology, perfusion measurements may in the future inform the surgeon whether anastomoses are at risk. In high colorectal anastomoses, anastomotic revision might be feasible, while a diverting stoma could be fashioned selectively instead of routinely for low anastomoses.

Keywords: Anastomotic leakage, Blood perfusion, Rectal cancer, Anterior resection, Diverting stoma

Core tip: Anastomotic leakage after anterior resection for rectal cancer is still common. Several preoperative risk factors may inform the surgeon of the leakage risk. The surgeon might choose to perform a diverting stoma to mitigate this risk, or to construct an end colostomy and thus avoid an anastomosis altogether. Intraoperatively, clinical judgment of the viability of the anastomosis is not reliable. However, research using blood perfusion measurement technology has evolved in recent years; technology using near-infra red light seems to be promising, allowing assessment of the bowel perfusion. In the future, such technology may aid in the decision-making concerning colorectal anastomoses.