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Colorectal anastomosis leakeage sorrento 2010

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Colorectal anastomosis leakeage sorrento 2010

  1. 1. Colonic anastomotic leak No disclosures JM Enríquez-Navascués Hospital Donostia Universidad País Vasco /EHU San Sebastián. Spain
  2. 2. INTESTINAL ANASTOMOSES - Patients general conditions: nutritional and inmunological status, presence of shock, hypovolemia, peritonitis, comorbility… - Local (technical) conditions: irrigation, lack of tension, precise aposition of non inflammed ends…
  3. 3. Colonic anastomotic leak • Most dreaded complication • Reported rates vary between 1-30% (3%-6%; 8-20%) • Result in increased morbi-mortality,LOS and tumoral recurrence. Definitive stoma (colorectal leak):15-30% • No accepted definition: -Clinical signs -Radiological parameters -Intra-re-operative findings • Timing of the leaks
  4. 4. Colonic anastomotic leak clinical signs and symptoms: • fever, leukocytosis, C-RP, procalcitonin (PCT) • localized or generalized peritonitis (abdominal/pelvic pain) • gas/purulent/faeces discharge from wound, drain, vagina (rectovaginal fistulae) or anus (pelvic abscess)
  5. 5. Colorectal anastomotic leak • Definition: - Defect of the intestinal wall integrity at the anastomotic site (and all stapled lines) leading to a communication between the intra and extra luminal compartments. - A pelvic abscess close to anastomosis is also considered as a leak • Grading of severity: A: No active therapy requiered B: Active intervention but not relaparotomy C: Re-laparotomy International Study Group of Rectal Cancer (Surgery, 2010)
  6. 6. Risk factors for anastomotic leakage • Preoperative patient factors • Preoperative management factors • Operative factors • Postoperative factors
  7. 7. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  8. 8. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  9. 9. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  10. 10. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  11. 11. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  12. 12. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  13. 13. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  14. 14. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  15. 15. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  16. 16. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  17. 17. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
  18. 18. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  19. 19. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  20. 20. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  21. 21. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  22. 22. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  23. 23. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  24. 24. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  25. 25. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  26. 26. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  27. 27. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  28. 28. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  29. 29. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
  30. 30. LAR: “chronicle of an announced severe suture failure” • Questionable vascularization after high tie IMA plus TME ? • Deep and sloping pelvic cavity (fluid accumulation) • Insufficient distensible rectal stump below anastomosis, lessening the strong proximal colonic motility (peristalsis), and a closed distal anal sphincters (distal obstacle) • Perianastomotic semiliquid faeces accumulation • Sensitive peritoneum excision: insidious sepsis, minimal symtoms.. CAA (handmade) is not the same than a stapled “ultra” LAR: A true coloanal anastomosis (ie: <3cms) is not intraperitoneal”
  31. 31. Colo-rectal anastomosis. RISK FACTORS • Anastomoses height : < 6 cm x6 (95% IC: 2,4-17) • ASA III : x3 (95% IC: 2 – 8,8) • Sex :  x2,7 >  (95% IC: 1,2-6,7). ULAR: 24% vs.12% • Obesity : x2 (95%IC: 0-2) (33% vs.15%) Routine proximal diverting stoma ? or Selective diversion with aggressive follow-up ? (early diagnosis and low threshold to re-operate)
  32. 32. RICA. LICA. • iso or anisoperistatic ? IRA
  33. 33. Double stapled anastomosis “ ear dog” “ cross stapling” “ donoughts”
  34. 34. Colorectal anastomotic leak • Timing of leaks • Leaks and cancer recurrence • New methods for preventing anastomotic leaks • Management of leaks and the expanding technology
  35. 35. Colorectal anastomotic leak Timing of leaks: • Detected anywhere from 3 to 45 days postop. • Two peaks: - Clinically the median is 7 days postop. - Radiographically the median is 16 days postop. • 12% are diagnosed >30 days after the operation
  36. 36. Colorectal anastomotic leak Leaks and cancer recurrence: • Many studies have examined this relationship • Leakage has an independent negative association with overall survival and cancer specific survival • Patients with leaks have: 10-20% less OS, and more local recurrences (1,8 HR; 95%CI, 1,2-2,6) • Several explanations: implant and grow of tumor cells present in the colonic lumen?; decreased inmune function?; even selection bias…
  37. 37. Colorectal anastomotic leak New methods for preventing anastomotic leaks: • Intraluminal tubes: Coloshield® (permanent); SBS tube® (absorbable) • Buttressing material: Fibrin glue (sealing anastomoses, Tissucol®) Bovin pericardial collagen strips (Veritas®) Bioabsorbable stapleline reinforcement (Gore Seamguard®) • Compression anastomoses CAR™27 (Colo-Ring®)
  38. 38. Colorectal anastomotic leak Management of leaks and the expanding technology Individualized / patient’s needs* Bowel rest + ivf+ abs; observation; percutaneous drainge; colonic stents; surgical revision or diversion + drains RC Re-anastomosis+ drain LC** Anastomotic take down + ostomies R Extensive drains + Proximal diversion •Endostenting? •Endoscopic vacuum devices?

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