the management of anastomotic leak john hartley academic surgical unit university of hull
TRANSCRIPT
![Page 1: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/1.jpg)
The Management of Anastomotic Leak
John Hartley
Academic Surgical Unit
University of Hull
![Page 2: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/2.jpg)
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
![Page 3: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/3.jpg)
Anastomotic Leak
Anastomoses in Lower Third of Rectum (0-6cm)
Leak rate 5 – 20%
UKUK Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196FranceFrance Ruler, Laurent, Premix: BJS, 1998, 85, 355Ruler, Laurent, Premix: BJS, 1998, 85, 355USAUSA Smith: DCR, 1981, 22, 236 Smith: DCR, 1981, 22, 236
![Page 4: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/4.jpg)
Anastomotic Leak
Leaking Anastomoses in Lower Third of Rectum
MORTALITY Increases by a factor of 20
MORBIDITY Hospital stay:10 days 30 daysPermanent colostomy > 50%
![Page 5: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/5.jpg)
Anastomotic LeakThe value of covering stoma:• 200 patients with low anterior resection
No defunctioning stoma: 8% peritonitis. Defunctioning stoma: <1%
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
![Page 6: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/6.jpg)
Anastomotic Leak- who’s 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)
![Page 7: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/7.jpg)
Anastomotic Leak
Diagnosis• Clinical signs• Leucocytosis• Positive blood cultures• Abdominal/chest X-ray• Gastrograffin enema• CT scan• Labelled white cell scan• Fistulogram
![Page 8: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/8.jpg)
Anastomotic Leak
Clinical signs
Depend upon:
• Severity of leak
• Degree of localisation
• Time of leak post op
• Whether the anastomosis is covered
![Page 9: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/9.jpg)
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 2004;6:21-2
![Page 10: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/10.jpg)
Anastomotic Leak
Anticipation
• “Off colour”
• Failure to diurese
• Prolonged ileus
• (diarrhoea)
• Fever
• Failure to meet milestones
![Page 11: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/11.jpg)
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
![Page 12: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/12.jpg)
Anastomotic Leak
Faecal Peritonitis
• Severe abdominal pain
• General tenderness and guarding
• Silent abdomen
• Tachycardia, hypotension
• Oliguria / anuria
• Faecal leakage from drain or wound
![Page 13: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/13.jpg)
Anastomotic Leak
Faecal Peritonitis – diagnosis
• Erect chest X-ray
• Gastrograffin enema
• ?? CT scan
![Page 14: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/14.jpg)
Anastomotic Leak
Faecal peritonitis – management• Confirm diagnosis• Urgent resuscitation
- iv fluids
- CVP monitoring
- Antibiotics
- Urinary catheter• Urgent re-exploration
![Page 15: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/15.jpg)
Anastomotic LeakOptions at re-laparotomy• External Drainage
• Suture DefectSuture Defect with Proximal Diversion
• Proximal DiversionProximal Diversion with Drainage
• Exteriorise Leaking Segment
• Resect Anastomosis with Re-anastomosisResect Anastomosis with end stoma, mucous fistula or Hartmanns
![Page 16: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/16.jpg)
Anastomotic Leak
Laparotomy for faecal peritonitis• Confirm diagnosis• Disconnect anastomosis Proximal stoma
Mucus fistulaClose distal end
• Wash out abdomen?• Drain?• Laparostomy
![Page 17: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/17.jpg)
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 2000;43:579-87
![Page 18: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/18.jpg)
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
![Page 19: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/19.jpg)
Sealed off leak with abscess• Vague localised or general
abdominal pain
• Localised peritoneal signs
• Temperature, tachycardia
• Ileus
• Multi organ failureJaundiceRenal failureARDS
![Page 20: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/20.jpg)
Anastomotic Leak
Sealed off major leak with abscess (ill patient)
S e ttles F is tu la
Im p ro ves
D iv id e A na s to m o s is C o ve ring S to m a & D ra in
L a pa ro to m y
B e com e s W o rse
L e ak
•Drainage•Nutritional support•Antibiotics
![Page 21: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/21.jpg)
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
![Page 22: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/22.jpg)
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
![Page 23: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/23.jpg)
Anastomotic Leak
Enterocutaneous fistula in clinically wellpatient• Delineate fistula CT
Fistulogram• Percutaneous drainage of abscess• Exclude distal obstruction / foreign body• Correct anaemia, malnutrition, electrolytes• Control fistula skin care
suction / bagssomatostatin
![Page 24: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/24.jpg)
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
![Page 25: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/25.jpg)
![Page 26: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/26.jpg)
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 failureARDS
![Page 27: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/27.jpg)
Free gas post Laparotomy • Plane XR almost always resolved by 5th day• New gas – worry!
![Page 28: The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull](https://reader030.vdocument.in/reader030/viewer/2022032723/56649cfa5503460f949cc29a/html5/thumbnails/28.jpg)
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