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Over-utilisation of radiography in the assessment of stapled colonic anastomoses
European Journal of Radiology. 12 (1991)
35-37
35
Elsevier
EURRAD
00124
Over-utilisation of radiography in the assessment of stapled colonic anastomoses Charles E. Williams’, Departments
Carol A. Makin2, Robert G. Reeve’ and Simon B. Ellenbogen2
of ‘Radiodiagnosis and ‘Surgerv,
University of Liverpool, Royal Liverpool Hospital, Liverpool, U.K.
(Received 20 April 1990; accepted
after revision
13 September
1990)
_Key words: Radiography,
overutilisation;
Radiography,
EEA staple; Colon, anastomotic
leakage
Abstract We have reviewed the radiological studies in 31 patients who underwent stapled colorectal anastomoses using the EEA staple gun. In 10 patients there was clinical evidence to suggest anastomotic dehiscence. Nine ofthese patients had a disrupted staple ring on plain abdominal radiograph. In these days of audit and financial constraint, we suggest that radiological investigation should be reversed for those patients with questionable clinical evidence of an anastomotic leak.
Introduction The use of the end-to-end anastomosis (EEA) stapling gun to fashion low rectal and colonic anastomoses has flourished over the last 10 years. The EEA stapling instrument manufacturer (AutoSuture Company, UK) originally recommended plain radiography in the early post-operative period, to demonstrate the integrity of the staple ring [ 11. However, as surgeons have become more familiar and confident with stapling devices, this practice seems to have fallen from routine management in many centres. Regarding the use of water-soluble contrast enemas to study the post-operative integrity of such anastomoses, surgeons fall into two groups: (1) those who arrange such an enema in all patients during the postoperative period, and (2) those who reserve such radiological examination for cases where a leak is suggested on clinical grounds. The rational behind the latter is that water-soluble contrast enemas overdiagnose leaks by a factor of 10% [2-41 and that the anastomosis [2,5] may be traumatised by insertion
Address for reprints: Dr. C.E. Williams, University Department of Radiodiagnosis, Royal Liverpool Hospital, Liverpool, L69 3BX, U.K. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
of the enema tube. Also it is only patients with clinical signs and symptoms of anastomotic dehiscence that require action. In the Royal Liverpool Hospital, our surgeons fall into the two groups described above. We decided to review the radiological findings in patients undergoing EEA stapled rectal and colonic anastomoses, and ask the question: “Are plain radiographs and water soluble contrast studies necessary?” Materials and Methods Thirty-one patients who had undergone colorectal EEA stapled anastomosis between 1984 and March 1989 were identified. There were 23 males and 8 females with an age range of 30-85 years and a mean age of 63 years. Twenty-three patients had low sigmoid or rectal carcinoma, five had diverticular disease, one had inflammatory bowel disease, and there was one case of solitary rectal ulcer. Radiographs were taken between 3 and 14 days post surgery, with a mean of 7.5 days. Ten patients had water-soluble contrast enemas in addition to plain films of the pelvis. All films were reassessed by two experienced radiologists together, without knowledge of the patient’s clinical course.
B.V. (Biomedical
Division)
36
Results The patients were divided into two groups: (A) those with and (B) those without clinical evidence to suggest leakage from the anastomosis. There were 10 studies in Group A, and 9 of these demonstrated staple-ring disruption of the plain film (Fig. 1). In five of these, this disruption was considered minimal (Fig. 2). All patients in this group had evidence of leakage confirmed either by water-soluble enema
Fig. 1. Marked disruption
of the staple ring. Fig. 3. Large leakage demonstrated enema.
by water soluble contrast
(8 cases) (Fig. 3), or at surgery (2 cases). In 1 case, the disruption was not appreciated on the pre-enema film, although it was shown on the contrast examination (Figs. 4 and 5). There were 21 studies in Group B and none of these displayed evidence of a disrupted ring on plain film. Three patients in this group had water-soluble contrast enemas as a routine and there was no evidence of leakage. Discussion
Fig. 2. Minimal disruption
of the staple ring (arrow).
