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MCC 2011 - Slide 19 Presentation Transcript

  • 1. Early detection and treatment of leakage ESO-ESSO Master Class in Colorectal Cancer Surgery 12 – 17 February 2011 Cascais, Portugal Torbjörn Holm MD PhD Section of Coloproctology Department of Surgery Karolinska University Hospital Stockholm, Sweden
  • 2. Anastomotic leakage Outline
    • The problem
    • Risk factors
    • Preventive measures
    • Detection
    • Treatment
  • 3. Anastomotic Leakage a dangerous surgical complication
    • Increased postoperative mortality
    • Increased morbidity
    • Prolonged hospital stay
    • Impaired function
    • Increased risk of local recurrence (?)
  • 4.
    • Definition :
      • A defect of the intestinal wall at the anastomotic site leading to a communication between the intra- and extra-luminal compartments
    • Grading :
      • According to the impact on clinical management
      • A : No change in management
      • B: Active therapeutic intervention but not re-laparotomy
      • C: Requires re-laparotomy
    • Surgery 2010;147:339-51
    Anastomotic Leakage Definition and Grading
  • 5. Case 1
    • 66 year old male
    • No previous medical history
    • Locally advanced rectal cancer at 10 cm, growing into prostate and base of bladder
    • Preoperative radio-chemotherapy
    • August 14, 2007
      • Pelvic excenteration with reconstruction of bowel,
      • ileum conduit (Bricker deviation), loop-ileostomy
  • 6. Case 1
    • CRP Temperature
    • 16/8 390 37.5
    • 18/8 300 38.3
    • 20/8 288 37.9
    • 22/8 284 38.6
    • 23/8 339 39.0
    • Patient mobilised, eating with bowel movements during this time
    • What would you do now ?
  • 7. Case 1
    • Aug 23
      • CT scan reveals anastomotic leak right posterior part of anastomosis
    • What would you do now ?
  • 8. Case 1
    • Aug 23
      • Patient taken to OR
      • Drain placed through anastomotic defect into abscess cavity
      • Intravenous antibiotics
  • 9. Case 1
    • CRP Temperature
    • 24/8 350 37.6
    • 25/8 218 36.2
    • 27/8 82 37.0
    • 29/8 35 37.1
    • Patient mobilised, eating with bowel movements during this time
    • Aug 30 discharged from hospital
  • 10. Case 2
    • 38 year old man
    • Crohn's disease since 20 years
    • Mainly colitis
    • No previous surgery
    • Since August 2007 altered bowel habits, bleeding, mucous discharge
  • 11. Case 2
    • MRI shows extensive low rectal cancer infiltrating pelvic floor, prostate, vesicles, caecum
    • Preoperative radio-chemotherapy
    • February 12 2008
      • Pelvic excenteration, APR en bloc pelvic floor, ileo-caecal resection
      • Colostomy
      • Ileal conduit (Bricker deviation)
      • Anastomosis between ileum and right colon
  • 12. Case 2
    • Feb 14
      • CRP 310, temp. 37.0, no bowel movements, vomiting
      • Intravenous antibiotics
      • What would you do now ?
    • Feb 15 CRP 320
    • Feb 16 CRP 288
    • Feb17 CRP 210
    • Still no bowel movements, mobilised, temp 37-38
    • What would you do now
  • 13. Case 2
    • Feb 18
      • CRP 380
      • Temp 39
      • Albumin 14
      • Signs of peritonitis
    • What would you do now ?
  • 14. Case 2
    • Feb 18 Laparotomy
      • Large amounts of fluid and faeces
      • Large defect in anastomosis ileum-colon
    • What would you do now ?
