**6. The anastomosis in an "emergency" setting, scared of a (potential) higher risk or do we still do the same?**

In perforated diverticulitis, for example, there has been no consensus in the management, which is why the Shaban and coauthors [19] felt compelled to

perform a systematic review and meta-analysis, particularly because many surgeons choose the Hartmann's procedure to avoid the risk of an anastomotic leak.

As a result, we proposed that in certain patients, resection with primary anastomosis is a healthy option.

The study found 1933 abstracts, of which 14 trials (2 RCTs, 4 prospective non-randomized, and 8 retrospective non-randomized) with 765 patients met the inclusion criteria, with 482 in the Hartmann's group and 283 in the primary anastomosis group.

Primary anastomosis had a slightly lower mortality rate (10.6%) than Hartmann's (20.7%) (*p* = 0.0003).

The rate of morbidity was also lower (41.8 vs. 51.2%) (*p* = 0.0483).

Primary anastomosis had a risk ratio of 0.92 in favor of mortality (*p* = 0.0019). The average rate of anastomotic leak was 5.9%.

Resection and primary anastomosis should be considered as a feasible and secure operative technique in selected patients with perforated diverticulitis, according to the findings of the study.

However, there is a scarcity of high-level data, and further research is needed.

Resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann's procedure (HP), laparoscopic lavage (LL), and damage control surgery were among the aspects reviewed in another and more complicated approach to damage control strategy in perforated diverticulitis with generalized peritonitis performed by Sohn and team [20] (DCS).

DCS is divided into two levels.

Limited resection of the diseased colon, oral and aboral closure, lavage, and vacuum-assisted abdominal closure are all options for emergency surgery.

After proper resuscitation, a second look operation is performed: definitive reconstruction with colorectal anastomosis (±DI) or HP.

The inclusion criteria were fulfilled by eight observational studies involving 256 patients.

There was no randomized study available.

Purulent peritonitis affected 67% of the patients, while feculent peritonitis affected 30%. Hinchey stage II diverticulitis was observed in 3% of the patients. The Mannheim peritonitis index (MPI) was greater than 26 in 49% of the cases. In 73% of cases, a colorectal anastomosis was developed during the second surgery. DI was used in 15% of the above group. HP was given to the remaining 27%. The postoperative mortality rate was 9%, and the morbidity rate was 31%. The rate of anastomotic leak was 13%. Without a stoma, 55% of patients were discharged.

Conclusions: DCS is a safe treatment for acute perforated diverticulitis with generalized peritonitis, with a high incidence of colorectal anastomosis and stomafree hospital discharge in more than half of patients.

#### **7. Long-term surveillance of the anastomosis**

Pickhardt [21] compared the accuracy of CT colonography versus optical colonoscopy for neoplastic involvement at the surgical anastomosis 1 year after curative-intent colorectal cancer resection for neoplastic involvement at the surgical anastomosis.

As part of a prospective, multicenter study, 201 patients (mean age 58.6 years; 117 men, 84 women) underwent same-day contrast-enhanced CT colonography and colonoscopy approximately 1 year (mean, 12.1 months; median, 11.9 months) after colorectal cancer resection.

#### *The Problem of the Colorectal Anastomosis DOI: http://dx.doi.org/10.5772/intechopen.100302*

Many of the patients enrolled had no clinical signs of illness and were found to have a low risk of recurrence (stage I–III).

Relevant intraluminal anastomotic pathology tends to be very rare 1 year after colorectal cancer resection in lower-risk cohorts, according to the findings.

Diagnostic contrast-enhanced CT colonography, unlike colonoscopy, successfully measures both the intraluminal and extraluminal dimensions of the anastomosis.

Yang and collab [22] investigated the use of stents as a bridge to surgery in the treatment of acute left-sided obstructive colorectal cancer.

In a meta-analysis of randomized controlled trials, the factor according to which the trials were conducted was taken into account.

The use of self-expanding metallic stents (SEMS) as a bridge to surgery in the treatment of acute left-sided obstructive colorectal cancer has remained contentious.

The following were the outcomes:

We chose 8 RCTs papers with a total of 497 instances.

The stent group had significantly lower directly stoma rates, significantly higher active primary anastomosis rates, and significantly lower post-procedural complication rates.

The stent party, on the other hand, had substantially higher tumor recurrence rates, leading to the following conclusions:

This meta-analysis confirms that SEMS placement can lower the rate of direct stomas and increase the rate of active primary anastomosis; however, it is linked to a higher rate of tumor recurrence.
