prevention, diagnosis and management of … · 2016-03-08 · this latest iipp booklet on the...

PREVENTION DIAGNOSIS ANDMANAGEMENT OF COLORECTAL

ANASTOMOTIC LEAKAGE

March 2016

wwwasgbiorguk wwwacpgbiorguk

1

ISSUES INPROFESSIONAL PRACTICE


ANASTOMOTIC LEAKAGE

AUTHORSF D McDermott S Arora J Smith R J C Steele

G L Carlson and D C Winter(on behalf of the joint ASGBIACPGBIAnastomotic Leakage Working Group)

PUBLICATION DATEMarch 2016

PUBLISHED BYAssociation of Surgeons of Great Britain and Ireland

35-43 Lincolnrsquos Inn Fields London WC2A 3PE

SPONSORED BYAN EDUCATIONAL GRANT FROM

No part of this publication may be reproduced stored or transmitted in any form or by any means withoutthe prior written permission of the publisher or in the case of reprographic reproduction in accordancewith the terms of licenses issued by the Copyright Licensing Agency in the UK [wwwclacouk] Enquiriesconcerning reproduction outside the terms stated here should be sent to the publisher at the above addressThe use of registered names trademarks etc in this publication does not imply even in the absence of a specificstatement that such names are exempt from the relevant laws and regulations and therefore for general use

Association of Surgeonsof Great Britain and Ireland

The Association of Coloproctologyof Great Britain and Ireland

2

FOREWORDIssues in Professional Practice (IIPP) is an occasional series ofbooklets published by the Association of Surgeons of Great Britainand Ireland to offer guidance on a wide range of areas whichimpact on the daily professional lives of surgeons Some topicsfocus on clinical issues some cover management and servicedelivery whilst others feature broader aspects of surgical workinglife such as education leadership and the law

This latest IIPP booklet on the Prevention Diagnosis andManagement of Anastomotic Leakage has been produced inpartnership with the Association of Coloproctology of Great Britainand Ireland and it is hoped that this joint collaboration will be ofsignificant clinical benefit to members of both societies

The Association intends that this publication and others in theseries (all of which are accessible atwwwasgbiorgukpublications) will provide concise advice andguidance on major current issues and prove to be a helpful andaccessible resource to support your professional practice Wewelcome feedback on this and other booklets in the Issues inProfessional Practice series and proposals and contributions forfuture issues in the series

Mr John MooreheadPresident

3

CONTENTS

Introduction 5

Patient Perspective 6

Acknowledgements 7

Abbreviations 7

Introduction 8

Development of Methodology and Delphi Meeting 8

Definitions and Epidemiology of AL 8

Definition 8

Epidemiology 8

Avoidance of Anastomotic Leakage 9

Preoperative considerations 9

Modifiable risk factors 9

Non-modifiable risk factors 11

Intraoperative considerations 13

Operative technique 13

Goal directed fluid therapy 13

Interventions 14

Postoperative considerations 15

(NSAIDS) 15

Diagnosis of Anastomotic Leakage 16

Scoring systems 17

Treatment of AL 17

Initial management 17

Subsequent and Definitive Management 18

1 General principles 18

2 Source control 18

Management of Specific Patterns of Anastomotic Leakage 20

1 Intraperitoneal Anastomotic Leakage 20

2 Extra-peritoneal Anastomotic Leaks 21

4

Appendix 23

Summary of findings from Delphi process for colorectalanastomotic leaks 23

Demographics and Format of Delphi Process 23

Regions 24

Delphi Process 25

Definition of anastomotic leaks 25



Periintraoperative risk factors 25

Reduce risk of anastomotic leaks 25

Risk factors required to consider defunctioning 27

Air Leak Testing 27

Intraoperative endoscopy 27

Useful indicators for anastomotic leaks 27

Investigation of anastomotic leak 28

Factors to determine whether to resect an anastomosis 28

References 29

5

INTRODUCTIONAn anastomotic leak as all colorectal surgeons are aware is adevastating complication that may not only result in severemorbidity but can also unfortunately lead to the demise of thepatient We all fear it and will do all we can to prevent it Howeverno matter how skilled the surgeon may be there are times when thiscomplication will occur despite best efforts

These guidelines which have been developed by an exhaustivereview of the literature and meticulous scientific process provideextremely valuable advice as how to prevent diagnose treat and -very importantly - counsel patients about the possibility of thisdreaded complication The group have worked diligently to sift andinterpret the information and are to be commended on producing adocument that is clear concise and balanced If teams follow theiradvice there is no doubt in my mind that the incidence ofanastomotic leakage will be reduced but also when it occurs liveswill be saved

I do hope that all practicing surgeons will heed the current thinkingthat is embodied in the document and apply it appropriately

Professor Sir Norman WilliamsMS FRCS FMed Sci FRCP FRCP (Edin) FRCA FDS (Hon)FACS (Hon) FRCSI (Hon) FRCSEd (Hon)

Past President The Royal College of Surgeons of EnglandDirector National Centre for Bowel Research and SurgicalInnovation Barts amp The London School of Medicine amp Dentistry

6

Patient PerspectiveWhilst this document is intended to review the clinical evidence onthe prevention diagnosis and management of anastomotic leakage itis essential that the impact of anastomotic leakage on the patient andtheir family is also considered Good communication remains animportant aspect of care

