The persisting presacral sinus following anastomotic leakage after anterior resection: incidence and outcome

Background Despite improvements of anastomotic techniques and specialised surgery, anastomotic leakage is still frequently encountered following anterior resection. Anastomotic leakage of a low anterior resection can eventually evolve into a presacral sinus. This study assesses the incidence, the natural course and outcome of the persisting presacral sinuses resulting from anastomotic leakages. Methods In a two center retrospective study, all consecutive patients who underwent anterior resection for cancer or restorative proctocolectomy for ulcerative colitis or familial poliposis were eligible. Patients with an anastomotic leakage or presacral abscess were included in this study. Primary outcome parameters were the incidence of persistent presacral sinuses, the closure rate of these sinuses, the average time to closure and the rate of successful closure of the ostomy. Results Between 1997 and 2007, 25 patients (M:F=14:11) had an anastomotic leakage complicated by a presacral sinus after low anterior resection (n=20) or a restorative proctocolectomy (n=5). Definitive resolution of the sinus occurred in 12 out of 25 patients (52%). This was achieved in a median of 340 days (range 23-731). In the malignant group in 10 patients (56%) the treatment was successful compared to three out of five patients (60%) in the benign group (p=1.000). At final follow-up, nine of the 23 patients had permanent fecal diversion due to recurrent abscesses or a persistent sinus, seven after low anterior resection and two after restorative proctocolectomy. Conclusions A significant part of patients with anastomotic leakage after low anterior resection or restorative proctocolectomy develop a chronic sinus of which only half heal over time. The persisting sinuses are the main cause of a permanent ostomy in these patients. Since treatment of the persistent sinus is difficult, all effort should be directed to the prevention of the development of the sinus once the anastomotic leakage has been established.