    • End ileostomy, closure of proximal colon, extensive wash-out of abdominal cavity was performed
  • 15. Case 2 CRP development Primary surgery Reoperation
  • 16. Case 2
    • Feb 19 – 22
      • In intensive care unit
      • Sepsis, pulmonary problems, pleural effusion
      • CT Feb 22 – small abscess around closed colon
      • Drained with pig-tail
    • Feb 23 - 24
      • Gradually improving
      • Bowel movements
      • CRP 210
  • 17. Anastomotic Leakage
    • Leak rates varies 1% - 30%
    • Postoperative mortality in colorectal surgery 1% - 8%
    • Postoperative mortality after leakage 6% - 40%
  • 18. Anastomotic Leakage
    • Difficult to predict
    • Several retrospective studies to identify risk factors
    • Commonly found risk factors related to:
      • Patient
      • Neoadjuvant treatment
      • Surgical procedure
      • Individual surgeon
    • Different independent risk factors in different studies
  • 19. Anastomotic Leakage Risk factors
    • Patient related
      • Age
      • Male gender
      • BMI
      • ASA status
      • Co-morbidity (diabetes, vascular disease)
      • Medications (mainly steroids)
      • Smoking
  • 20. Anastomotic Leakage Risk factors
    • Related to neoadjuvant treatment
      • Preoperative radiotherapy in rectal cancer did not increase leakage in large randomised trials
      • Several retrospective reports and case control studies show an increased risk
      • Neoadjuvant radio-chemotherapy considered a risk factor, despite lack of strong evidence
  • 21.
    • Related to surgical procedure
      • Emergency surgery
      • Duration of operation
      • Blood loss
      • Intraoperative adverse events
      • Low anastomosis
      • Absence of pelvic drain
      • Absence of stoma
    Anastomotic Leakage Risk factors
  • 22.
    • Related to individual surgeon
      • Surgical skill
      • Case volume
      • Case mix
      • Selection of patients
    Anastomotic Leakage Risk factors
  • 23. JWT. Dekker et al. Journal of Surgical Research Published on line
  • 24. JWT. Dekker et al. Journal of Surgical Research Published on line
  • 25. Anastomotic Leakage
    • Preventive measures
    • Leak impossible to predict in the individual patient
    • Leak probably impossible to eliminate
    • Reduced risk of leak with temporary stoma ?
    • Less severe consequences with a temporary stoma ?
  • 26. RECTODES 1999 – 2005
    • Preoperative inclusion criteria
      • Biopsy proven rectal adenocarcinoma
      • Tumour below 15 cm
      • Age > 18 years
      • Informed consent
      • Estimated survival > 6 months
    • Intraoperative inclusion criteria
      • Anastomosis below 7 cm
      • Negative air leak test
      • Intact anastomotic stapler rings
      • No major intra-operative adverse events
  • 27. RECTODES
    • Randomisation by sealed envelope after construction of anastomosis
    • 234 patients randomised
      • Stoma 116 patients
      • No stoma 118 patients
    • All patients had bowel preparation and prophylactic antibiotics
  • 28. RECTODES
    • Definition of anastomotic leakage – Clinical leak
      • Symptoms caused by leakage from any staple line
      • Recto-vaginal fistula
      • Pelvic abscess without radiologically proven leakage
    • Radiologically demonstrated leakage without clinical symptoms was not included
  • 29. RECTODES
    • Anastomotic leakage
    • Overall 19% (45/234)
    • Stoma No stoma p
    • 10% (12/116) 28% (33/118) <0.001
  • 30. RECTODES
    • Detection of leakage
    • 60% diagnosed in hospital; median day 8 (3-18)
    • 40% diagnosed at readmission; median day 24 (13-172)
    • Leakage and type of anastomosis
    • J-pouch 22%
    • End to side 20% not statistically significant
    • End to end 13%
  • 31. RECTODES
    • Need for urgent relaparotomy
    • Stoma No stoma p
    • 9% (10/116) 25% (30/118) <0.001
    • In the no stoma group, 28/30 patients were reoperated because of leakage and had a stoma
    • In the stoma group, 9/10 patients were reoperated for causes not related to leakage
  • 32. RECTODES
    • Remaining stoma at a median follow up of 42 months
    • Randomised to stoma Randomised to no stoma
    • 14% (16/116) 17% (20/118) ns
    • Thus, due to anastomotic leakage more patients randomised to no stoma had a remaining stoma at the end of follow up
  • 33. Anastomotic Leakage Risk factors in Dutch TME Trial Peeters et al. BJS 2005; 92: 211–2
  • 34.
    • Preventive measures
      • Make the patient stop smoking
      • Optimise diabetes and cardiovascular disease
      • Stop steroids if possible
      • Meticulous, atraumatic surgical technique
      • Check blood supply
      • Test anastomosis
      • Use pelvic drain (LAR)
      • Use defunctioning stoma (LAR)
    Anastomotic Leakage
  • 35.
