[Anastomotic leakage after rectal cancer surgery: classification and management]

Many studies have focused on the identification of risk factors and prevention of anastomotic leakage following rectal cancer surgery. However, there is little knowledge regarding classification and management of anastomotic leakage in clinic. Herein, we reviewed and summarized the classification and management of anastomotic leakage after rectal cancer surgery. The relevant treatments of anastomotic leakage should be chosen based on patient's manifestation, including general and local reactions, anatomical location, and nature of the leakage (contained or free, controlled or uncontrolled leakage). 1) Surgery is imperative for anastomotic leakage with acute general peritonitis and sepsis. 2) Circumscribed peritonitis and the pelvic abscess can be managed conservatively with complete drainage. During the conservative management, diverting stoma, minimally invasive techniques of seal or repair should be implemented at an appropriate time, if necessary. 3) Subclinical leakage seldom requires surgical intervention promptly. 4) For persistent anastomotic leakage after diverting stoma, we should consider whether chronic presacral abscess, epithelialized sinus, fistula or local recurrence of cancer is present. With regard to definitive salvage surgery, reconstruction of the coloanal anastomosis or permanent stoma is usually required under these circumstances. 5)Complicated fistula often necessitates surgical repair with advancement tissue flap or tissue interposition under the condition of diversion. Reconstructing the coloanal anastomosis is the alternative management, whereas other treatments are invalid, including ultra-low anterior resection, intersphincteric resection, proctectomy with colon pull-through, and primary or staged coloanal anastomosis. 6) During the surgical repair of recto-vaginal fistula and recto-urinary fistula, colorectal surgeons may require the cooperation of gynecologists, urologists, and orthopedists. 7) For anastomotic leakage with local recurrence of cancer after conservative management, diverting stoma should be performed promptly to facilitate the subsequent chemoradiotherapy. Surgeons should pay more attention to systemic knowledge and understanding of the classification and management of anastomotic leakage following rectal cancer surgery. Accordingly, we can follow the principles of management, individualize the treatments, apply the concepts of damage control and minimally invasive surgery, and enhance the recovery of anastomotic leakage. Prevention remains more important than remedies. To prevent the occurrence of permanent injuries, not only early diagnoses and treatments should be performed, but also the timing of cancer treatments is warranted for anastomotic leakage.