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Int J Gastrointest Interv 2022; 11(4): 168-173
Published online October 31, 2022 https://doi.org/10.18528/ijgii220039
Copyright © International Journal of Gastrointestinal Intervention.
Ji Hoon Kim1 
, Ji Hoon Shin1,* , and Jung Suk Oh2
1Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
2Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Korea
Correspondence to:*Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
E-mail address: jhshin@amc.seoul.kr (J.H. Shin).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gastrointestinal (GI) leakages after surgery are significant complications that are associated with high morbidity and mortality. Due to recent technology advancements, interventional management of postoperative GI leakage may be a better alternative than surgical treatments in terms of less invasiveness, decreased mortality, morbidity, and hospital stay. Furthermore, new interventional management techniques are still being developed. We discuss GI fistulas’ clinical and radiological characteristics as well as its interventional management. This study intends to highlight the many GI organ-specific interventional management techniques for the treatment of postoperative GI leakage.
Keywords: Anastomotic leakage, Digestive system surgical procedures, Drainage, Radiology, interventional
One of the most significant complications of gastrointestinal (GI) surgery is postoperative leaking. Despite constant improvement in surgical techniques, GI leakages remain a leading cause of postoperative mortality and morbidity. The anastomosis site generally affects the rates of GI anastomotic leakage (Table 1).1–24
Table 1 . Incidence of Anastomotic Leakages after Gastrointestinal Surgery.
| Site of the anastomosis | Incidence of anastomotic leak |
|---|---|
| Esophagus | 2%–16% |
| Stomach | 1.1%–17% |
| Small bowel | 1%–12.1% |
| Colon | 2.8%–13% |
| Rectum | 5%–19% |
After the diagnosis of anastomotic leakage is established, possible therapeutic options are medical treatment alone, reoperation, or interventional management. Anastomotic leaks historically required reoperation. Due to technical advancements, interventional radiology has currently offered appealing alternatives to reoperation in terms of decreased mortality, morbidity, and hospital stay.25–31 Furthermore, due to its exceptional advantages for reduced invasiveness, interventional radiology has seen an expansion in its role.
This update aims to describe interventional radiology management of postoperative GI leakage with an emphasis on organ categorization
After esophagectomy, anastomotic leakage may result in high mortality because it can damage the major vessels.32 The clinical spectrum may vary from nonspecific findings such as leukocytosis, tachycardia, dysrhythmia, and respiratory failure, and specific issues such as a change in drain output, erythema, and swelling along the neck and chest. Regarding the timing and the modality of the anastomotic leaking diagnostic process, there is no broad consensus. Low et al33,34 suggested classification and algorithm access to diagnosis and treatment of esophageal anastomotic leaks (Table 2). Usually, the diagnosis can be made by computed tomography (CT) with oral contrast and esophagography utilizing a water-soluble contrast agent. Although numerous therapies have been documented, treating an anastomotic leakage is still difficult, and the optimal treatment has not yet been determined.35–37
Table 2 . Classification of Anastomotic Leakage According to the Esophagectomy Complications Consensus Group (ECCG).
| Leakage severity | Criteria |
|---|---|
| Grade 1 | Local defect requiring no change in therapy or treated medically or with dietary modification |
| Grade 2 | Localized defect requiring interventional but not surgical therapy (interventional radiology drain, stent or bedside opening, and packing of incision) |
| Grade 3 | Localized defect requiring surgical therapy |
The immediate evacuation of the accompanying mediastinal and thoracic inflammation and infection is crucial in the management of anastomotic leakage following esophagectomy. The percutaneous abscess drainage tube is considered to manage the perianastomotic abscess. Under the supervision of ultrasonography and fluoroscopy, a 10-F or 12-F tube placement was done at the base of the abscess.38 Nasogastric placement of the drainage tube through the leakage under fluoroscopy guidance also can be performed after optimal fluoroscopic visualization of the leakage.39 A feeding tube inserted into the proximal jejunum can enable early enteral feeding to promote the anastomosis leakage's repair by providing nutrients. Under fluoroscopic guidance, a nasogastric tube can be placed to stop the reflux of gastric contents into the leak.39
Fluoroscopic placement of an esophageal covered stent is also used for the leakage closure. The most common complication of esophageal covered stent was migration, with reported rates ranging from 26% to 87%.40–42
The drainage tubes and stents could be removed if complete eradication of abscess and healing of the leakage was confirmed by esophagography and CT.
