Original Articles
 

By Dr. Antonio Manenti , Dr. Gianrocco Manco , Dr. Elena Vezzelli , Dr. Salvatore Donatiello
Corresponding Author Dr. Antonio Manenti
Department Surgery, - Italy
Submitting Author Dr. Antonio Manenti
Other Authors Dr. Gianrocco Manco
Department of Surgery - University of Modena, - Italy

Dr. Elena Vezzelli
Institute of Radiology - University of Modena, - Italy

Dr. Salvatore Donatiello
Institute of Radiology - University of Modena, - Italy

SURGERY

Colon anastomosis leakage, Computed Tomography, Postoperative peritonitis

Manenti A, Manco G, Vezzelli E, Donatiello S. Leakage of Colonic Anastomosis: Computed Tomography Diagnosis. WebmedCentral SURGERY 2012;3(4):WMC003264
doi: 10.9754/journal.wmc.2012.003264

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
No
Submitted on: 18 Apr 2012 07:27:25 AM GMT
Published on: 18 Apr 2012 01:14:43 PM GMT

Abstract


Postoperative peritonitis following leakage of a colonic anastomosis is a challenging surgical complication, where a prompt clinical diagnosis, sometimes difficult, is requested before any therapeutic decision. In these cases Computed Tomography (CT) plays an important role.

Introduction


Colonic resection can complicate with anastomotic leakage and secondary peritonitis. The clinical diagnosis of this condition can be difficult, because (the) physical signs can vary from those of a frank peritonitis to others subtler, in case of localized abscesses. The picture of the correlated sepsis can be not absolutely specific, and often masqueraded by a symptomatic medical treatment, and can be referred to other possible sites of infection (pleuro-pulmonary, urological,etc.) (1,2). The severity of this complication and the necessity of an adequate treatment demand an urgent and certain diagnosis, based also on unequivocal imaging documents, among which today CT is of primary importance (3-6).

Methods


We have re-examined our experience of the years 2009-2011, based on 20 cases of post-operative peritonitis after colonic resection for carcinoma and complicated by anastomotic leakage, of which 17 referred from other surgical centres. 16 cases concerned left hemicolectomies or sigmoidectomies, 4 right hemicolectomies. After the usual diagnostic procedures (plain Rx of the abdomen, and echography), a multidetector CT was performed with multi- slice technique and intravenous contrast enhancement.
In our experience, the main indications to CT are the following:
- Diagnosis of peritonitis, distinguishing cases of diffuse peritonitis from others of localized abscesses.
-Topography and size of peritoneal abscesses, in view of their possible percutaneous drainage.
-Origin of the peritonitis, distinguishing cases of anastomotic colonic leakage from other possible post-operative conditions, as pancreatitis, cholecystitis, diverticular sigmoiditis, perforated gastro-duodenal ulcer, vascular, arterial or venous, accidents (thrombosis, dissection, aneurysm rupture).
-Detection of other surgical pitfalls, responsible of secondary peritonitis: injuries to duodenum, colon, small intestine, ureters, bladder, spleen, etc.
When evaluating the CT findings, the following morpho-radiological signs are of particular value:
-Intraperitoneal unencapsulated effusion, with different amount of gas inside (Illustration 1).
-Oedematous swelling, hypervascularization and venous congestion of the mesentery, retroperitoneum and intestinal walls, and lymph nodes enlargement (Illustration 2).
-Intraperitoneal abscess with an hyperenhanced peripheral rim, air - fluid levels or gas bubbles inside(Illustration 3); when localized between the sacrum hollow and the rectum, the sign of “double rectum” can be observed.  
-Haematomas, localized especially in the pre-sacral space, perisplenic region or retroperitoneum.
-Conditions of the colonic segments above and below the anastomosis (Illustration 4).

