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THE INCIDENCE AND MANAGEMENT OF ANASTOMOTIC BLEEDING REQUIRING ENDOSCOPIC OR SURGICAL INTERVENTION IN COLORECTAL SURGERY
Roy Hajjar
*, Sidrah Khan, Ian Reynolds, Emilio Sanchez, Lauren Gleason, William Perry, Kellie L. Mathis, Nicholas P. McKenna
Surgery, Mayo Clinic Minnesota, Rochester, MN
BackgroundAnastomotic bleeding is a relatively common and usually self-limiting complication of colorectal surgery. While most cases resolve with conservative management, some require endoscopic or surgical management. These events are poorly characterized in the literature, with limited data on their incidence and management.
MethodsA retrospective review of patients undergoing colorectal operations with anastomoses or diverting loop ileostomy closure over 5 years (January 2019–December 2023) was conducted. Cases requiring postoperative endoscopic or surgical intervention for anastomotic bleeding were identified. Patient demographics, clinical characteristics, surgical indications, procedures, and complications were analyzed.
ResultsAmong 3981 colorectal operations with anastomosis, 13 patients (0.3%) required active intervention for anastomotic bleeding. The cohort included 10 males and 3 females with a median age of 55 years (range 23-89). Comorbidities included hypertension (54%), hyperlipidemia (38%), diabetes (23%), and coronary artery disease (23%). No patients were on therapeutic anticoagulation, but antiplatelet agents were common; 2 patients were on aspirin, 1 on clopidogrel, and 2 on both.
The operations included 3 sigmoid colectomies, 3 low anterior resections, 3 right or left hemicolectomies, 2 ileoanal pouch anastomoses, and 2 diverting loop ileostomy reversals. Indications included diverticular disease (N=6), cancer (N=5), and ulcerative colitis (N=2). All anastomoses were stapled, and most (69%) were visualized endoscopically intraoperatively, except in the 2 right hemicolectomies and the ileostomy reversals. Prophylactic subcutaneous heparin was administered to all patients.
Symptoms began a median of 5 days post-surgery (range 0–18). Nine patients (69%) presented with tachycardia or hypotension, and 10 (77%) required blood products. Endoscopy, performed in 9 cases, identified active staple-line bleeding in 4 cases and friable anastomosis in 1. Endoscopic clips were used in 4 cases, and electrocautery with injection of diluted epinephrine in 1.
Five patients (38%) underwent surgery; 3 required a redo of the anastomosis (ileocolic, ileo-ileal, and colorectal), 1 had the staple-line sutured and 1 had both an exploratory laparoscopy and endoscopic assessment. All patients recovered with no postoperative mortality.
Discussion/conclusionAt our institution, anastomotic bleeding requiring intervention occurred in <1% of cases over 5 years. Most were managed endoscopically, predominantly with clips, while surgical exploration was reserved for severe cases. Although all patients had stapled anastomoses, it is considered the standard of care, with no clear association with bleeding. Due to the rarity of this complication, this cohort remains small and heterogeneous. Further research is needed to better assess and potentially prevent these events.
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