A patient undergoes anterior resection for rectal cancer with a colorectal anastomosis 7 cm from the anal verge. On postoperative day 5, CT shows a pericolic collection with air adjacent to the anastomosis, and the patient has a temperature of 38.8°C with mild peritonism. The defunctioning loop ileostomy is intact. What is the most appropriate next step?

• A Laparotomy, washout, and Hartmann's procedure
• B Endoscopic placement of a transanal drain (TAMIS)
• C Conservative management with IV antibiotics alone
• D CT-guided percutaneous drainage and antibiotics ✓

Explanation

This is a Grade B anastomotic leak (Dindo-Clavien classification) — clinically significant but without generalised peritonitis, and the defunctioning ileostomy provides faecal diversion. First-line management is CT-guided percutaneous drainage of the pericolic collection combined with intravenous antibiotics, which resolves most such leaks without reoperation. Hartmann's procedure is reserved for Dindo Grade C leaks with diffuse peritonitis.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.