Results


After a careful reading of CT findings, two main different conditions must be distinguished.
A) An intraperitoneal liquid collection, largely diffused in the peritoneal cavity or in a quadrant, indicates a condition of acute peritonitis. Frequent concomitant lesions are oedematous swelling and hypervascularity of the mesentery, with venous congestion and enlarged lymph nodes. The walls of the adjacent small intestine and of the colon, above and below the anastomotic leak, often appear oedematous and thickened. A secondary pleural effusion is frequent.
B) Localized abscess appearing as a spherical or ovoidal fluid collection, often with inside gas bubbles, surrounded by thick and hyperenhanced walls, often localized in particular endoperitoneal regions (pelvic cavity, sub-phrenic , sub-hepatic, peri-splenic, central mesenteric, pre-sacral space); its size can be easily measured.
Other important morphological elements must be researched:
- Lesions of bladder, ureter or kidney, clearly appearing in the phase of CT excretory urography (7) (Illustration 5).
- Lesions of the small intestine, spleen, pancreas, gallbladder, often indirectly demonstrated by a surrounding hematoma, abscess, or a localized intraperitoneal effusion.
- Pathology of the colonic walls, above and below the anastomotic leak: oedematous thickening, signs of inadequate arterial vascular supply or venous thrombosis.   
After CT examinations, we directly proceeded to a laparotomy in 11 cases; in 6 to a simple percutaneous drainage, and in the other 3 cases of single small abscess, a conservative medical treatment was sufficient. In all cases the CT diagnosis was confirmed.

Conclusion(s)


Our retrospective study confirms the essential role of CT  for an early diagnosis of post-operative peritonitis, permitting also to determine its origin and severity. A diffuse peritonitis must be distinguished from a localized abscess, with possible indication to a percutaneous drainage or a conservative treatment, in case of  small size(diameter inferior to 3 cm) (8-10).
Today, decision to an early re-laparotomy or a trans-cutaneous drainage demands a previous diagnostic procedure, and cannot be based only on clinical signs, without a complete research of all possible associated lesions. In case of diffuse peritonitis, there is a straight indication to a re-laparotomy with complete abdominal exploration and adequate drainage, considering the simple diverting colostomy rarely sufficient. Besides, lesions discovered by CT in the colonic walls, as oedematous thickness or ischemia, or leaks demonstrated of large size warn away a direct repair of the failed anastomosis, in favour of its complete take-down with resection of both the intestinal segments anastomosed.
Our experience demonstrates the importance of the collaboration between radiologists and surgeons, also in these difficult post-operative circumstances.

Reference(s)


1. Chambers W.M., Mortensen N.J. Postoperative leakage and abscess formation after colorectal surgery. Best Pract.Res.Clin.Gastroenterol. 2004;18:865-880.
2. Buchs N.C., Gervaz P., Secic M. et al. Incidence, consequence, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int.J.Colorectal Dis. 2008; 23:265-270.
3. GoreR.M., Berlin J.W., Yagmai V. et al. CT diagnosis of postoperative abdominal complication. Semin.Ultrasounds CT MR 2004; 25:207-221.
4. Zissin R., Gayer G. Postoperative anatomic and pathological findings at CT following colonic resections. Semin. Ultrasound CT MRI. 2004;25 222-238.
5. Zappa M., Sibert A., Vuillerme M.P. et al. Postoperative imaging of the peritoneum and abdominal wall [in French]. J.Radiologie 2009; 90:969-979.
6. Hoeffel C., Marcus C., Arrivé L. et al. Postoperative imaging after colorectal surgery.[in French]. J.Radiologie 2009; 90:954-968.
7. Gayer G., Hertz M., Zissin R. Ureteral injuries: CT diagnosis. Semin.Ultrasound CT MR. 2004; 25:277-285.
8. Phitayakorn R., Delaney C.P., Reynolds H.L. et al. Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery.World J.Surg.2008;32:1147-1156.
9. Alves A., Panis Y., Pocard M. et al. Management of anastomotic leakage after nondiverted large bowel resection. J.Am.Coll.Surg. 1999; 189: 554-559.
10. Maggiori L., Bretagnol F., Lefevre J.H. et al. Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer. Colorectal Dis. 2011; 13:632-637.

Source(s) of Funding


none

Competing Interests


none

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
1 review posted so far

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)