Leakage from colorectal anastomoses represents a serious complication and an early diagnosis is clearly desirable. Our review suggests that not only are routine radiographs unnecessary, but that radiology has no role to play in the diagnosis of disruption when there is firm
31
Fig. 4. The low position ofthe staple ring results in poor delineation. The staple ‘suture’ line further obscures detail (hollow arrows).
clinical evidence to suggest this. However, the symptoms and signs of disruption are not always clear, and we feel that in these cases a plain pelvic radiograph may be helpful in supporting the diagnosis. In such instances, the staple ring must be viewed clearly en face and additional angle films may be necessary to achieve this. We agree with the Birmingham group [ 51 that watersoluble contrast enemas for routine surgical audit and clinical research projects cannot be justified. However, we would go further and say that a contrast enema is only indicated in the rare instance of an intact staple ring in a patient with questionable clinical evidence of an anastomotic leak. In conclusion, we feel that routine radiology is not required in cases of clinical disruption, but may be of value when signs and symptoms are less clear. Acknowledgements We wish to thank the surgeons Liverpool Hospital for their assistance this study.
of the Royal in carrying out
References
Fig. 5. The leakage shown on the subsequent
enema is arrowed.
Fielding JWL, Gourevitch A, Lee JR, Keighley MRB. Late disruption of initially satisfactory stapled anastomoses. Br Med J 1980; 1: 1418-1419. Doricott MJ, Baddeley RM, Keighley MRB, Lee J, Gates DG, Alexander-Williams J. Complications of rectal anastomoses with end-to-end anastomosis (EEA) stapling instrument. Ann Roy Co11 Surg Engl 1982; 64: 171-174. Waxman BP. Large bowel anastomoses: the circular staples. Br J Surg 1983; 70: 64-67. Kirwan WO. Integrity of low cola-rectal EEA-stapled anastomosis. Br J Surg 1981; 68: 539-540. Haynes IG, Goldman M, Silverman SH, Alexander-Williams J, Keighley MRB. Water-soluble contrast enema after colonic anastomosis. Lancet 1986; i: 675-676.
35-37
35
Elsevier
EURRAD
00124
Over-utilisation of radiography in the assessment of stapled colonic anastomoses Charles E. Williams’, Departments
Carol A. Makin2, Robert G. Reeve’ and Simon B. Ellenbogen2
of ‘Radiodiagnosis and ‘Surgerv,
University of Liverpool, Royal Liverpool Hospital, Liverpool, U.K.
(Received 20 April 1990; accepted
after revision
13 September
1990)
_Key words: Radiography,
overutilisation;
Radiography,
EEA staple; Colon, anastomotic
leakage
Abstract We have reviewed the radiological studies in 31 patients who underwent stapled colorectal anastomoses using the EEA staple gun. In 10 patients there was clinical evidence to suggest anastomotic dehiscence. Nine ofthese patients had a disrupted staple ring on plain abdominal radiograph. In these days of audit and financial constraint, we suggest that radiological investigation should be reversed for those patients with questionable clinical evidence of an anastomotic leak.