After a gastrectomy, mortality from leakage ranged 19%–64%.37,43 Other than mortality, anastomotic leakage can result in decreased digestion and quality of life.44–52 After a gastrectomy, the median time to diagnosis of leakage was about 7 days.45–47 Endoscopy, CT imaging, or fluoroscopy using contrast agents are all used to identify anastomotic leaking. After a gastrectomy, anastomotic leakage can lead to a fluid collection or abscess in the surgical bed. Fluid collections or abscesses may develop in unusual locations because of the changes in normal anatomic barriers (peritoneal ligaments and mesenteries) after gastrectomy.48
To begin treating the abscess, percutaneous drainage catheter placement under various imaging guidance (ultrasonography, CT, or fluoroscopy), or via a closed, air-tight postoperative drainage, may be an option (Fig. 1). In most cases, the shortest transabdominal route is used to drain an abscess. If transgression of the small bowel or pleural space is required, it can be done carefully. For a pelvic abscess, a transgluteal, transvaginal, or transrectal approach can be performed.49,50
Figure 1. A 92-year-old female who underwent a distal gastrectomy for advanced gastric cancer. (A) Axial computed tomography (CT) image shows an air-containing complicated fluid collection (asterisk) around the remnant stomach. Note a closed, air-tight postoperative drainage present within the fluid collection (arrow). (B) Fluoroscopic spot film images show the closed, air-tight postoperative drainage (arrowheads) (C) A 0.035-inch guidewire was inserted through the closed, air-tight postoperative drainage (arrowheads). (D) A 10.2-F pigtail catheter was placed through the guidewire. (E) Follow-up axial CT image 1 week after drainage catheter insertion shows pigtail catheter (empty arrow) within the markedly decreased fluid collection.
For enteral feeding and decompression, nasogastric tube insertion under fluoroscopic guidance is helpful. If a long period is required until tube removal, percutaneous transesophageal gastro-tubing (access to the stomach via percutaneous access to the cervical esophagus) can be an alternative option to nasogastric tube (Fig. 2).51
Figure 2. An 86-year-old male who underwent subtotal gastrectomy for advanced gastric cancer. (A) Fluoroscopic image shows an 18-mm balloon catheter (arrow) in the esophagus. (B) Ultrasound (US) image shows an inflated balloon (asterisk) within the esophagus and left carotid artery (empty arrow). (C) The fluoroscopic image shows a punctured balloon with a 21G needle (arrowhead) by US guidance. (D) A 14-F feeding tube (arrow) was inserted with the tip in the jejunum.
Small bowel anastomotic leakage rates depend upon the types of surgery. In patients with anastomotic leaks confirmed, mortality rates were reported to be 24.1%–33%.52,53 For the diagnosis of small intestinal anastomotic leakage, CT has emerged as the preferred imaging technique.54
If a patient’s pancreaticodigestive or biliodigestive anastomosis leaked and created a fluid accumulation or abscess, percutaneous drainage was performed (Fig. 3).
Figure 3. A 62-year-old female who underwent pancreaticoduodenectomy for pancreatic cancer. (A) Axial computed tomography image shows air-containing fluid collection (asterisk) around the pancreaticojejunostomy site (arrow). (B, C) A 8.5-F percutaneous drainage catheter (empty arrow) was inserted by ultrasound guidance.
