Anastomotic leak after colorectal surgery
In this context, we describe two consecutive cases of colorectal anastomotic leak managed with VACStent without proximal diversion, providing practical insights into patient selection, technical nuances, the value of synchronized internal–external drainage, and determinants of successful therapy.
A comparative summary of the main clinical, anatomical, and technical differences between the two cases is presented in the table below
|
Variable |
Case 1 |
Case 2 |
|---|---|---|
|
Sex / Age |
Female, 66 years |
Male, 71 years |
|
BMI |
60 kg/m² |
35 kg/m² |
|
ASA |
IV |
III |
|
Initial surgery |
Open Hartmann for presumed perforated diverticulitis (final pathology: perforated adenocarcinoma). Complicated by prolonged admissionand pulmonary embolism. |
Open Hartmann for prepyloric perforation and perforated diverticulitis.Early postoperative complications included colostomy necrosis and evisceration. |
|
Restoration of continuity |
Laparoscopic; extensive adhesiolysis; parastomal hernia repair (no mesh) |
Open; antegrade colonic lavage; colorectal anastomosis ~10 cm from anal verge. Prior mesh in situ. |
|
Postoperative complications |
Early enteric leak, subcutaneous infection, and evisceration |
No early complications after restoration of continuity |
|
Time to leak |
30 days |
3 months |
|
Defect type |
<1 cm contained leak with associated collection |
Late fistula with chronic cavity in the space of Retzius and subcutaneous extensions |
|
Fistulous opening |
Small |
Small, partially epithelialized |
|
Proximal diversion |
No |
No |
|
Previous treatments |
None |
15 days of TPN; wound care; failed OTSC attempt |
|
Interval to VACStent |
Immediate |
After outpatient follow-up and readmission |
|
VACStent cycles |
1 cycle |
4 cycles (7 + 7 + 3 + 3 days) |
|
Negative pressure |
–120 mmHg |
–300 mmHg initially (pressure-related ulcer), then –120 mmHg |
|
Additional techniques |
None |
External NPWT (“sandwich technique”) in cycles 3 and 4 |
|
Tolerance / transit |
Well tolerated; transit preserved |
Initial disturbance; later normalization |
|
Confirmation of closure |
Endoscopy + fluoroscopy |
Endoscopy + contrast-enhanced CT |
|
Final outcome |
Complete closure |
Complete closure |
|
Follow-up |
6 months, no recurrence |
3 months, no recurrence |
VACStent appears to be a promising minimally invasive option for selected patients with complex colorectal anastomotic leaks, even without proximal diversion. In these cases, VACStent preserved intestinal continuity and avoided major reinterventions, including stoma creation. Technical success depends on precise placement, early vacuum stability, and, when indicated, synchronized external drainage. Larger comparative studies are needed.