Folie 1

1
Management of Anastomotic Leakage of der Lower
GI-Tract
Professor Dr.med. Dr.h.c. Norbert
Runkel Department of General and Visceral
Surgery Schwarzwald-Baar Klinikum Teaching
Hospital of the University of Freiburg
2
(No Transcript)
3
Schwarzwald-Baar-Klinikum

• Municipal hospital serving 250.000 people
• Teaching Hospital of University of Freiburg
• 21 clinical departments
• 2.700 staff
• 1.084 beds
• 41.000 inpatients
• gt80.000 outpatients
• 200.000.000 turnover

4
Department of General and Visceral Surgery

• Center of Excellence/ Certification
• Surgical Oncology (Onkologischer Schwerpunkt
  Schwarzwald-Baar-Heuberg)
• Coloproktologie (CACP)
• Center für Colorectal Cancer (Darmzentrum)
• Continence-Center Südwest (DKG)
• Surgical Endoscopie (CAES)
• Bariatric Surgery Center
• Minimal Invasive Surgery Center
  (Hospitationsklinik der CAMIC)
• Wound- and Enterostomy-Center

5
Colorectal Procedures 2007
total laparoscopic Ileocoecalresekti
on 20 6 Hemicolektomie rechts 86 38 Transvers
umresekion 6 - Hemicolektomie
links 40 31 Sigmaresektion 62 37 Segmentrese
ktion 10 1 Erweiterte Resektion 10 3 Subtota
le/totale Colektomie 7 2 Stoma-Anlage 100 St
oma-Revision 20 Stoma-Rückverlagerung 96 Rek
tumresektionen 147 93 Peranale
Excision 19 Anteriore Resektion 49 30 Tiefe
Resektion 69 57 Amputation 10 6
6
Colon-Can116
2006

• Mortality 4,3
• 5 electiv, 2 emergent
• anastomotic leakage 2
• re-laparotomy 6
• wound infection 8

Management of Leakage

• Sesis-MOF-death 13-66 Rate of intervention
  100
• Re-Operation
• Healing results in scaring/stricture
• frozen pelvis
• Increased local tumour recurrences

mortality 6,25 anastomotic leakage
11 conservative 4 x revision surgery 3 x
(1 x enterostomy, 2 x Hartmann)
Rectal Ca n64
7
Protective Stoma
Stomas do not prevent leakage but reduce clinical
serverity/catastrophy
In high risk patients and situations protect! An
ostomy is not a surgical failure!
Prevention
Prevention Diagnosis Therapy Cases
8
Protective Stoma
Defunctioning Stoma Reduces Symptomatic
Anastomotic Leakage After Low Anterior Resection
of the Rectum for Cancer A Randomized Multicenter
Trial Peter Matthiessen, MD, PhD, Olof Hallböök,
MD, PhD, Jörgen Rutegård, MD, PhD, Göran
Simert, MD, PhD, and Rune Sjödahl, MD, PhD Ann
Surg. 2007 August 246(2) 207214.
Besonderheiten 1999-2005 intraop. randomisiert
234 Patienten Anastomose lt 7 cm
Prevention
Prevention Diagnosis Therapy Cases
9
Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention
Prevention Diagnosis Therapy Cases
10
Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention
Prevention Diagnosis Therapy Cases
11
Protective Stoma
Matthiessen et al., Ann Surg. 2007
12
Protektives Stoma
Defunctioning Stoma Reduces Symptomatic
Anastomotic Leakage After Low Anterior Resection
of the Rectum for Cancer A Randomized Multicenter
Trial Peter Matthiessen, MD, PhD, Olof Hallböök,
MD, PhD, Jörgen Rutegård, MD, PhD, Göran
Simert, MD, PhD, and Rune Sjödahl, MD, PhD Ann
Surg. 2007 August 246(2) 207214.
Results Symptomatic Leakage 10 vs
28 Permanent Stoma 14 vs 17
Prevention
Prevention Diagnosis Therapy Cases
13
Protective Stoma
In all low rectal anastomoses!
Prevention
Prevention Diagnosis Therapy Cases
14
Drainage

• Drainage is not important intraperitoneally
• Drainage is essential in extraperitoneal
  anastomoses
• In addition transanal drainage

Prevention
Prevention Diagnosis Therapy Cases
15
Fast Tract Surgery

• Fast Tract Rehabilitation

Reduction of averall morbidity from 20 to 7 No
reduction of surgical complication rate 17
leakage rate 3 Hensel et al. Charite Mitte
Anaesthesist 2006
Prevention
Prevention Diagnosis Therapy Cases
16
Closure of peritoneum

• Peritonealisation of pelvis

Prevented peritonitis after 307 colorectal
anastomoses Eckmann et al., Lübeck Int J
Colorectal Dis 2004
17
Diagnosis

• overt secretion
• highly suspicious peritonitis, septic shock
• suspicious leucocytosis, prolonged
  paralysis, abdominal distension and pain

OP!
18
Diagnostics classic and modern
Sensitivität 96,7 bei 307 colorectalen
Anastomosen Eckmann et al., Lübeck Int J
Colorectal Dis 2004
19
Diagnositics Ultrasonography
20
Diagnostics Endoscopy
21
Management

• Key questions
• Is the leakage well drained?
• Signs of SEPSIS?

