Anastomotic leak colorectal surgery
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Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/
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Anastomotic leak colorectal surgery
- 1. Management of Anastomotic Leak (Colorectal Surgery) Dr Dhaval Mangukiya GI & HPB Surgeon
- 2. Improving Safety of Surgery • Preoperative preparation • Antibiotic prophylaxis • Surgical technique • Postoperative management complications such as those related to colorectal anastomoses continue to occur
- 3. Anastomotic Complications • Bleeding • Dehiscence and leakage • Strictures • Fistulas
- 4. Incidence • 2 to 7 percent • Kingham TP, Pachter HL. Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg 2009; 208:269. • Hyman N, Manchester TL, Osler T, et al. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 2007; 245:254. • Park JS, Choi GS, Kim SH, et al. Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 2013; 257:665. • Ileocolic anastomoses (1 to 3 percent) Coloanal anastomosis (10 to 20 percent) • Dietz, DW, Bailey, HR. Postoperative complications. In: ASCRS Textbook of Colon and Rectal Surgery, Church, JM, Beck, DE, Wolff, BG, Fleshman, JW, Pemberton, JH, (Eds), Springer-Verlag New York, LLC, New York 2006. p.141.
- 5. • Most anastomotic leaks usually become apparent between five and seven days postoperatively. • Almost one half of all leaks occur after the patient has been discharged • Up to 12 percent occur after postoperative day 30 Hyman N, Manchester TL, Osler T, et al. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 2007; 245:254. Incidence
- 6. • Late leaks – low-grade fever – prolonged ileus – nonspecific symptoms
- 7. Definition and manifestations The clinical signs include: • Pain • Fever • Tachycardia • Peritonitis • Feculent drainage • Purulent drainage The radiographic signs include: • Fluid collections • Gas containing collections The intraoperative findings include: • Gross enteric spillage • Anastomotic disruption
- 8. Postoperative Pneumoperitoneum • Free air after an abdominal procedure is common; it occurs in 60% of laparotomies and 25% of laparoscopic procedures. Two-thirds of cases resolve within 2 d and 97% of cases resolve within 5 d • Nielsen KT, Lund L, Larsen LP, Knudsen P. Duration of postoperative pneumoperitoneum. Eur J Surg 1997; 163: 501-503 • Natalia Spinelli et al Postoperative pneumoperitoneum after colorectal surgery: Expectant vs surgical management World J Gastrointest Surg 2012 June 27; 4(6): 152-156 Proposed management of
- 9. Risk factors • A prospective review of 1598 patients undergoing 1639 anastomotic procedures for benign or malignant colorectal disease found a significantly increased risk of anastomotic leak with extraperitoneal compared with intraperitoneal anastomoses (6.6 versus 1.5 percent; 2.4 percent overall) Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007; 9:71.
- 10. Extraperitoneal anastomotic leak • The distance of the anastomosis from the anal verge • Anastomotic ischemia • Male gender • Obesity
- 11. Intraperitoneal anastomotic leak • ASA score grade III to V (4.6 versus 0.8 percent in less then grade III) • Emergency surgery (4.4 versus 1.0 percent) • Choi HK, Law WL, Ho JW. Leakage after resection and intraperitoneal anastomosis for colorectal malignancy: analysis of risk factors. Dis Colon Rectum 2006; 49:1719. • Prolonged operative time (5.1 versus 0.5 percent when time ≥4 hours) • Konishi T, Watanabe T, Kishimoto J, Nagawa H. Risk factors for anastomotic leakage after surgery for colorectal cancer: results of prospective surveillance. J Am Coll Surg 2006; 202:439. • Hand-sewn ileocolic anastomosis (6.0 versus 1.4 percent) • Choy PY, Bissett IP, Docherty JG, et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2007; :CD004320. A Retrospective review of 1417 patients A prospective study of 391 elective colorectal resections A meta-analysis of six trials with 955 participants
- 12. Controversial, inconclusive, or negative • Neoadjuvant radiation therapy • Drains • Protective stoma
- 13. • Hand-sewn colorectal anastomosis • Fibrin glue • Laparoscopic procedure Controversial, inconclusive, or negative
- 14. • Mechanical bowel preparation • Nutrition • Perioperative corticosteroids • Nonsteroidal anti-inflammatory drugs (NSAIDs) Controversial, inconclusive, or negative
- 15. Management • Intraperitoneal anastomotic leak • A subclinical leak • localized peritonitis and low-grade sepsis • contained abscesses (<3 cm) • larger abscesses (>3 cm), multiloculated collections, or multiple collections • generalized peritonitis or high-grade sepsis with hypotension • inoperable phlegmon • major anastomotic defect • defect is minor and the tissue quality is adequate
- 16. • Extraperitoneal anastomotic leak • generalized peritonitis and high-grade sepsis • pelvic abscess • contained abscess • very low pelvic abscesses Management
Editor's Notes
- Late leaks often present insidiously with low-grade fever, prolonged ileus, and nonspecific symptoms attributable to other postoperative infectious complications. Small, contained leaks present later in the clinical course and may be difficult to distinguish from postoperative abscesses by radiologic imaging, making the diagnosis uncertain and underreported.
