A break in the line: anastomotic leak triggered by a traumatic fall

Abstract

Anastomotic leak is a well-documented complication of anterior resection, a procedure commonly performed for colorectal carcinoma or inflammatory bowel disease (IBD). Multiple factors contribute to anastomotic leaks, often related to surgical technique or impaired bowel healing. However, blunt trauma or physical injury has not been widely recognised as a risk factor for this complication. This report presents the case of a 72-year-old gentleman who returned to the hospital with a severe anastomotic leak following a physical incident. This case aims to highlight the potential role of trauma as a contributing factor in patients with atypical presentations of anastomotic leak.

Introduction

Colorectal cancer is the third most common cancer in the UK, with an average age of diagnosis exceeding 50 years [1, 2]. Rectal cancer accounts for approximately one-third of all colorectal cancer cases [3]. While various treatment options are available, including adjuvant and neoadjuvant chemotherapy and radiotherapy, surgical resection remains the cornerstone of definitive management [3]. In recent years, minimally invasive approaches, such as laparoscopic and robotic surgery, have gained popularity over traditional open laparotomy [4].

Anterior resection is a frequently performed procedure for rectal cancer, involving resection of the rectum, intraoperative anastomosis, and total mesorectal excision (TME) [3, 4]. Anastomotic leak is a well-recognized postoperative complication of anterior resection. However, non-iatrogenic causes, such as trauma, have not been widely documented in the literature.

We present the case of a 72-year-old patient with a suspected trauma-induced anastomotic leak following laparoscopic low anterior resection (LAR).

Case report

A 72-year-old patient was referred to the colorectal surgical team via the two-week wait cancer pathway following a positive faecal immunochemical test (FIT) and colonoscopy findings. Colonoscopy revealed an impassable malignant rectal mass located 8 cm from the anal verge. Although the MRI was of poor quality, it demonstrated a semi-annular mid-rectal lesion measuring 4 cm in length, situated 8 cm from the anal verge and 3 cm from the anorectal junction. An extra-nodal tumour deposit was noted at the 1 o’clock position. Initial staging was T2/T3 M1c due to the extra-colonic deposit, but the circumferential resection margin was clear. A CT scan of the thorax, abdomen, and pelvis (CT TAP) showed no distant metastases.

Following multidisciplinary team (MDT) discussion, two management options were proposed: immediate surgery for symptomatic relief or neoadjuvant therapy if the patient was asymptomatic. The patient reported significant difficulty in bowel movements despite trying multiple laxatives, prompting a preference for surgical intervention.

The initial surgical approach was laparoscopic. However, significant adhesions were encountered due to a previous inguinal hernia mesh repair. The omentum was adherent to the descending colon, and omental bleeding during splenic flexure mobilisation necessitated conversion to an open approach. The tumour was found adherent to the seminal vesicles, and rectal perforation occurred during dissection. After a pelvic washout, a successful anastomosis was achieved using a CDH 29 stapler, with a negative leak test confirmed three times. A defunctioning loop ileostomy was created in the right iliac fossa (RIF). Due to the extended procedural duration of 7.5 hours, the patient was transferred to the intensive care unit (ICU) postoperatively.

The patient initially recovered well, with a functioning stoma, and was discharged on postoperative day 7. At a follow-up in the colorectal outpatient clinic on day 14, his observations were stable, and no concerns regarding his recovery were noted. However, on day 16, the patient experienced severe acute abdominal pain and vomiting immediately following a fall in the garden. A CT TAP revealed an anterior rectal defect. An urgent Hartmann’s procedure was performed, during which intraoperative findings included four-quadrant purulent peritonitis, a large defect in the colo-anal anastomosis, and a presacral faecopurulent collection.

The anastomosis was taken down, leaving a very short rectal stump, and an end colostomy was created. The patient remains well following the second procedure.

Discussion

Anastomotic leaks following surgery are associated with significant morbidity and mortality and may delay crucial subsequent treatments, such as chemo-radiotherapy, in patients with rectal cancer.

The incidence of anastomotic leaks post-colorectal surgery ranges from 2.8% to 30%, with approximately 75% of these cases involving rectal anastomoses [5]. For low anterior resection (LAR), the reported leak rate is around 10% [6]. Factors associated with an increased risk of leaks include male gender (linked to a narrow pelvis in laparoscopic approaches), high BMI, increased stapler firings, prolonged operative time, and the tumour’s location within the rectum [6, 7]. Other contributing factors include smoking, alcohol consumption, diabetes, hospital case volume, surgeon experience, emergency surgery, inadequate colonic vascularisation, anaemia, and perioperative blood transfusion [5]. These risks typically influence either bowel healing or the technical integrity of the anastomosis. However, blunt trauma or physical injury to the site is not a widely recognised cause of anastomotic leaks.

In this case, while the operation was prolonged (>7 hours) and involved an ultra-low anterior resection in a male patient—both recognised risk factors—the postoperative recovery was uneventful. Intraoperative leak testing was negative after three separate attempts, and a protective ostomy, which is a mitigating factor against leaks, had been created [5, 8].

The sudden presentation of a grade C leak (as per the ISREC classification) without prior symptoms raises the likelihood of trauma being a direct cause of the leak. Trauma-induced bowel injury or perforation is typically caused by one of two mechanisms. The first involves a compressive force, such as from an object or blunt weapon, which can temporarily increase intraluminal pressure, potentially leading to rupture [9, 10]. This is more common in severe incidents, such as motor vehicle collisions or assaults. The second mechanism involves deceleration forces (a sudden slowing or stopping of motion), which may result in stretching and shearing of bowel segments [9].

In this case, where the patient reported tripping and falling in the garden, the deceleration mechanism appears more plausible. While a greater force would generally be required to cause bowel injury in an otherwise healthy individual, in a postoperative patient with a healing anastomosis just 16 days after surgery, a much lesser degree of abdominal trauma could result in significant injury.

Conclusion

While there are numerous recognised causes of anastomotic leaks following anterior resection, physical trauma as a contributing factor is rarely, if ever, mentioned. This omission is particularly relevant in the context of post-discharge advice for patients, many of whom are discharged within a week of surgery under enhanced recovery protocols (ERAS) designed to minimise inpatient stays [11].

Notably, a significant proportion of anastomotic leaks occur approximately two weeks postoperatively, making the timing of events a critical consideration when evaluating potential causal factors [5, 12]. This case report aims to underscore the role of physical activity and trauma as important, yet under-recognised, causes of anastomotic leaks in the postoperative period.

Author contributions

Mr. Ian Farrell served as the lead clinician overseeing the patient’s clinical care and supervised the manuscript preparation. All authors were actively involved in the patient’s care. Specifically, Mr. Ian Farrell and Mr. Amir Iskandar participated in the surgical procedures, while Dr Areen Hassan Haleem and Dr Aiman Ibrahim contributed to postoperative ward care. Dr Areen Hassan Haleem and Dr Aiman Ibrahim played key roles in drafting the case report, with Mr. Amir Iskandar and Mr. Farrell assisting with editorial revisions. Dr Areen Hassan Haleem also obtained the patient’s consent for the case report. All authors have reviewed and approved the final manuscript and accept responsibility for all aspects of the work, ensuring that any issues related to accuracy or integrity are appropriately investigated and addressed.

Conflict of interest statement

The authors declare that there are no conflicts of interest that could have influenced the outcomes or interpretation of this work.

Funding

There are no funding sources or financial support associated with this research.

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