Careful history taking may elicit important risk factors foranastomotic leakage (eg a history of smoking or alcohol abuse)which may not otherwise be evident and about which some patientsmay be reticent

It is important to prepare patients and their families for surgerywhere an anastomosis is being considered by giving a balancedassessment of the risk of anastomotic leakage This will allow better-informed decision-making regarding whether the risk of ananastomosis (in particular a higher risk anastomosis) is acceptableor whether a stoma may be preferable This may enable patients tomake a better-informed choice and to be better prepared to deal withthe consequences of an anastomotic leak should this occur

Good quality timely information before and after surgery is part ofthis process and should include input from an enterostomal therapistwhich may help allay the patientrsquos fears with regard to a stoma andits impact on future quality of life

Patients who have suffered from anastomotic leakage should notonly be offered prompt and appropriate medical attention but afrank open and honest discussion about the complication as soon astheir condition permits They should have access to psychologicalsupport to help them deal with associated anger grief and stress

Jo ChurchPatient Representative

7

AcknowledgementsThe authors wish to thank the following members of theASGBIACPGBI joint anastomotic leak working group for generouslygiving their time and effort in assessing the clinical evidence andproviding expert opinion

Austin Acheson Tan Arulampalam Arnie Bhowmick Cat BoereboomKen Campbell Jo Church (Patient Liaison) Mark Coleman JustinDavies Michael Davies Peter Dawson Nicola Fearnhead NaderFrancis Richard Guy Nigel Hall Athur Harikrishnan Deena HarjiCharles Hendrickse Stephen Holtham Kourosh Khosraviani RobinKennedy Anil Lala Gerald Langman Charles Maxwell-ArmstrongBrendan Moran Neil Smart Henry Tilney Jared Torkington JanindraWarusavitarne

Thank you to Louise Hull for her assistance with the DelphiMethodology

AbbreviationsAL Anastomotic leak

ASA American Society of Anaesthesiologists Physical StatusClassification

BMI Body mass index

CI Confidence intervals

CRP C-reactive protein

DFS Disease free survival

IR Interventional radiology

NSAID Non-steroidal anti-inflammatory drug

OS Overall Survival

OR Odd Ratio

RCT Randomised Control Trial

SDD Selective decontamination of the digestive tract

TNF Tumour necrosis factor

WHR Waist hip ratio

8

IntroductionAnastomotic leaks (AL) are potentially catastrophic complicationsof colorectal surgery The spectrum of clinical severity associatedwith AL is broad however ranging from a small-contained leakwithout sepsis in a patient with a defunctioning stoma to a patientwith four-quadrant peritonitis and septic shock ALs increase theneed for reoperation the risk of local recurrence1 and reduce bothoverall (OS) and disease free survival (DFS)2-4 Despite the gravityof the complication and potential sequelae data regarding riskfactors and optimal perioperative management of ALs are relativelypoor and few attempts have been made to bring together the datawhich are available in order to provide clinical guidance Thisdocument aims to present the current best evidence and utilisedDelphi methodology to provide expert colorectal opinion

Development Of Methodology amp Delphi Meeting A systematic review of the literature searching for colorectalanastomotic leaks was performed5 Due to low quality evidenceacross multiple domains of risk factors assessment and managementof ALs a Delphi methodology was proposed Following the reviewand Delphi process it was agreed that formal gradingstrength ofrecommendation would be inappropriate due to the lack of highquality evidence A formal cut-off for consensus was not used ratherthe evidence was discussed and the percentage consensus after 3rounds of discussion is presented in brackets

A steering group of colorectal consultants and trainees was formedand met at the Tripartite meeting in Birmingham in July 2014Current evidence was presented and on the basis of this it wasagreed that a Delphi format would be beneficial to help developguidelines A questionnaire was developed using Survey Monkey6

and distributed to ACPGBI members covering all ACPGBI regionalchapters The initial round was completed on-line by participantsprior to a meeting with a further 2 rounds (See Table 7 Appendix)

Definitions and epidemiology of ALDefinitionThe preferred definition for anastomotic leaks was lsquoA leak ofluminal contents from a surgical join between two hollow viscerarsquo7

EpidemiologyThe prevalence of AL varies from 1 to 19 depending uponanatomical site pre intra and postoperative factors5 These arediscussed below

9

Avoidance of Anastomotic LeakagePreoperative considerationsIdentification of significant preoperative risk factors may guide theproposed treatment and allow modification of risk Preoperativealteration of lifestyle andor treatment may not always be possibleparticularly in the emergency setting However consideration of riskfactors is relevant in the decision-making process with regard towhether an anastomosis is a safe option and whether a defunctioning(or permanent) stoma should be considered At the very least if apatient opts for a ldquohigh riskrdquo anastomosis despite the identification ofsignificant risk factors for AL this should be on the basis of clearlydocumented discussion regarding the alternative safer optionsPreoperative risk factors for AL may be modifiable or non-modifiable

Modifiable risk factors

AlcoholEthanol consumption in excess of recommended levels (gt105galcohol per week) is associated with an increased risk of AL8 In theUK 1 unit of alcohol is the equivalent of 8 grams of pure alcohol

SmokingTobacco smoking both current and historical is associated with anincreased risk of AL Several studies have demonstrated currentsmoking to be an independent risk factor9-13 Additionally a previoussmoking history (gt40 pack years) is an independent risk factor for AL14