The treatment objective in biliodigestive anastomosis, such as hepaticojejunostomy or hepaticoduodenostomy, is to facilitate healing of the biliodigestive anastomosis and restore normal bile flow into the small bowel by diversion of bile. Retrievable covered stent placement is considered first-line treatment.55 Complications of stent placement are known to be haemobilia, stent migration, and obstruction of intrahepatic bile ducts.56
To decompress and drain bile and pancreatic fluid and to reestablish continuity between the biliary system and the digestive system, percutaneous transhepatic biliary drainage insertion with the drainage catheter tip at the small bowel can be carried out.57–61
The mortality rate for postoperative duodenal stump leaking has reached 3% to 5%.62–64 When duodenal stump leakage is detected, a drainage catheter is first inserted under the guidance of US, CT, or through a closed, air-tight postoperative drainage. After the fluid collections or abscesses are reduced (about 1 week), an indwelling urinary catheter is inserted into the duodenal stump by fluoroscopic guidance (Fig. 4). It can control leakage as well as enable early enteral feeding.64 To ensure that the duodenal stump opening and fistula tract may be completely closed without intraperitoneal leakage, an indwelling urinary catheter should only be removed once the enterocutaneous fistula tract has fully matured.
Figure 4. (A, B) When a duodenal stump leak is found (asterisk), a pigtail catheter is inserted at firstly under the guidance of ultrasound, cone-beam computed tomography or through a closed, air-tight postoperative drainage. (C, D) After the accumulated fluid and inflammation are reduced, a indwelling urinary catheter is inserted over the guidewire and the balloon was dilated. (E) Indwelling urinary catheter allows for early oral intake by preventing additional leakage through blockage of the opening via ballooning.
After colorectal surgery, an anastomotic leak is associated with high mortality and may result in peritonitis and sepsis.65,66 The mortality rate after colorectal surgery can be up to 50% and account for one-third of deaths.67,68 Anastomotic leaks are also associated with late complications, including stricture or obstruction.53
Symptoms suggestive of an anastomotic leakage usually manifest in the first 2 weeks, most commonly between days 5 and 7 after surgery.69 At the first radiologic follow-up, 5.7% to 10.7% of patients had subclinical. The International Study Group of Rectal Cancer suggested a grading system for the treatment of colorectal anastomotic leakage (Table 3).70,71
Table 3 . Classification for the Management of Colonic Anastomosis Leakage According to the Grading System Proposed by the International Study Group of Rectal Cancer.
| Leakage severity | Criteria |
|---|---|
| Grade 1 | Identified by radiographic findings without accompanying clinical complaints Anastomotic leakage requiring no active therapeutic intervention |
| Grade 2 | Anastomotic leakage requiring active therapeutic intervention but manageable without re-operation |
| Grade 3 | Anastomotic leakage requiring re-operation |
Diagnosis is based on transanal contrast administration with fluoroscopic imaging or CT.72
Transabdominal approach of percutaneous drainage placement using US guidance is usually performed to manage contained anastomotic leakages.73,74 Depending on the locations of the leakage, drainage catheter can be placed either transgluteally or transanally (Fig. 5).75–77 The decision to remove the catheter is made when the daily drainage is < 10 mL, the symptoms have improved, there is minimal or no residual cavity, and nonpurulent drainage.50
Figure 5. A 52-year-old male who underwent ultralow anterior resection for rectal cancer. (A) Axial computed tomography image shows air-containing fluid collection (asterisk) around the coloanal anastomosis. (B) A fluoroscopic image with transanal contrast administration shows extraluminal leakage of contrast media (arrow). (C, D) A 5-F percutaneous drainage catheter (empty arrow) was inserted by the US and fluoroscopic guidance.
Interventional radiological techniques offer complete therapy options for the management of postoperative leaks in the GI tract since they are practical and far less invasive than reoperation. However, not all cases will respond to interventional management alone. Therefore, to maximize the chances of a good outcome, interventional radiologists constantly take into account a combination of different alternatives and organ-specific circumstances.
None.
No potential conflict of interest relevant to this article was reported.
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