Management of Low Colorectal/Coloanal Anastomotic Leak: Results of a French National Intergroups Practice Survey (FRENCH-GRECCAR-SFCD).

Abstract

Aims: Anastomotic leakage (AL) impacts short-term and long-term outcomes after colorectal surgery, yet no consensus exists regarding its diagnosis and management. The aim was to establish a proactive consensus-based approach for diagnosing and treating AL following rectal cancer surgery through a national survey.

Methods: A questionnaire was designed to assess 24 clinical scenarios related to the diagnosis and management of fistulas in low colorectal (LCA) or coloanal anastomosis (CAA) with a diverting ileostomy.

Results: A total of 203 surgeons from three surgical societies participated. Consensus was reached on four key indicators warranting further investigation of AL: CRP > 250 mg/L, fever ≥ 38.5°C, tachycardia > 100 bpm, and diffuse abdominal pain. In the presence of any warning sign, 87% recommended an urgent contrast-enhanced abdominopelvic CT scan without routine rectal contrast as the first-line diagnostic tool. Isolated extra-digestive air bubbles or uncollected effusions without air bubbles were managed with antibiotics (61%-78%). A perianastomotic collection required an anal examination under general anesthesia (70%). For treatment, transanal drainage (56%) was preferred over image-guided percutaneous drainage, combined with endoluminal vacuum therapy and at least 7 days of antibiotics (97%). Drain removal was recommended (64%) when imaging confirmed the absence of residual collection.

Conclusions: This national survey established a consensus-driven proactive management algorithm for LCA/CAA fistulas. Further validation controlled trial is needed to confirm the effectiveness in reducing AL-related complications.