ObesitySeveral studies have shown obesity to independently increase therisk of AL15-18 While obesity has often been poorly defined in thesestudies and the degree of obesity and associated increase in risk mayconsequently be open to interpretation it is nevertheless clearlyassociated with a measurable increase in the risk of AL Measuresof central obesity such as waist circumference and waist-hip ratiosmay be more sensitive than BMI in predicting AL19

MedicationTable 1 details medication reportedly associated with an increasedrisk of AL Some of the evidence is however weak orcontradictory There is experimental evidence of increased risk ofAL for several immunosuppressant drugs used in patients who haveundergone organ transplantation This is consistent with reports ofa higher AL rate in immunosuppressed patients after renaltransplantation20

10

Table 1 Medication associated with increased risk of AL

Nutrition and HypoalbuminaemiaMalnutrition (defined as an unintentional loss of weight of gt10 in thepreceding 6 months) and a serum albumin concentration of lt35gLincreases the risk of AL32-36 Hypoalbuminaemia is more likely to beassociated with a systemic inflammatory response secondary to necroticor perforated tumours or sepsis (see below) than related to nutritionaldepletion per se Nutritional assessment should be undertaken in allpatients being prepared for surgery and an attempt made to correctmalnutrition The underlying cause of hypoalbuminaemia should also becorrected where possible (for example by treating infection) It shouldbe noted that it is not the hypoalbuminaemia itself which confers theadditional risk but the metabolic conditions which lead to it (systemicinflammation and increased capillary permeability) Thus preoperativeadministration of albumin to temporarily increase serum albuminconcentration will not abnegate the associated increase in risk of AL Inthe event that it is not possible to correct significant malnutrition (gt10unintentional weight loss) andor hypoalbuminaemia (lt32gL)preoperatively (for example in a patient with a large necrotic tumourandor because of impending intestinal obstruction or perforation) theoperative strategy should be modified so as to avoid undertaking ananastomosis at that time if it is possible to do so

Medication Type Evidence amp Recommendations

Corticosteroids Steroid Prolonged use may increase AL21 22

Infliximab Anti-TNFprop Slows woundmonoclonal healing but noanti-body impact on AL rate23 24

Mycophenolate Immunosuppressant Mycophenolate ALmofetil25 risk based on clinical

observational studyCyclosporine A26

For other drugs

Tacrolimus27 experimental evidencesuggests increased

Everolimus28 AL risk

Azathioprine Purine analogue Contradictoryimmunosuppressant evidence29 30

Bevacizumab VEGF inhibitor Should be stopped andnot restarted for at least 28 days either side of surgery (manufacturer advice)31

11

Mechanical Bowel Preparation (MBP)Mechanical bowel preparation (MBP) has traditionally been usedto reduce stool burden in the colon with the additional benefitsof improving visualisation for intraoperative endoscopy andfacilitating the insertion of stapling devices Withholding MBPdoes not appear to have resulted in increased AL rate in severalrandomised trials and a systematic review37-41 The GRECCAR IIIRCT demonstrated an overall reduction in septic complications inrectal surgery alone in patients receiving MBP although therewas no difference in AL42 Bowel preparation is unpleasant forpatients and is not essential for colorectal surgery

RadiotherapyNeoadjuvant radiotherapy usually in combination withchemotherapy has been demonstrated to reduce local recurrenceand to downstage rectal tumours43 Retrospective series havepreviously suggested that chemoradiotherapy might increaseAL44 45 However this has not been supported by several RCTsincluding the MRC CR07 and Dutch TME trials46-48 A previoushistory of pelvic radiotherapy does however increase AL rateand is discussed in Table 2

Preoperative antibiotics and selective decontamination of thedigestive tractPreoperative broad-spectrum intravenous antibiotics are routinelyused in elective and emergency colorectal surgery with the goalof reducing postoperative infective complications and thispractice is recommended by ACPGBI49 In the USA somesurgeons routinely use non-absorbable oral antibiotics such asTobramycin and Amphotericin B - also known as selectivedecontamination of the digestive tract (SDD) A systematicreview has indicated that SDD reduces anastomotic leak ratesfrom 74 to 3350 This finding has also been replicated in arecent study of over 8000 colorectal resections demonstratingboth lower surgical site infection and anastomotic leak rates inthe treatment group51 Despite this SDD is not currently inwidespread practice in the United Kingdom and Ireland

Non-modifiable risk factors

Gender and ageMale gender and increasing age (especially age over 60) mayincrease the risk of AL While the effect of gender on rectalanastomotic leakage might be attributable to greater technicaldifficulty of undertaking surgery in the narrower male pelvis thisdoes not explain the higher rate of AL seen in colonic surgery Theeffect of chronological age is not observed consistently and is mostprobably accounted for by co-morbidity (Table 2)

12

Table 2 Summary of non-modifiable risk factors for anastomotic leak

History of RadiotherapyWhile immediate preoperative radiotherapy might represent amodifiable risk factor a history of previous pelvic radiotherapyclearly does not Previous radical pelvic radiotherapy is associatedwith a very high risk of AL in the radiotherapy field Considerationshould be given to avoiding anastomoses in bowel previouslysubjected to radiation (however many years earlier) particularly inthe presence of other risk factors

