The term anastomosis has been derived from a Greek word, with a literal meaning of ‘without a mouth’. Intestinal anastomosis is one of the most commonly performed surgical procedures, both in the emergency and routine setting.1 Primary repair of intestine is done for intestinal obstruction, perforation peritonitis, radiation enteritis, inflammatory bowel disease and malignancy.

The contra-indications for primary repair of intestine are severe sepsis, poor nutritional status, disseminated malignancy with serosal, peritoneal deposits and ascites, faecal or purulent peritonitis.

Complications can occur during surgery and postoperative course. Surgical wound infection is the common complication following anastomoses.  Anastomotic leaks are more common in patients with inflammatory bowel disease. Pelvic abscess may also occur in association with an anastomotic leak or due to an infection of hematoma collection. Leakage from an anastomosis in the intestine that is often associated with increased morbidity, mortality rate 2 and adversely affects length of hospital stay and cost.3 The cause of the leakage may be multifactorial, including faulty technique, ischemia of the intestine at the suture line, excessive tension across anastomosis and mesentery, the presence of local sepsis, presence of obstruction distal to the anastomosis. The old patients, anemia, malnourished with several coexisting diseases, receiving high doses steroids, after chemoradio-therapy is more prone to develop the anastomotic leakage.4 among other factors are male gender, smoking, obesity, alcohol abuse, long duration of operation, peri-operative blood transfusion and duration between onset of symptoms and surgery.5

Surgeons are all familiar with potentially devastating consequences of anastomotic leak. Patients classically develop agonizing abdominal pain, tachycardia, high fever and a rigid abdomen, often accompanied by hemodynamic instability. In these cases urgent return to the operating room for peritoneal washout and faecal diversion is generally required.6 The mortality rate for an anastomotic leak in the literature typically is in the 6 to 39% range and a 10- 100% rise of permanent stoma.7 However, a large number of patients ultimately found to have an anastomotic leak develop a more insidious presentation, often low grade fever, prolonged ileus, or failure to thrive.8 In these patients making the diagnosis may be much more difficult as the clinical course is often similar to other postoperative infectious complications. Anastomotic leakage and dehiscence remain frequent and serious problems associated with high morbidity and mortality. This dissertation focuses on the factors that influence the healing process of intestinal primary repair and anastomosis, aiming to improve outcomes and reduce complications associated with these common surgeries.9,10

AIMS: To define the risk factors, presentation and outcome of anastomotic leakage after intestinal primary repair and anastomosis.

This prospective clinical study included 140 patients who underwent Intestinal Resection and Anastomosis and Primary Repair at Bundelkhand Medical College and Hospital, Sagar, Madhya Pradesh from February 2023 to February 2025, after taking approval from Institutional Ethics Committee, letter no. IECBMC/2023/116 dated 03/02/2023.

Inclusion Criteria:

Primary closure of intestinal perforation, Intestinal anastomosis either in the emergency/ routine surgery, Closure of stoma and Abdominal trauma requiring primary repair and intestinal anastomosis surgery

Exclusion Criteria:

Biliary enteric anastomosis, Intestinal anastomosis at multiple sites and Stapler Anastomosis 

Methods: Data was collected from detailed history, clinical examination and investigations (both haematological as well as radiological).

Variables chosen for analysis

Demography, Associated Comorbidities, Biochemical Parameters, Benign or Malignant Lesions of Intestine, Routine or Emergency, Surgical Anastomotic Technique and Surgery related Complications

After surgery, patients were followed up daily in the hospital until discharge. The post-op complications like Surgical Site Infection, Anastomotic Leak, Septicaemia, Acute Renal Failure, Respiratory Complications, Abdominal Wound Dehiscence/ Burst Abdomen were recorded.

The outcome was summarized as: Healed, Leaks and Deaths

Table 1: Anastomotic Leak - Demography

Anastomotic leaks are higher in males (11.4%) than females (6.4%).

Most common age group affected above 60 years (4.3%).

Table 2. Associated Co-morbidities

The leak rate in diabetic group is 3.6% (05 patients). 04 hypertensive patients (2.9%) had anastomotic leak.

