Is air leak testing really necessary after stapled anterior resection?-a case series and a literature review

Abstract

Background: Air leak testing (ALT) after a stapled anterior resection (AR) is still being used despite the paucity of strong evidence to advocate for its usefulness in predicting postoperative leaks. A standardized technique that pays rigorous attention to achieving a tension free anastomosis while ensuring demonstrable vascularisation of the stapled ends is a better guarantor of a reduced leak rate. We aim to assess the leak rate in consecutive cases of stapled AR where no ALT was performed. Methods: We performed a retrospective analysis of a prospectively maintained database of consecutive patients undergoing AR with stapled anastomosis during the period 2004-2019. We documented demographic data [age, sex, American Society of Anesthesiologists (ASA)], type of procedure undertaken (laparoscopic, open) and length of stay (LOS). We routinely paid attention to the concept of 'double verification of vascularity' during the fashioning of the anastomosis. The endpoint assessed was the presence of leak. Results: Seventy-one stapled AR were performed (17 open and 54 laparoscopic). Median age was 64 years, male to female ratio was 41 to 30, median ASA was 2 and median LOS was 7 days. We had an overall anastomotic leak rate of 4.2%: one postoperative grade C leak treated by laparoscopic washout and two minor delayed anastomotic vaginal fistulae (grade A leaks) successfully managed conservatively. There was no procedure related mortality in our cohort. Conclusions: Our leak rate compares favourably to the published literature despite not performing ALT, hence questioning the dogmatic reliance on the ALT to predict postoperative leak after AR. � Annals of Laparoscopic and Endoscopic Surgery. All rights reserved.