Risk Factor Evidence

Gender Male gender increases AL rate in colonic10 andrectal45 52 anastomoses

Age Some studies have demonstrated that increasingage or age gt60 is associated with an increasedrisk of AL53 54 Other studies in elderlypopulations have failed to report this55 It isprobably more important to consider thebiological age of the patient and other riskfactors rather than chronological age per se

History of Patients previously treated with radiotherapy egradiotherapy for cervical or prostate cancer have AL rates

documented to be as high as 3656 This must beconsidered when planning an anastomosis

Diabetes The evidence is contradictory Two studies haveMellitus suggested an increased AL rate in ileocolic

anastomoses15 or low anterior resection57 whereasanother paper has demonstrated no change in ALrate but higher mortality in those who do sustaina leak58

Co-morbidity Increase in AL rate

bull Pulmonary disease21 22 59

bull Vascular disease44

bull Renal diseaserenal replacement therapyimmunosuppressed renal transplant patients20 60 61

(Haemodialysing patients pre and post-surgicalintervention reduces surgical complications butnot anastomotic leaks anastomosis should beavoided in emergency cases)

bull ASA of greater than 262 315 and 463 have beendemonstrated to increase risk of AL

13

DiabetesAlthough there is conflicting evidence for an increased risk of AL inpatients with diabetes (see Table 2) there is evidence for increasedperioperative mortality64 and increased length of stay65 In additionthere is evidence of increased perioperative morbidity due to pre-existing complications including cerebrovascular cardiovasculardisease and nephropathy66-68 There are NHS guidelines published inconjunction with ASGBI and other organisations for the optimumperioperative management of diabetes69

Elective vs Emergency SurgeryEmergency surgery is predictably associated with higher AL ratescompared with elective practice However an emergency operationper se is not an absolute contraindication to an anastomosis withseveral studies demonstrating for example that an anastomosis with adefunctioning stoma is a safe option for perforated diverticulitis70-72However the risk factors outlined in this document and in particularhaemodynamic instability shock inotrope requirements andhypoalbuminaemia must be taken into account when considering ananastomosis and the need for a defunctioning stoma Wheneverpossible the risks and benefits of and alternatives to a primaryanastomosis should be discussed with the patient before surgery sothat an appropriately informed decision can be made However therewill be some emergency circumstances when this may not be possible

Tumour factorsDistal anastomoses particularly those of infraperitoneal rectum havethe highest anastomotic leak rates Distance from the anorectaljunction is an independent predictive risk factor for AL9 45 73 Otherfactors that increase AL rate are tumour size gt3cm74 or gt4cm75advanced tumour stage45 and in particular the presence of distantmetastases11 It is likely that many of these factors are interrelatedFor example late presentation with advanced disease is likely to beassociated not only with lower socioeconomic status but also poornutritional status smoking and medical comorbidity

Intraoperative considerationsOperative TechniquePoor operative technique for example failing to avoid tension on orpoor vascularity at an anastomosis will impact negatively onanastomotic healing and is likely to result in AL Operative duration ofgreater than 4 hours intraoperative contamination blood loss over100ml and blood transfusion are risk factors for AL76-79 as is hypoxia80The use of vasopressors is associated with a threefold increase in AL81

Goal directed fluid therapyThe National Institute for Health and Care Excellence (NICE)recommends the use of goal directed therapy eg the use ofoesophageal doppler82 Goal directed therapy has been shown to

14

reduce postoperative complications for major surgery but it has notbeen shown to reduce anastomotic leak rates per se83 84

Interventions Suturing as opposed to stapling an anastomosis may be associatedwith a higher risk of AL although the difference may be only detectedradiologically and is not manifest clinically85 Specifically meta-analysis favours stapled anastomosis in ileocolic resections86 but nosuperiority has been demonstrated between anastomotic techniquesfor anterior resection of the rectum87 Other technical interventionsthat may reduce the risk of AL include utilising air leak tests88 lowversus high ties on vascular pedicles89 and open compared tolaparoscopic surgery90 although the last finding has not beensubstantiated on meta-analysis91

Irrespective of the quality of scientific evidence it is appropriate tonote that a recent legal judgement in England regarding the routineuse of air leak testing in rectal anastomoses (Shortall-v-Mid EssexHospital Services NHS Trust 2014) concluded that failure to use thistechnique was held to be negligent While the technique may not besupported by sufficient weight of clinical evidence (and clearlycannot provide reassurance regarding leakage caused by excessivetension or ischaemia) it seems sensible to recommend that all rectalanastomoses (and probably all left sided colonic anastomoses) forwhich a defunctioning proximal stoma is not being undertaken shouldroutinely be tested for immediate ldquotechnicalrdquo defects by airinsufflation (or a similar technique)

The use of a defunctioning stoma andor an omentoplasty to isolatethe anastomosis may reduce the adverse consequences of AL butdoes not appear to reduce the likelihood of AL per se 92 93

Drains have historically been used following colorectal anastomoseswith the perceived benefit of identifying and potentially reducingpostoperative complications The use of drains for both colonic andinfraperitoneal rectal anastomoses is debated However there havebeen several large systematic reviews including a Cochrane review onthe use of drains for colorectal anastomoses that do not demonstratea significant reduction in AL rate94-96 The Cochrane review assessed1140 patients from 6 RCTs and showed no reduction in clinical orradiological anastomotic leaks (or any other complications forcolorectal anastomoses) Specific to rectal infraperitonealanastomoses a meta-analysis combining 3 RCTs and 5 retrospectivestudies demonstrated a reduction in anastomotic leak (OR 051 95CI 036 ndash 073)97 This effect was not seen however when the 3 RCTswere analysed in isolation96 In summary drainage is not routinelyrequired for colonic anastomoses but to properly assess their use ininfraperitoneal rectal anastomoses would require an appropriatelypowered RCT Their use in this setting specifically with respect toavoidance of AL is therefore currently a matter of personal choice

