Expert Commentary on Early Detection and Active Management of Anastomotic Leaks Improve Outcomes

A 62-year-old man with a 3-year history of multiple episodes of clinical sigmoid diverticulitis underwent robotic anterior resection because of persistent abdominal pain and negative impact on quality of life.CT images obtained during the first episodes showed uncomplicated diverticulitis, and during the last episode, there was a microperforation with a possible evolving abscess.Intraoperative findings included inflammation and induration of the midsigmoid folded over the anterior rectum, consistent with chronic diverticulitis.Side-toend intracorporeal anastomosis was performed after immunofluorescence confirmation of viable descending colon and upper rectum.Anastomotic integrity was tested using intraluminal air insufflation with saline in the pelvis and direct endoscopic visualization of anastomotic mucosa.The specimen extraction site was the Pfannenstiel location.Although the estimated blood loss was 10 mL and the operative field was dry at the conclusion of the procedure, the postoperative course was complicated by mesenteric bleeding that required 3 units of packed red blood cells.Pathology confirmed perforated diverticulitis with purulent serositis.The bleeding stopped spontaneously, his diet was advanced, and he was ready for discharge on postoperative day 7.However, follow-up CT images on the day of planned discharge showed a new small anastomotic leak with adjacent 3.5-cm fluid collection and a stable appearance of the mesenteric hematoma.After full mechanical bowel preparation, endoscopy revealed a 10-mm defect in the side-to-end colorectal anastomosis.Coagulation for resurfacing was done using argon plasma at 1 L/min and 60 W (Fig. 1A).Endoscopic sutures attached to endoscopic tacks were deployed around the defect.The suture was cinched with complete closure of the anastomotic defect (Fig. 1B).Follow-up CT imaging 3 days later showed no anastomotic leak.The diet was advanced and the patient was discharged on postoperative day 14. CLINICAL QUESTIONS What options exist for the management of anastomotic leak? What are the indications for endoscopic management of anastomotic leak?Earn continuing education (CME) credit online at cme.lww.