Introduction The use of the end-to-end anastomosis (EEA) stapling gun to fashion low rectal and colonic anastomoses has flourished over the last 10 years. The EEA stapling instrument manufacturer (AutoSuture Company, UK) originally recommended plain radiography in the early post-operative period, to demonstrate the integrity of the staple ring [ 11. However, as surgeons have become more familiar and confident with stapling devices, this practice seems to have fallen from routine management in many centres. Regarding the use of water-soluble contrast enemas to study the post-operative integrity of such anastomoses, surgeons fall into two groups: (1) those who arrange such an enema in all patients during the postoperative period, and (2) those who reserve such radiological examination for cases where a leak is suggested on clinical grounds. The rational behind the latter is that water-soluble contrast enemas overdiagnose leaks by a factor of 10% [2-41 and that the anastomosis [2,5] may be traumatised by insertion
Address for reprints: Dr. C.E. Williams, University Department of Radiodiagnosis, Royal Liverpool Hospital, Liverpool, L69 3BX, U.K. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
of the enema tube. Also it is only patients with clinical signs and symptoms of anastomotic dehiscence that require action. In the Royal Liverpool Hospital, our surgeons fall into the two groups described above. We decided to review the radiological findings in patients undergoing EEA stapled rectal and colonic anastomoses, and ask the question: “Are plain radiographs and water soluble contrast studies necessary?” Materials and Methods Thirty-one patients who had undergone colorectal EEA stapled anastomosis between 1984 and March 1989 were identified. There were 23 males and 8 females with an age range of 30-85 years and a mean age of 63 years. Twenty-three patients had low sigmoid or rectal carcinoma, five had diverticular disease, one had inflammatory bowel disease, and there was one case of solitary rectal ulcer. Radiographs were taken between 3 and 14 days post surgery, with a mean of 7.5 days. Ten patients had water-soluble contrast enemas in addition to plain films of the pelvis. All films were reassessed by two experienced radiologists together, without knowledge of the patient’s clinical course.
B.V. (Biomedical
Division)
36
Results The patients were divided into two groups: (A) those with and (B) those without clinical evidence to suggest leakage from the anastomosis. There were 10 studies in Group A, and 9 of these demonstrated staple-ring disruption of the plain film (Fig. 1). In five of these, this disruption was considered minimal (Fig. 2). All patients in this group had evidence of leakage confirmed either by water-soluble enema
Fig. 1. Marked disruption
of the staple ring. Fig. 3. Large leakage demonstrated enema.
by water soluble contrast
(8 cases) (Fig. 3), or at surgery (2 cases). In 1 case, the disruption was not appreciated on the pre-enema film, although it was shown on the contrast examination (Figs. 4 and 5). There were 21 studies in Group B and none of these displayed evidence of a disrupted ring on plain film. Three patients in this group had water-soluble contrast enemas as a routine and there was no evidence of leakage. Discussion
Fig. 2. Minimal disruption
of the staple ring (arrow).
Leakage from colorectal anastomoses represents a serious complication and an early diagnosis is clearly desirable. Our review suggests that not only are routine radiographs unnecessary, but that radiology has no role to play in the diagnosis of disruption when there is firm
31
Fig. 4. The low position ofthe staple ring results in poor delineation. The staple ‘suture’ line further obscures detail (hollow arrows).
clinical evidence to suggest this. However, the symptoms and signs of disruption are not always clear, and we feel that in these cases a plain pelvic radiograph may be helpful in supporting the diagnosis. In such instances, the staple ring must be viewed clearly en face and additional angle films may be necessary to achieve this. We agree with the Birmingham group [ 51 that watersoluble contrast enemas for routine surgical audit and clinical research projects cannot be justified. However, we would go further and say that a contrast enema is only indicated in the rare instance of an intact staple ring in a patient with questionable clinical evidence of an anastomotic leak. In conclusion, we feel that routine radiology is not required in cases of clinical disruption, but may be of value when signs and symptoms are less clear. Acknowledgements We wish to thank the surgeons Liverpool Hospital for their assistance this study.
of the Royal in carrying out
References
Fig. 5. The leakage shown on the subsequent
enema is arrowed.
Fielding JWL, Gourevitch A, Lee JR, Keighley MRB. Late disruption of initially satisfactory stapled anastomoses. Br Med J 1980; 1: 1418-1419. Doricott MJ, Baddeley RM, Keighley MRB, Lee J, Gates DG, Alexander-Williams J. Complications of rectal anastomoses with end-to-end anastomosis (EEA) stapling instrument. Ann Roy Co11 Surg Engl 1982; 64: 171-174. Waxman BP. Large bowel anastomoses: the circular staples. Br J Surg 1983; 70: 64-67. Kirwan WO. Integrity of low cola-rectal EEA-stapled anastomosis. Br J Surg 1981; 68: 539-540. Haynes IG, Goldman M, Silverman SH, Alexander-Williams J, Keighley MRB. Water-soluble contrast enema after colonic anastomosis. Lancet 1986; i: 675-676.