15

Table 3 Summary of preoperative and intraoperative risk factors

Postoperative considerationsNSAIDsThere is growing evidence that NSAIDs should be used with cautionin the postoperative period A meta-analysis has demonstrated thatnon-selective NSAIDs were associated with an increased risk of ALHowever many of the studies included were flawed and had selectionbias98 More recently a retrospective cohort study of over 13000bariatric and colorectal operations has demonstrated a 24 increasein the likelihood of AL with NSAID use This effect appears to have

Preoperative considerations Intraoperative considerations

Non-modifiable risk factors Increase risk

bull Male gender bull Intraoperative contamination

bull Distal rectal anastomosis bull Duration gt4 hours

bull Tumour size gt3cm bull Inotropes

bull Advanced tumour stage bull Blood loss

bull Metastatic disease bull Blood transfusion

bull History of radiotherapy

bull ASA gt2

bull Diabetes

bull Pulmonary disease

bull Vascular disease

bull Emergency surgery

bull Ex-smoker (gt40 pack years)

Potentially modifiable Reduce riskrisk factors

bull Smoking bull Preoperative antibiotics

bull Obesity (intravenous and selective

bull (High BMI Waist hip ratiodecontamination

Visceral fat)digestive tract)

bull Alcohol excess (gt21units105g alcohol week)

bull Corticosteroids

bull Bevacizumab

bull Malnutritionhypoalbuminaemia

16

been attributable to emergency colorectal operations 123 vs 83in the NSAID and non-NSAID group respectively (OR 17 [95 CI111 ndash 268] p = 001)99

Diagnosis of Anastomotic LeakagePrompt diagnosis of AL is essential for effective management Delayeddiagnosis of AL is associated with worse outcomes100 Clinicians musttherefore be alert to early and subtle signs of AL including non-specific signs notably cardiac arrhythmias including atrialfibrillation101102 Postoperative ileus is unusual after uncomplicatedlaparoscopic colorectal surgery and should lead to urgent assessmentfor anastomotic leakage Rectal bleeding or passage of bloody mucusper rectum should cause suspicion of anastomotic leakage after arectal anastomosis It cannot be emphasised strongly enough thatfailure to make anticipated postoperative progress in any patient witha colorectal anastomosis should above all raise the suspicion ofanastomotic leakage

In patients in whom there is a departure from the expected pattern ofpostoperative recovery frequently repeated assessment by a seniorexperienced clinician and careful analysis of trends in observationsremain the most valuable and reliable means of establishing earlydiagnosis of AL It can be difficult for any surgeon to remain entirelyobjective when considering the likelihood of leakage from ananastomosis they have created themselves Asking a similarlyexperienced colleague to provide a second opinion in thesecircumstances is therefore extremely valuable and is stronglyrecommended103

Raised concentrations of serum C-reactive protein and procalcitoninmay be useful (but non-specific) markers for AL particularly if CRPis very high (gt150mgL) on postoperative days 3-5104 105 andespecially if the serum albumin continues to fall or fails to return tonormal postoperatively The negative predictive value of a normalCRP in this context may be particularly useful In contrast white cellcount appears to be less reliable as a marker of AL44

Diagnostic imaging is not essential when a patient is unwell and a leakis clinically evident and imaging under these circumstances may giverise to unnecessary delay in management The sensitivity of commonimaging modalities such as CT scanning and water-soluble contrastenema is dependent on the timing of investigations the quality of thetechnique used and the skill and experience of the radiologist Thediagnostic accuracy of CT for suspected leakage from the distal colonmay be improved with the addition of rectal and intravenouscontrast106 Cross sectional imaging should not be undertaken in thepresence of haemodynamic instability unless invasive monitoring isavailable and the patient is accompanied throughout by critical carepersonnel who can provide immediate cardiorespiratory supportIntravenous contrast should be used with caution (or avoided) in thepresence of dehydration hypotension or acute kidney injury

17

Scoring systemsA variety of scoring systems have been developed to assist inprediction diagnosis or grading the severity of AL None has provedsufficiently valuable to gain widespread acceptance or incorporationinto routine practice The colon leakage score (CLS) attempts topredict AL for left sided colonic resection using 11 patient andoperative factors107 The modified DULK score is an aid to thediagnosis of AL but has a low positive predictive value108 TheInternational Study group of Rectal Cancer devised a grading systemfor severity of leak but this is relatively simplistic suggesting only ldquonointervention active non-operative intervention or re-laparotomyrdquo109

