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Are We Too Slow to Act?

Scott M. Damrauer, MD; Liliana Bordeianou, MD; David Berger, MD

Arch Surg. 2009;144(4):333-338.

Hypothesis  Contained and free anastomotic leaks, which occur in a small percentage of patients after colorectal surgery, are different clinical entities and consequently should be managed differently.

Design  Retrospective medical record review.

Setting  Academic medical center.

Patients  Patients who underwent colectomy with primary anastomosis (N = 4019) between January 1, 1992, and December 13, 2004, were eligible for participation in the study. Fifty-eight patients (1.5%) with an anastomotic leak demonstrated by communication between the collection and the gastrointestinal tract were identified. Twenty-eight of the patients had free leaks and 30 had contained leaks.

Main Outcome Measures  Time to presentation, symptoms at presentation, rates of reexploration, and in-hospital mortality.

Results  Baseline characteristics, presenting symptoms, physical examination findings, and laboratory values were similar between patients with contained and free leaks. Almost all patients with free leaks were taken directly to the operating room, whereas those with contained leaks were initially more likely to be treated nonoperatively. However, 24 of the 28 patients with contained leaks (86%) ultimately required surgical intervention. In-hospital mortality was the same in both groups (18% in the contained leak group and 17% in the free leak group).

Conclusions  In patients with contained leaks who have documented communication between the abscess cavity and the bowel, there is no difference in the rate of operative management or morbidity and mortality when compared with those with free leaks. This finding suggests that the categorization of leaks as free or contained may not be justified and argues for early operative intervention even in patients with contained leaks.

Author Affiliations: Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston.

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