The leaking colorectal anastomosis; why does it happen and how do we prevent it?

The ingredients predisposing for an anastomotic leak can be attributed both to the patient and to the surgeon. Some causative elements can be remedied; others cannot be changed very much. In cancer surgery the quest for cure involves ligation of the inferior mesenteric artery in the treatment of left-sided tumours. This obviously creates a conflict with the goal of constructing a well circulated anastomosis. In the treatment of rectal cancers total mesorectal excision has in recent years been put forward as the crucial step in avoiding local recurrences. The use of drains is a matter of controversy. The rationale for using them is to avoid pelvic collections with subsequent infection. The anastomosis is the point of least resistance so this is where a pelvic abscess is liable to break through, thus creating a leak. The choice of anastomosis, single layer or double layer, has been extensively dealt with and is beyond the scope of this presentation. My opinion is that you should stick to the type of anastomosis you are familiar with and try to refine your technique as much as possible. Continuous surgical audit and improved surgical training are likely the most important measures to lower the complication rates in colorectal surgery.