Treatment of Anastomotic Leakage Initial ManagementThere is an international drive to improve the management of sepsiswhich remains the major cause of morbidity and mortality associatedwith AL Systemic inflammatory response syndrome (SIRS) consistsof 6 criteria temperature gt383˚C or lt36˚C respiratory rate gt20minheart rate gt90min white cell count lt4x109l or gt12x109l alteredmental state and a blood glucose level of gt77mmoll in the absenceof diabetes Sepsis is currently defined as the presence of at least 2of the SIRS criteria as a result of infection Severe sepsis is definedas sepsis with evidence of super-added organ dysfunction(hypotension oliguria high serum lactate) Septic shock is definedas failure of these parameters to respond to adequate fluidresuscitation Patients with severe sepsis are at particular risk ofdeveloping septic shock and it is imperative that septic shock isavoided in order to avoid associated high mortality rate A delay ofsource control in excess of 12 hours after the development ofhypotension compared with less than 3 hours has been previouslyshown to increase mortality from 25 to 60110

Timely and appropriate intervention is therefore imperative if apatient develops sepsis as a consequence of AL Initial managementshould include the ldquosepsis sixrdquo care bundle111 ldquoSepsis sixrdquo is a set of6 criteria which when implemented have been shown to result in a466 reduction in the relative risk of mortality from sepsis112 Theseinterventions are administering high flow oxygen taking bloodcultures measuring lactate and full blood count urine outputadministration of broad-spectrum antibiotics and intravenous fluidchallenge

18

Subsequent and Definitive Management 1 General principles

Subsequent management requires a thorough assessment of thepatientrsquos clinical stability A stable patient may initially beadequately managed conservatively with fluids antibiotics andoxygen together with close clinical observation Conversely anurgent attempt to achieve source control should be undertaken inany patient with an AL and severe sepsis or septic shock withinthe time frame indicated below

A patient with an AL should be nursed in an environmentappropriate to their level of systemic illness and the consequentneed for monitoring Recommended time limits for interventionin the treatment of abdominal sepsis associated with AL havebeen identified previously and are determined by the severity ofsepsis113 In the absence of organ dysfunction surgical orradiological intervention to achieve source control should beundertaken as soon as possible (where this is required) but alwayswithin 18 hours of diagnosis If sepsis is complicated by evidenceof organ dysfunction source control should be achieved as soonas possible but always within 6 hours of diagnosis Septic shockshould result in source control immediately and always within 3hours if preventable death is to be avoided

2 Source controlControl of the source of infection associated with AL mayoccasionally be unnecessary Such patients will usually be stableand well without evidence of sepsis but may have some localisedabdominal tenderness raised inflammatory markers andgastrointestinal dysfunction (for example ileus andor diarrhoea)Imaging in these cases usually shows no evidence of anastomoticdiscontinuity and little more than a small perianastomoticcollection Complete resolution can be expected in most caseswith conservative treatment including intravenous antibioticsintestinal rest (oral fluids only or parenteral nutrition) and closemonitoring in the ward environment for signs of sepsis

A small contained AL in a haemodynamically stable patientwithout radiological evidence of anastomotic discontinuity maybe managed successfully by radiologically guided drainageandor washout and defunctioning rather than taking down theanastomosis and creating a stoma provided there is continuedclose observation and evidence of improvement Radiologicaldrainage should not be undertaken when there is radiologicalevidence of complete anastomotic discontinuity as it is unlikelyto control sepsis adequately and anastomotic healing cannotoccur Multiple separate foci of intraabdominal infectionassociated with AL are not usually suitable for radiologicaldrainage and if present on cross sectional imaging generally

19

represent an indication for surgical source control Laparotomy isusually required

In low rectal ALs transanal drainage may be effective Endoscopicplacement of vacuum devices into the presacral cavity (eg anEndo-SPONGEreg) may also be of benefit under thesecircumstances but adequate evaluation of the efficacy and costeffectiveness of this technique is required114

Development of or deterioration in the severity of sepsis in apatient treated conservatively or by radiological drainage for ALshould be considered ldquofailedrdquo treatment and a low thresholdmaintained for taking a patient urgently to theatre and taking downthe anastomosis Attempts to ldquorepairrdquo an AL should never beundertaken in the presence of severe sepsis or septic shock inpatients with AL requiring inotropes and in those with significanthypoalbuminaemia (lt32gL) A repair should not be attempted ifthere is an established abscess cavity at the anastomosisSatisfactory healing under these circumstances is unlikely to occurand it is far safer to exteriorise the affected segments Similarlyenterotomies made during laparotomies under these circumstancesare unlikely to heal adequately and injured bowel should beresected andor exteriorised if further abdominal sepsis andintestinal failure is to be prevented103 Operating upon a patientwith an AL can not only be technically challenging but alsoemotionally difficult for the surgeon who constructed the ldquofailedrdquoanastomosis It may be associated with significant feelings of guiltand can impair objective decision-making Involving the assistanceof a second consultant colleague in re-operative procedures is notan admission of failure or inadequacy but is good practice underthese circumstances and is strongly encouraged103

20

Management of Specific Patterns ofAnastomic Leakage1 Intraperitoneal Anastomotic Leakage

Table 4 details grades of increasing severity for intraperitonealAL Table 5 presents suggested management of these leaks basedon the Delphi process

Table 4 Grades of clinical severity for AL

Clinical Clinical Haemodynamic Setting Inotropesstatus signs of changes

peritonitis

Infectionor sepsis

1 without No None Level 0 Noneed for (Ward)

interventionalprocedure

Infection Noneor sepsis (or tachycardiawith ileus No rapidly Level 0 No

2 responsive responsive to (Ward)

to abscess treatment)drainage

Sepsis withileus Persistent Level 12

requirement Single tachycardia (Ward with No3 for nasogastric quadrant but critical care

drainage amp normotensive inputHDU)urinary

catheterisation

More than Tachycardiasingle amp hypotension

4 Severe sepsis quadrant (responsive toLevel 2

Nobut not fluid therapy)