Therapy
Implication Prevention Therapy Cases
22
Stages and Concepts
grade I well drained, no sepsis
gt conservative therapy
grade II well drained but sepsis

• defunctioning stoma

grade III poorly drained and sepsis

• Surgical revision,
• radical clearing of focus

23
Therapeutic Algorisms

• Intraabdominal anastomosis

early lt 5 days
late gt 5 days
Peritonitis/Sepsis
conservative
Re-Laparotomy
Wait, Liquids Interventional drainage antibiotics
endoskopic fibrin glue
Good general condition Resection, new
anastomosis, stoma
Poor condition disconnection
24
Therapeutic Algorisms

• Rectal Anastomosis

without stoma
with stoma
endoscopy ischemia of simple leak relaparotomy il
eostomy intraop colon washout additional
drainages omental flap Hartmann-resection transana
le Easyflow-Drainagen
Transanal Procedures washout debridement decompre
ssion using Easyflow drainages Endovac fibrin glue
25
Endo-Songe
26
Endo-Songe
27
dem Patienten erfolgen. Anwendung des
Endo-SPONGE Systems zur Therapie einer großen
Anastomoseninsuffizienz nach tiefer
anteriorer Rektumresektion mit TME und J-Pouch
Anlage Abb 8 Ausgangssituation zu Beginn der
Endo-SPONGE-Therapie Die Insuffizienz hat
eine Ausdehnung über 1/3 der Zirkumferenz und ist
20 cm tief mit dem Endoskop einzuspiegeln. Ein
Schwammsystem reicht zur Therapie der großen
Höhle nicht aus, ein weiteres System
wird anschließend eingelegt. Abb 9 12 Tage nach
Therapiebeginn ist die Höhle vollständig von
schmutzigen Fibrinbelägen gereinigt und mit
sauberem Granulationsgewebe ausgekleidet. Abb 10
Die Höhle kann inzwischen bereits mit nur
mehr einem Schwammsystem behandelt werden. Abb
11 Nach 21 Tagen Therapie ist eine deutliche
Verkleinerung der Insuffizienzhöhle
eingetreten. Die Höhle granuliert aus der Tiefe
zu. Das Schwammsystem wird weiter
kontinuierlich von Wechsel zu Wechsel verkleinert.
Abb 12 Nach 33 Tagen Therapie ist nur mehr eine
kleine Rest-Mulde zu erkennen. Diese Mulden
heilen in der Regel ohne zusätzliche Therapie
ab. Dr. med. Rolf Weidenhagen Chirurg Klinikum
Großhadern, München
28
Therapeutic Algorisms

• Intraabdominal anastomosis

early lt 5 days
late gt 5 days
Peritonitis/Sepsis
conservative
Re-Laparotomy
29
Therapeutic Algorisms

• Rectal Anastomosis

without stoma
with stoma
endoscopy ischemia of simple leak relaparotomy il
eostomy intraop colon washout additional
drainages omental flap Hartmann-resection transana
le Easyflow-Drainagen
Transanal Procedures washout debridement decompre
ssion using Easyflow drainages Endovac fibrin glue
30
Case I

• Bodo H, geb. 1.1.36
• 12/2005 peranal bleeding
• 2/2006 Colonoscopy und polypectomy bei 40 und 56
  cm
• Histology GII,smII,L1 bei 40 cm
• 16.3.2006 endoscopic tatooing
• 17.3.2006 lap. Left colectomy

31

• Bodo H, geb. 1.1.36
• 12/2005 peranaler Blutabgang
• 2/2006 Coloskopie und Polypektomie bei 40 und 56
  cm
• Histologie GII,smII,L1 bei 40 cm
• 16.3.2006 Tuschemarkierung
• 17.3.2006 lap. Hemicolektomie links
• 20.3. Appetitlosigkeit, sauberes Sekret, L 13100
  CRP 13,8

20.3. Nahrungskarenz, Antibiose
21.3. Colon-KE
32
20.3. nil by mouth, antibiotics
23.3. colonoscopic firbin glue
33
Therapeutic Algorisms

• Intraabdominal anastomosis

early lt 5 days
late gt 5 days
Peritonitis/Sepsis
conservative
Re-Laparotomy
Wait, Liquids Interventional drainage antibiotics
endoskopic fibrin glue
Good general condition Resection, new
anastomosis, stoma
Poor condition disconnection
34
Case II

• Gertraud S, 10.2.27
• 1/2006 malena, malaise, anemia
• medical history obesity, liver cirrhosis
• 1/2006 colonoscopy carcinoma at 80cm
• 9.2. left colectomy
• postop. pneumonia, SIRS, 4 days ICU
• 19.2. dyspnoe, resp. Insufficiency, abdomen not
  distended
• 20.2. ICU, Sepsis, MOF

