Diagnostic Approach to Surgical Site Infection After Colostomy Closure
Diagnostic Algorithm
- The American College of Radiology recommends contrast-enhanced CT scan with oral contrast as the first-line diagnostic modality to rule out anastomotic leak and fistula formation, followed by endoscopic evaluation in stable patients 1, 2
- The administration of both oral and intravenous contrast is fundamental to find landmarks and improve sensitivity and specificity of radiological assessment, with a reported sensitivity of 91% and specificity of 100% for detecting postoperative anastomotic leaks 1, 3, 4
- Specific CT findings suggestive of leak include extraluminal extravasation of contrast material, perianastomotic gas or fluid collection, and disruption of staple line integrity 5
- Endoscopic evaluation should follow CT in stable patients with suspected leak or fistula, and should be performed by an expert endoscopist familiar with post-surgical anatomy 1, 6, 7
Clinical Indicators to Monitor
- Fever, tachycardia, or other systemic symptoms may indicate infection extending beyond a simple surgical site infection, and purulent discharge from the incision, spreading erythema or cellulitis beyond the incision site, and severe pain disproportionate to expected healing process are clinical indicators of anastomotic leak 9
Management Considerations
- Endoscopic management of leaks and fistulae is effective and safe when performed in expert centers, and several endoscopic techniques are available, including internal drainage with pigtail plastic stents, self-expanding metal stents (SEMS), clipping techniques, and tissue sealants and suturing systems 6, 8