(HDU)

generalised

Tachycardia Level 35 Septic shock Generalised hypotension (ITU) Yes

and shock

Gra

de

21

Table 5 Suggested management of intraperitoneal AL based onDelphi meeting (percentage consensus in brackets) In these scenariosit is assumed in all cases that patients are being appropriatelyresuscitated with oxygen intravenous fluids and antibiotics

2 Extra-peritoneal Anastomotic LeakageThe highest leak rates occur with extra-peritoneal (low pelvic)anastomoses9 45 115 116 However because peritoneal contaminationis less likely to occur and the majority of patients will have acovering loop stoma the clinical signs may be more subtleManagement (Table 6) will depend upon the patientrsquos clinical

CaseManagement Source Control SettingScenario

No sepsis (Grade 1)1 Conservative None Level 0 1

(89) (96)

Sepsis contained leak abscess (Grade 2)

Drainage needed Radiological drainage if Level 0 -2(80) possible If unavailable (100)

laparoscopy laparotomy2 washout drain and repair AL

with proximal defunctioningstoma or resect anastomosisand create stoma(85)

Sepsis ileusSingle quadrant peritonitis (Grade 3) Level 2

Resuscitate and Laparoscopy Laparotomy (96)operation washout drain and proximal3(85) defunctioning stoma or resect

anastomosis and create stoma(92)

Severe sepsismore than single quadrant peritonitis (Grade 4)

4Resuscitate and Laparoscopy Laparotomy Level 23operation washout resect anastomosis (100)(100) and create stoma (85)

5 Septic shockgeneralised peritonitis (Grade 5)

Resuscitate and Laparoscopy Laparotomy Level 3operation washout resect anastomosis (96)(100) and create stoma (100)

22

stability as indicated above (Table 6) Take down of the anastomosisis recommended for all patients who develop severe sepsis or septicshock after an extraperitoneal AL

Table 6 Suggested management of extraperitoneal AL based onDelphi meeting (percentage consensus in brackets) In thesescenarios it is assumed in all cases that patients are beingappropriately resuscitated with intravenous fluids and antibiotics


No sepsis (Grade 1)

1 Conservative Drainage (IRtransperineal Level 0 1(89) transanal) plusmn proximal (96)

defunctioning stoma (76)

Sepsis with contained leak abscess lt3cm (Grade 2)

Drainage needed bull Transperinealtransanal drainage Level 0 -2(70) plusmn proximal defunctioning (100)

2a stoma (56)bull Laparoscopylaparotomy and Level 1

drain plusmn proximal (56)defunctioning stoma (33)

Sepsis with contained leak abscess gt3cm (Grade 2)

Drainage needed bull Radiological drainage (37) Level 2(93) bull Surgical drainage (56) (67)

deg LaparoscopyLaparotomywashout drain and proximal

2b defunctioning stoma (44)deg Transperineal drainage plusmn

proximal defunctioningstoma (26)

deg Laparotomy and take downanastomosis (22)

3 Sepsis ileusSingle quadrant peritonitis (Grade 3)

Resuscitate and bull Drain and proximal Level 2operation (82) defunctioning stoma (30) (74)

bull Take down anastomosis (48)

Severe sepsis more than one quadrant peritonitis (Grade 4)

4 Resuscitate and Laparoscopy Laparotomy washout Level 23operation (100) and take down anastomosis (93) (100)

Septic shock generalised peritonitis (Grade 5)


23

Appendix

Summary of findings from Delphi process forcolorectal anastomotic leakage

bull Initial meeting at Tripartite meeting in Birmingham(July 2014)

bull Delphi meeting held on 14th October 2014 RCS England

bull Invited Consultants and colorectal trainees from ACPGBI

bull Round 1 completed prior to meeting with on-linequestionnaire

bull Further 2 rounds completed at meeting

bull Results presented here are after 3 rounds ofquestionnaires

Key (SD strongly disagree D ndashdisagree N ndash neither agree ordisagree A ndash agree SA ndash strongly agree)

Demographics and Format of Delphi Process

Table 7 Format and numbers completing rounds of Delphi process

Figure 1 Age groups of surgeons within anastomotic leakworking group

Round 1 Round 2 Round 3

No of participants 36 31 31

Format On-line Meeting Meeting

Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group

Figure 2 Gender of anastomotic leak working group

Figure 3 Seniority of anastomotic leak working group

RegionsAll regions of the UK andIreland were representedbased on ACPGBIchapters

Figure 4 Regionalrepresentation ofanastomotic leak workinggroup

24

Num

ber

ofV

alue

s

0

0

0

30

Male

Gender ofWorking Group

Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar

Consultant lt5 years post CCT

Consultant gt5 years post CCT

Patient Liaison

Current Position

25

Delphi ProcessDefinition of anastomotic leaks

Table 8 Percentage agreement of definitions for anastomotic leak

Non-modifiable risk factorsbull All gt70 Male gender distal anastomosis advanced

tumour stage metastatic disease historical radiotherapyASAgt2 diabetes vascular disease emergency surgeryex-smoker (gt40 pack years)

bull Others Tumours gt3cm (15) pulmonary disease (63)

