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
University of Modena - Department of Surgery, - Italy

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

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


Colon anastomosis leakage, Colon ischemia, Computed Tomography

Manenti A, Manco G, Vezzelli E, Donatiello S. Vascular Risk Factors in Left Colon Anastomosis Leakage: A Computed Tomography Guided Study. WebmedCentral SURGERY 2012;3(5):WMC003346
doi: 10.9754/journal.wmc.2012.003346

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.
Submitted on: 08 May 2012 08:59:22 AM GMT
Published on: 08 May 2012 07:37:49 PM GMT


25 cases of left colon anastomosis, complicated by an early post-operative leakage, have been studied by Computed Tomography (CT): in 20 of them an arterial vascular insufficiency was observed, and considered a pathogenetic factor of this pitfall.


Many risk factors have been considered in order to explain leakage of left colon anastomosis, colo-colic or high colo-rectal : ischemia of the colon segments anastomosed, their inadequate mobilization, or patient’s poor conditions (1-7).  On the other hand, the utility of CT in the diagnosis of  post-operative peritonitis is well known ( 8-10).  We have considered CT a useful tool also in demonstrating post-surgical conditions, particularly concerning  vascular supply of the colon, directly correlated to anastomotic leakage: this has been the aim of the present study.


We have examined  25 cases of the left colon anastomosis leakage ( 17 colo-sigmoid and 8 high colo-rectal) observed in the years 2010-2012 ; 22 of these patients were referred us from other centres. CT was performed in all the patients within the 4th post-operative day, with a multislice technique and intravenous contrast enhancement. The diagnosis of diffuse peritonitis or of localized abscess was possible in all the cases.  Vascular lesions, observed in  the colonic segments anastomosed, were relevant in 20 cases with the following morpho-radiological signs considered indicative :

1)Arterial hypovascularization, demonstrated by  a poor or attenuated  arterial network in the colonic mesentery;
2)Poor contrast enhancement of the walls of the colonic anastomosed segments;
3)Their oedema and thickening, with absence of the normal contrast hyper-enhancement of the mucosa (Illustration 1);
4)Dilatation of one or both colon anastomosed segments.


All the above mentioned CT signs have been found associated in the  16 cases of severe diffuse peritonitis, treated promptly by a re-laparotomy.  A less evident hypoperfusion, demonstrated only in the afferent loop of the anastomosis, was observed in the other 4 cases of pelvic abscess, treated  successfully by a  percutaneous drainage.


Ischemia of the colon segments is an important pathogenetic factor in anastomotc leakage. It can be CT proved by two fundamental signs:

1)Absence of a clear  arterial network of the colon mesentery (Illustration 2,3,4);
2)Contrast hypo-enhancement of the colonic walls, with unclear visualization of the corresponding mucosa.

Oedema of the colon walls can be easily ascribed to an ischemic damage of the  micro-circulatory apparatus, while their dilatation can be a consequence of  the diffuse peritonitis, with subsequent autonomous nervous system paralysis, resulting in a condition of  muscle atony. The same diffuse inflammatory condition can explain the venous congestion and oedema, with lymph nodes enlargement, often observed in the small bowels mesentery.

CT can also demonstrate signs of mesenteric venous thrombosis, complication infrequent today, because of the largely diffused anti-thrombotic prophylaxis.


Surgeons must be interested to know the causes of operative pitfalls, especially if related to anatomo-surgical factors; in case of colon anastomotic  dehiscence CT can demonstrate a condition of arterial insufficiency, which must be considered an important pathogenetic factor (11-13).

A demonstrated condition of frank arterial insufficiency often is followed by a diffuse peritonitis, obliging to a prompt re-laparotomy and to a complete take-down of both the colonic segments anastomosed.

An adequate study of the colon vascular anatomy can also be obtained pre-operatively by CT, which permits to detect anatomical variations or pre-existing pathological conditions in the colon vascular supply, and subsequently to choose an adequate operative planning (14,15).  An  intra-operative recognition of the colonic arterial anatomy must follow,in order to perform a radical lymphadenectomy, and contemporarly assure an adequate vascular supply to the intestinal segments, before their anastomosis.


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15. Manenti A. The left hemicolectomy: technical reflections towards standard and enlarged procedures. WebmedCentral SURGICAL TECHNIQUE 2011; 2(10):WMC 002375.

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7 reviews posted so far

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Posted by Anonymous Reviewer on 11 Jun 2012 11:20:42 PM GMT

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