ANASTOMOTIC LEAK AFTER COLORECTAL SURGERY: A NARRATIVE REVIEW OF CLASSIFICATION, RISK FACTORS, DIAGNOSIS, AND STRATEGIES FOR PREVENTION AND MANAGEMENT

Abstract

Anastomotic leak (AL) remains the most feared complication following colorectal surgery, contributing to significant morbidity, mortality (2–16%), and poorer long-term oncological outcomes. Despite advancements in surgical technology and perioperative care, its incidence has remained stable, ranging from 3% to 19% depending on anastomosis location. In this review, we synthesize current evidence on multifaceted risk factors of AL and propose integrated, multimodal strategies for its prevention and management. Key findings suggest that effective prevention must span the entire perioperative continuum, beginning with preoperative optimization of nutritional status, smoking cessation, and adoption of combined mechanical bowel preparation with oral antibiotic prophylaxis. Intraoperatively, meticulous technical execution focused on tension-free union and adequate perfusion—increasingly assessed through indocyanine green (ICG) fluorescence angiography—is essential to ensuring biological integrity. Postoperatively, early diagnosis is facilitated by standardized surveillance protocols utilizing biochemical markers—specifically dynamic C-reactive protein (CRP) trajectories—alongside contrast-enhanced computed tomography (CT) imaging. Management of AL has become increasingly tailored to individual’s clinical stability and leak severity according to the International Study Group of Rectal Cancer (ISREC) grading, utilizing wide spectrum of interventions from conservative percutaneous drainage and emerging endoscopic vacuum therapy to definitive surgical re-intervention for source control. In conclusion, while technological innovations continue to evolve, the persistent challenge of AL necessitates coordinated, evidence-based approach to perioperative care, highlighting urgent need for further high-quality, multicenter research to validate emerging predictive models and salvage techniques.