Modifiable risk factorsbull All gt70 Smoking obesity alcohol excess

corticosteroids biological agents biologics in combinationwith steroids malnutritionhypoalbuminaemia pre-opshort and long course DXT

bull Others Bevacizumab (629) Age gt60 (42)

Periintraoperative risk factorsbull All gt70 contaminated surgery single and multiple

inotropes blood loss

bull Others Duration gt2 hours (23) blood transfusion (48)

Reduce risk of anastomotic leaksbull Preoperative intravenous antibiotics 26 agree or

strongly agree

bull Selective decontamination of digestive tract 741 (ASA)

bull Goal directed fluid therapy 78 (ASA)

A leak of luminal contents from asurgical join between two hollow viscera7 63

A breach in a surgical join between two hollowviscera with or without active leak of luminal contents 37

26

Table 9 Pre and postoperative non-modifiable and modifiablerisk factors

Preoperative Intraoperative


bull Male bull Intraoperative contamination

bull Distal anastomosis bull Duration gt4 hoursparticularly rectal bull Inotropes

bull Tumour size gt3cm bull Blood lossbull Advanced tumour stage bull Blood transfusionbull Metastatic disease

bull Historical radiotherapy

bull ASA gt2

bull Diabetes










bull Alcohol excess (gt21units bull Cardiac monitoringgoal 105g alcoholweek) directed fluid management


bull Bevacizumab


27

Risk factors required to consider defunctioning

Figure 5 How many risk factors from Table 9 would a patientrequire to consider defunctioning an anastomosis

Air Leak Testing

Table 10 Percentage agreement with statement should air leaktesting be performed on the following anastomoses

Intraoperative endoscopy

22 agreed or strongly agreed that endoscopy should be performedfollowing anterior resections

Useful indicators for anastomotic leaks

Over 70 agreed or strongly agreed that Tachycardia Pyrexia CRPWCC pain out of proportion arrhythmia ileus and failure toprogress are useful indicators for anastomotic leak Others indicatorsincluded Pro-calcitonin (19) and urinary retention (27)

0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA

Anterior resections 100

Other colonic anastomoses 36

Small bowel anastomoses 4

All patients without a defunctioning stoma 29

28

Investigation of anastomotic leakbull Contrast enhanced CT (Oral or rectal contrast) 100 ASA

bull Right hemicolectomy contrast CT (100)

bull High anterior resection contrast CT (96)

bull Low anterior resection contrast CT (92)

Factors to determine whether to resect an anastomosis

bull gt70 Generalised pus faecal peritonitis severe sepsis

bull Others localised pus 16 elderly age of patient 63

bull Other comments size of defect ischemia of anastomosis

29

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wwwasgbiorguk


1



ANASTOMOTIC LEAKAGE










2





3

CONTENTS

Introduction 5


Acknowledgements 7

Abbreviations 7

Introduction 8



Definition 8

Epidemiology 8








Interventions 14


(NSAIDS) 15


Scoring systems 17

Treatment of AL 17




2 Source control 18




4

Appendix 23



Regions 24

Delphi Process 25







Air Leak Testing 27





References 29

5






6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

2





3

CONTENTS

Introduction 5


Acknowledgements 7

Abbreviations 7

Introduction 8



Definition 8

Epidemiology 8








Interventions 14


(NSAIDS) 15


Scoring systems 17

Treatment of AL 17




2 Source control 18




4

Appendix 23



Regions 24

Delphi Process 25







Air Leak Testing 27





References 29

5






6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

3

CONTENTS

Introduction 5


Acknowledgements 7

Abbreviations 7

Introduction 8



Definition 8

Epidemiology 8








Interventions 14


(NSAIDS) 15


Scoring systems 17

Treatment of AL 17




2 Source control 18




4

Appendix 23



Regions 24

Delphi Process 25







Air Leak Testing 27





References 29

5






6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

4

Appendix 23



Regions 24

Delphi Process 25







Air Leak Testing 27





References 29

5






6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

5






6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

6







7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

7






BMI Body mass index






OS Overall Survival

OR Odd Ratio




WHR Waist hip ratio

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

8







9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

9







10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

10








For other drugs





11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

11






12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

12
















13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

13






14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

14






15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

15











bull ASA gt2

bull Diabetes












bull Bevacizumab


16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

16






17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

17




18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

18






19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

19




20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











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20





peritonitis

Infectionor sepsis









catheterisation




(HDU)

generalised


and shock

Gra

de

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











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40














wwwasgbiorguk

21





(89) (96)












22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











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wwwasgbiorguk

22




No sepsis (Grade 1)




















23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











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40














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23

Appendix















Num

ber

ofV

alue

s

0

5

0

5

20

31-40 41-50 51-60 61-65 65+

Age ofWorking Group





24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









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35











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24

Num

ber

ofV

alue

s

0

0

0

30

Male


Female

Num

ber

ofV

alue

s

0

0

0

0

40

Registrar



Patient Liaison

Current Position

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

25













strongly agree





26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











36











37











38











39










40














wwwasgbiorguk

26








bull ASA gt2

bull Diabetes












bull Bevacizumab


27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












30











31











32











33









34












35











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40














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27



Air Leak Testing






0

20

40

60

80

100

0 1 2 3 4 5 gt5

A SA





28









29












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