Table 3. Biochemical parameters-

16 patients with Haemoglobin <12g/dL (11.5%) have anastomotic leak. 13 patients with Serum Albumin level < 3 g/dL (9.3 %) have anastomotic leak.

Table 4. Benign or Malignant Lesions of Intestine

            The proportion of leaks in benign lesions is lesser than malignant lesions (17.5:: 22.2).

Table 5. Routine/ Emergency:

                  Anastomosis leaks occur in 20 patients (14.3%) undergoing emergency operation.

Table 6. Surgical anastomotic technique –

                               Majority of leaks belonged to End-to-end group, 22 patients (15.7%).

Table 7. SURGERY-RELATED COMPLICATIONS

The post-operative complications showed maximum incidence of surgical site infection (33.3%) in 40 patients, followed by respiratory complications in 30 patients (21.4%), Abdominal wound dehiscence in 28 patients (20%), anastomotic leak in 25 patients (17.9%) and septicaemia rates of 11.4%, in 16 patients. The least common complication was Acute Renal Failure (9 patients, 6.4%).

OUTCOME

The outcome of the study was determined by number of patients healed, which forms the majority, i.e., 111 patients (79.3%). The anastomotic leak occurred in 25 patients (17.86%) out of total 140 patients. The mortality rate in our study was 2.86% (04 patients).

Patient related factors:

Anastomotic leaks occur maximum in age group > 60 years (4.3%), comparable to a study by Schiff A et al, 6.1% such leaks.11 Anastomotic leak occurred in 11.4% males and 6.4% females, comparable to a study by Saikaly E et al, seen in 11% males and 7% females.12 Anastomotic leaks occur in 3.6% diabetics, comparable to a study by Telem DA  et al (3.7%).13 Anastomotic leaks occur in 2.9% hypetensives, comparable to a study by Shankar, Vishnu et al (2.5%).14

Anastomotic leaks occurred in 11.5% patients with Haemoglobin < 12 g/dL and 9.3% with Serum Albumin levels < 3 g/dL, comparable to a study conducted by Shankar, Vishnu et al (10% and 8.75%, respectively) .14 Anastomotic leak occurs in 22.2% malignant and 17.5% benign lesions, comparable to a study by  Jina et al, which concluded anastomotic leak is higher in malignant conditions (23.07%).15 Anastomotic leaks occur in 7.1% such patients, comparable to a study by Eriksen et al (6.77%). 16

Technical Factors:

14.3% anastomosis leaks occur in emergency operation and 3.6% in routine operation, comparable to a study by Pujari KK et al (10.3% emergency and in 2.3% elective patients).17 15.7% patients with end-to-end anastomosis result in anastomotic leak, comparable to a study by Telem AD et al (12.6%).13

Surgery Related Complications

33.3% patients suffered surgical site infection, comparable to a study by Ajinkya et al  (30%).18 17.9% patients suffer anastomosis leaks, comparable to 20.8% according to a study by Wassef Pola et al.19 Septicaemia occurred in 11.4% patients, comparable to a study by Mulita F et al (12.77%).20 ARF occurred in 6.4% patients, comparable to a study by Ajinkya et al (6%).19 21.4% patients reported respiratory complications comparable to a study by Miskovic A et al (23%).21 20% patients presented with burst abdomen, comparable to a study by Pujari KK et al (18.75%).17

Outcome

17.9% patients suffered anastomosis leaks, comparable to a study by Ashok et al (14.6%).22 The mortality rate is 2.86%, comparable to a study by Ziegler et al (3%).23

Anastomotic leak is a dreaded complication following resection-anastomosis procedures. Our study aims to assess factors affecting healing of intestinal anastomosis. If early intervention is done, these complications can be minimized. Patient related factors and technical factors were implicated in occurrence of anastomotic leaks. The modifiable risk factors must be corrected pre-operatively to ensure the integrity of anastomotic sites. The non-modifiable risk factors must be carefully assessed and alternative options such as ileostomy/ colostomy creation or drain placement in emergency operations may be considered, in such cases. The complications arising post resection-anastomosis procedures, must be kept in mind while managing such cases in post-operative period. The mortality rate in our study is low, i.e. 2.86% due to raised awareness regarding the implicated factors.

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