The Management of Anastomotic Leak

1
The Management of Anastomotic Leak

• John Hartley
• Academic Surgical Unit
• University of Hull

2
The Management of Anastomotic Leak

• Surgical disaster
• Increased morbidity, mortality, hospital stay,
  cost etc etc
• Best avoided
• Will happen
• Suspect it (Assume it)
• Identify early and treat aggressively

3
Anastomotic LeakAnastomoses in Lower Third of
Rectum (0-6cm)

• Leak rate 5 20

UK Karanjia, Corder, Holdsworth, Heald BJS,
1991, 78, 196 France Ruler, Laurent, Premix BJS,
1998, 85, 355 USA Smith DCR, 1981, 22, 236
4
Anastomotic LeakLeaking Anastomoses in Lower
Third of Rectum

• MORTALITY Increases by a factor of 20
• MORBIDITY Hospital stay10 days 30
  days Permanent colostomy gt 50

5
Anastomotic Leak

• The value of covering stoma
• 200 patients with low anterior resectionNo
  defunctioning stoma 8 peritonitis.
  Defunctioning stoma lt1
• Karanjia et al 1991, BJS 78, 196
• 1115 pts Geneva Multicentre Study Mortality 0.9
  v 3.6 for covered vs not covered
• Kassler et al, 1993, Int J Colorectal Dis, 8,
  158

6
Anastomotic Leak- whos to blame?

• Technical factors
• Ischaemia of bowel ends
• Oedema of bowel ends
• Anastomotic tension
• Poor suturing technique
• Haemorrhage
• Sepsis

• Patient factors
• Anaemia
• Sepsis
• Malnutrition
• Steroids
• Radiotherapy
• Cardiovascular problems
• (Bowel preparation)

7
Anastomotic Leak

• Diagnosis
• Clinical signs
• Leucocytosis
• Positive blood cultures
• Abdominal/chest X-ray
• Gastrograffin enema
• CT scan
• Labelled white cell scan
• Fistulogram

8
Anastomotic Leak

• Clinical signs
• Depend upon
• Severity of leak
• Degree of localisation
• Time of leak post op
• Whether the anastomosis is covered

9
Anastomotic Leak

• Clinical Signs - may be non-specific
• Clinical leak in 22 of 379 pts (6) undergoing
  surgery for CRC
• - 7 (32) obvious peritonitis
• - 15 (68) initial misdiagnosis for mean of 4
  days (range 0-11), 13 treated for cardiac
  problems
• 30 patients (8) developed cardiac symptoms of
  whom 13 had a leak
• Sutton CD et al. Colorectal Dis 2004621-2

10
Anastomotic Leak

• Anticipation
• Off colour
• Failure to diurese
• Prolonged ileus
• (diarrhoea)
• Fever
• Failure to meet milestones

11
Anastomotic Leak

• Clinical presentation
• Faecal peritonitis
• Clinically ill patient with abscess, no gross
  abdominal signs
• Clinically ill patient without abscess, no gross
  abdominal signs
• Clinically well patient with enterocutaneous
  fistula

12
Anastomotic Leak

• Faecal Peritonitis
• Severe abdominal pain
• General tenderness and guarding
• Silent abdomen
• Tachycardia, hypotension
• Oliguria / anuria
• Faecal leakage from drain or wound

13
Anastomotic Leak

• Faecal Peritonitis diagnosis
• Erect chest X-ray
• Gastrograffin enema
• ?? CT scan

14
Anastomotic Leak

• Faecal peritonitis management
• Confirm diagnosis
• Urgent resuscitation
• - iv fluids
• - CVP monitoring
• - Antibiotics
• - Urinary catheter
• Urgent re-exploration

15
Anastomotic Leak

• Options at re-laparotomy
• External Drainage
• Suture Defect
• Suture Defect with Proximal Diversion
• Proximal Diversion
• Proximal Diversion with Drainage
• Exteriorise Leaking Segment
• Resect Anastomosis with Re-anastomosis
• Resect Anastomosis with end stoma, mucous
  fistula or Hartmanns

16
Anastomotic Leak

• Laparotomy for faecal peritonitis
• Confirm diagnosis
• Disconnect anastomosis Proximal stoma Mucus
  fistula Close distal end
• Wash out abdomen?
• Drain?
• Laparostomy

17
Anastomotic Leak

• Laparotomy for leak following anterior resection
• 32 pts lavage, drainage, diversion
• 22 Hartmans (size of leak, viability of colon,
  site of anastomosis)
• - 8 of 19 survivors continuity restored
• 10 proximal diversion all had stoma reversed
• Parc et al. Dis Colon Rectum 200043579-87

18
Anastomotic Leak

• Clinical presentation
• Faecal peritonitis
• Clinically ill patient with abscess, no gross
  abdominal signs
• Clinically ill patient without abscess, no gross
  abdominal signs
• Clinically well patient with enterocutaneous
  fistula

19
Sealed off leak with abscess

• Vague localised or general abdominal pain
• Localised peritoneal signs
• Temperature, tachycardia
• Ileus
• Multi organ failure Jaundice Renal failure ARDS

20
Anastomotic Leak Sealed off major leak with
abscess (ill patient)

• Drainage
• Nutritional support
• Antibiotics

21
Anastomotic Leak

• Clinical presentation
• Faecal peritonitis
• Clinically ill patient with abscess, no gross
  abdominal signs
• Clinically ill patient without abscess, no gross
  abdominal signs
• Clinically well patient with enterocutaneous
  fistula

22
Anastomotic Leak

• Clinical presentation
• Faecal peritonitis
• Clinically ill patient with abscess, no gross
  abdominal signs
• Clinically ill patient without abscess, no gross
  abdominal signs
• Clinically well patient with enterocutaneous
  fistula

23
Anastomotic Leak

• Enterocutaneous fistula in clinically well
• patient
• Delineate fistula CT Fistulogram
• Percutaneous drainage of abscess
• Exclude distal obstruction / foreign body
• Correct anaemia, malnutrition, electrolytes
• Control fistula skin care suction /
  bags somatostatin

24
Anastomotic Leak

• Conclusions
• Leaks are common
• Leaks cause considerable morbidity and mortality
• Maintain high index of suspicion
• Manage aggressively and safely
• Leaks are better avoided than treated covering
  stoma

25
(No Transcript)
26
Anastomotic Failure

• Sealed off major leak with abscess
• Vague localised or general abdominal pain
• Localised peritoneal signs
• Temperature, tachycardia
• Ileus
• Multi organ failure Jaundice Renal
  failure ARDS

27

• Free gas post
• Laparotomy
• Plane XR almost
• always resolved
• by 5th day
• New gas worry!

28
Anastomotic Leak

• Enterocutaneous fistula management
• Improve general condition
• Feeding line with specialist nursing
• Control if possible with stoma or proximal loop
• Drain abscess / collection if possible
• Intensive attention to input / output
• Specialised skin / stoma care
• ? Help from fistula unit