Chronic Anastomotic Leaks After Low Anterior Resection: Rethinking Evaluation and Management

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Abstract
Background: Chronic anastomotic leaks following low anterior resection (LAR) with primary anastomosis and diverting loop ileostomy (DLI) pose a complex management challenge. Optimal strategies for evaluating and managing chronic leaks remain poorly defined, particularly regarding the timing and safety of stoma reversal. Methods: We conducted a retrospective study of patients with stage I-III rectal cancer who underwent LAR with DLI between 2011-2022 and subsequently developed a chronic anastomotic leak, defined as a defect persisting beyond 30 days on imaging or endoscopy. Demographic, procedural, and outcome data were abstracted from the electronic medical record. Patterns of imaging and procedural evaluation, time to clinical disposition (defined as DLI reversal, conversion to colostomy, or decision to maintain DLI), and clinical decision-making factors were analyzed. Results: Nineteen patients met inclusion criteria. During their clinical course, 68.4% of patients underwent percutaneous drainage, with management guided by serial abdominopelvic computed tomography (CT). Gastrografin enemas and endoscopies were performed for anastomotic assessments but demonstrated limited predictive value, as one patient with a normal study developed postoperative pelvic sepsis, while three patients with persistent defects achieved successful reversal. The median time to clinical disposition was 367 days. Ten patients remained with a permanent ostomy, while nine underwent attempted reversal, of whom seven (36.8%) achieved durable bowel continuity. Discussion: Management of chronic anastomotic leaks was individualized, influenced by imaging findings, patient preferences, and surgeon judgment. These findings highlight the limitations of relying solely on structural assessments and underscore the need for integrated, patient-centered frameworks to guide evidence-based reversal decisions.

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