MCC 2011 - Slide 19

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MCC 2011 - Slide 19

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

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