    • Look at the patient every day!
      • General condition
        • Fever
        • Cardio-pulmonary status
        • Mental status
        • Urine output
        • Ileus
      • Laboratory
        • Signs of infection
        • Kidney function
    Anastomotic Leakage Detection
  • 36. M. den Dulk et al. EJSO 35 (2009) 420-426
  • 37. Median scores in patients with and without anastomotic leakage per postoperative day M. den Dulk et al. EJSO 35 (2009) 420-426
  • 38.
    • If the patient is ill – look where the surgeon has been
    • A standardised postoperative surveillance program may shorten the delay between the first signs and symptoms to the confirmation of anastomotic leakage
    • Always perform CT with rectal contrast
    • Short delay to diagnosis and prompt treatment probably reduces morbidity and mortality
    Anastomotic Leakage Detection
  • 39.
    • Leakage – clinical signs and severity varies significantly
    • No signs – no treatment
    • Multiorgan failure – maximal treatment
    Anastomotic Leakage Treatment
  • 40.
    • Different situations
      • Sepsis confined to pelvis – no peritonitis
      • Leakage after LAR with diverting stoma
      • Leakage after LAR without diverting stoma
      • Leakage with peritonitis
      • After LAR
      • Intra-abdominal anastomosis
    Anastomotic Leakage Treatment
  • 41. Damage Control Surgery in Generalised Peritonitis
    • Anastomotic leaks Perforations
    • Peritonitis
    • Generalised Localised
    • Sepsis
    • MOF
    • Death
    DCS
  • 42. Damage Control Surgery in Generalised Peritonitis
    • Primary treatment aim – survival
    • Control leaking source
    • Rinse / clean abdomen
    • Stabilise patient in ICU
    • Secondary reconstructive procedures
  • 43. Control leaking source
    • Different options
      • Resection of perforation or leaking anastomosis and
        • New primary anastomosis or
        • Stoma formation or
        • Closed bowel ends
      • Drainage alone
      • Closed abdomen
      • Open abdomen
  • 44. Control leaking source
    • Base decision on:
    • Assessment of patient
      • Sepsis, acidosis, hypothermia, coagulopathy?
      • Age, co morbidity, medications?
    • Degree of peritonitis
      • Early or late intervention?
    • Quality of bowel
      • Inflammation or ischemia?
  • 45.
    • Resection of perforation or leaking anastomosis and
      • New anastomosis – only in highly selected cases
        • Healthy patient, early intervention, good bowel
      • Stoma formation – for the majority of patients
      • Closed bowel ends – in unstable patients
        • Open abdomen necessary, ischemia, planned second look
      • Drainage alone – if resection too complicated
  • 46.
    • Closed abdomen
      • Most convenient but risky
        • Stable patient, early intervention, low risk for ACS
    • Open abdomen
      • Less convenient but safer
        • Unstable patient, late intervention, high risk for ACS, second look necessary
  • 47. Rinse / clean abdomen
    • One stage procedure may be sufficient with early intervention
    • Multiple procedures safer if heavily contaminated abdominal cavity
    • Vac Pac system facilitates management
  • 48.
    • Stabilise patient in ICU
      • Close cooperation with anaesthesiologists
      • Daily surgical assessment necessary
      • Repeated wash outs and debridement
      • Check stomas
    • Secondary reconstructive procedures
      • Vac Pac system
      • Mesh sutured to fascia with gradual closure
      • Reconstructed abdominal wall within 1 month in the vast majority
  • 49. Different methods to dress an open abdomen “ Bogota bag” Vac Pac system
  • 50. Bukförslutning med polypropylennät Polypropylennät Plast med kompress eller inre Vac Pac svamp Fascia
  • 51.  
  • 52. Bukförslutning med polypropylennät Bukväggen dras gradvis samman
  • 53. Bukförslutning med polypropylennät
  • 54. Bukförslutning med polypropylennät Fascian sutureras när fasciekanterna har approximerats
  • 55. Conclusion
    • Anastomotic leakage is a common and serious complication
    • It cannot safely be predicted in the individual patient
    • Always suspect it if the patient is ill
    • Early diagnosis is essential
    • Early treatment reduces morbidity and mortality