Techniques in Coloproctology

, Volume 23, Issue 7, pp 625–631 | Cite as

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis

  • E. RausaEmail author
  • M. A. Zappa
  • M. E. Kelly
  • L. Turati
  • A. Russo
  • A. Aiolfi
  • G. Bonitta
  • L. G. Sgroi
Original Article



Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL.


A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology.


Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14–0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21–1.30) and IOC (RR 0.49; Crl 0.10–1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14–0.87) and IOC (RR 0.44; Crl 0.14–0.87).


This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.


Postoperative complication Anastomotic leak Colonoscopy Indocyanine green 



This work was not supported.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable.

Informed consent

Not applicable.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • E. Rausa
    • 1
    Email author
  • M. A. Zappa
    • 2
  • M. E. Kelly
    • 3
  • L. Turati
    • 1
  • A. Russo
    • 1
  • A. Aiolfi
    • 4
  • G. Bonitta
    • 1
  • L. G. Sgroi
    • 1
  1. 1.Surgical Oncology UnitTreviglio HospitalTreviglioItaly
  2. 2.Division of General SurgeryFatebenefratelli HospitalMilanItaly
  3. 3.Department of Colorectal SurgerySt James HospitalDublinIreland
  4. 4.Department of Biomedical Science for Health, Division of General Surgery, Istitituto Clinico Sant’AmbrogioUniversity of MilanMilanItaly

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