20.2. CT
Operation direct drainage of abscess Result
stool fistula
35
Case II

• Gertraud S, 10.2.27
• 1/2006 malena, malaise, anemia
• medical history obesity, liver cirrhosis
• 1/2006 colonoscopy carcinoma at 80cm
• 9.2. left colectomy
• postop. pneumonia, SIRS, 4 days ICU
• 19.2. dyspnoe, resp. Insufficiency, abdomen not
  distended
• 20.2. ICU, Sepsis, MOF

20.2. CT
20.2. Operation 22.2. Stool fistula
36
Case II
20.3. CT demission late April
37
Therapeutic Algorisms

• Intraabdominal anastomosis

early lt 5 days
late gt 5 days
Peritonitis/Sepsis
conservative
Re-Laparotomy
Wait, Liquids Interventional drainage antibiotics
endoskopic fibrin glue
Good general condition Resection, new
anastomosis, stoma
Poor condition disconnection
38
Case III

• Horst F., 26.11.26
• Medical history alcoholism, Korsakow, obesity,
  sigmoid double cancer with liver metastasis
• 25.4.2005 emergency surgery for acute
  obstruction left colectomy, on table-Lavage
  via appendectomy
• 29.4. aspiration, subileus 2 days ICU
• 6.5. relaparotomie for 4-quadrant peritonitis
  due to leakage from cecum

39
Case III

• Horst F., 26.11.26
• Medical history alcoholism, Korsakow, obesity,
  sigmoid double cancer with liver metastasis
• 25.4.2005 emergency surgery for acute
  obstruction left colectomy, on table-Lavage via
  appendectomy
• 29.4. aspiration, subileus 2 days ICU
• 6.5. relaparotomie for 4-quadrant peritonitis
  due to leakage from cecum closure and
  ileostomy, ICU
• 13.5. death in MOF

40
Case IV

• Gisela F., 20.2.45
• 9/2005 DVT
• 9/2005 Colonoscopy cacer at right flexure
• CT liver metastases

41
Case IV

• Gisela F., 20.2.45
• 4.10. right colectomy and liver biopsy
• postop fever with pneumonia ICV 6 days
• 20.10. L 15600. CRP 27 abdomen soft
• 20.10. CT

20.10. Re-laparotomy, drainage and ileostomy No
sepsis, ICU 6 days
42
Fallbeispiel IV
1.11 CT (postop day 11)
Result local sepsis and enterocutaneous fistula
43
Case IV
44
Fallbeispiel IV
Gisela F., 20.2.45 4.10. right colectomy and
liver biopsy 20.10. Re-laparotomy, drainage and
ileostomy 29.11. Re-laparotomy for short bowel
syndrom, intraabdominal abszess and
fistulation Debridenemnt, drainage, resction
of anastomosis and ileostoma-take down 6.12
Re-laparotomy for enterocutaneous fistula and
wound dehiscence anastomotic stoma 16.12
transferal to surgical ward 3.1. demission 1.3.
take down of stoma, i.v.-port for chemotherapy
45
Therapeutic Algorisms

• Intraabdominal anastomosis

early lt 5 days
late gt 5 days
Peritonitis/Sepsis
conservative
Re-Laparotomy
Wait, Liquids Interventional drainage antibiotics
endoskopic fibrin glue
Good general condition Resection, new
anastomosis, stoma
Poor condition disconnection
46
Aachener Algorithmus
47
RisikofaktorenPatient

• Patientenalter, Geschlecht
• Begleiterkrankungen DM, Tumorerkrankung, CED,
  Dialyse
• Lifestile Adipositas, Nikotin, Alkohol

Adipositas, Nikotin, Alkohol Nickelsen et al.,
Glostrup, Dänemark Acta Oncol 2005
48
Risikofaktorennicht-chirurgisch

• Neoadjuvante Therapie

N246 TME, konv. Radiochemotherapie,
retrospektiv 93 (28 mit vs 65 ohne RXT)
Anastomose lt 6 cm Insuffizienz 18 vs 6 RXT
einziger unabhängiger Faktor in multivariater
Analyse Buie et al., Calgary, Dis Colon Rectum
2005
n924 TME, Kurz-Radiotherapie, randomisiert-retros
pektiv symptomatische Insuffizienz 11,6 Peeters
et al Dutch Coloretal Cancer Group Br J Surg 2205
49
Diskonnektions-Op

• Hartmann
• Stoma und Schleimfistel
• Doppelläufiges Anastomosenstoma (Mikulicz-Stoma)

50
Therapeutischer Algorithmus

• intraabdominelle Anastomose

spät gt 5 Tage
Abwarten, Tee, Astronautenkost ggf.
interventionelle Drainage Somatostatin Antibiose e
ndoskopische Fibrinklebung
konservativ
51
Therapeutischer Algorithmus

• intraabdominelle Anastomose

früh lt 5 Tage
spät gt 5 Tage
Peritonitis/Sepsis
Re-Laparotomie
Guter Zustand Resektion, Neuanlage, Stoma
schlechter Zustand Diskonnektion
Peritonitis-Therapie (Fokussanierung) allg.
Sepsis-Therapie