- Extraperitoneal anastomotic leak — Major risk factors for an extraperitoneal anastomotic leak include: ●The distance of the anastomosis from the anal verge – Patients with a low anterior resection and an anastomosis within 5 cm from the anal verge are the highest risk group for an anastomotic leak [23,24]. In the above-mentioned series of 1639 procedures, the risk of a leak was highest (8 percent) with ultra-low anterior anastomoses [23]. ●Anastomotic ischemia – Two prospective studies using laser Doppler flowmetry assessed blood flow to the colon and rectum before and after mobilizing, dividing, and anastomosing the colon [17,25,26]. A decrease in colonic tissue perfusion proximal to the anastomotic site, at the anastomotic site, and at the rectal stump was reported. The magnitude of decrease in blood flow correlated with the subsequent development of an anastomotic leak. ●Male gender – In a prospective study of 196 patients undergoing rectal cancer resections, multivariate analysis showed a significantly higher rate of anastomotic leak in men with an anastomosis less than 5 cm from the anal verge [21]. It is likely that male gender has the greatest influence on anastomotic leak rates because operating in the narrower male pelvis is technically more challenging. In contrast, male gender does not appear to be a risk factor for intraperitoneal anastomotic leaks [27]. ●Obesity – Data are conflicting regarding the role of obesity in anastomotic leak complications. A prospective review of 1417 patients found no association between obesity and the risk of an intraperitoneal anastomotic leak [27]. However, obesity may be a risk factor for an anastomotic leak for low colorectal anastomoses. A retrospective review of 131 patients found that obese patients undergoing an anterior resection less than 5 cm from the anal verge had a significantly increased risk of anastomotic leak compared with non-obese patients (33 versus 15 percent) [28].
- Intraperitoneal anastomotic leak — Major risk factors for an intraperitoneal anastomotic leak include: ●American Society of Anesthesiologists (ASA) score grade III to V – A retrospective review of 1417 patients found a significantly increased risk of leak with ASA score grade III to V after an intraperitoneal anastomosis compared with those with an ASA score grade I to II (4.6 versus 0.8 percent) [27]. ●Emergency surgery – The same retrospective review found a significantly increased risk of leak with emergency surgery after an intraperitoneal anastomosis compared with elective surgery (4.4 versus 1.0 percent) [27]. For patients with both an ASA score grade III to V and an emergency operation, the risk of an anastomotic leak was 8.1 percent. ●Prolonged operative time – A prospective study of 391 elective colorectal resections identified a significantly higher leak rate when the operative procedure was ≥4 hours in duration compared with shorter procedures (5.1 versus 0.5 percent) [24]. More difficult dissections and anastomoses were attributed to the longer operating times and increase in anastomotic leaks. ●Hand-sewn ileocolic anastomosis – In a meta-analysis of six trials with 955 participants with benign and malignant disease, hand-sewn anastomoses were associated with a significantly higher rate of overall anastomotic leaks compared with stapled ileocolic anastomoses (6.0 versus 1.4 percent) [2]. For the subgroup of 825 patients with cancer, hand-sewn anastomoses were also associated with significant risk of an anastomotic leak (6.7 versus 1.3 percent).
- ●Neoadjuvant radiation therapy – Retrospective studies have found a positive, inconclusive, and no association between the use of neoadjuvant radiation therapy and the risk of an anastomotic leak [4,17,28-31]. There are no high-quality data from randomized trials that specifically address neoadjuvant radiation therapy as a risk factor. ●Drains – It is unclear if drains are a risk factor for anastomotic leaks, and the location of the anastomosis may be important. A randomized trial found no increase in anastomotic leaks with drains in patients undergoing elective colonic resection [Merad F, Yahchouchi E, Hay JM, et al. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research. Arch Surg 1998; 133:309.], while a large observational study found a significant increase in anastomotic leaks with drains in patients undergoing a low anterior resection for rectal cancer [Yeh CY, Changchien CR, Wang JY, et al. Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients. Ann Surg 2005; 241:9.]. ●Protective stoma – The controversy regarding a protective stoma involves whether or not the stoma prevents a leak and reduces the corresponding clinical consequences. Proximal fecal diversion by a protective stoma (eg, loop ileostomy, loop colostomy, or end ostomy) significantly reduces the overall risk of a reoperation following an anastomotic leak [34]. •In a prospective multicenter study of 2729 patients undergoing a low anterior resection, the overall anastomotic leak rate was similar in patients with and without a stoma (14.5 versus 14.2 percent) [Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 2009; 96:462.]. However, patients with a stoma had significantly lower rates of leaks that required surgical intervention (3.6 versus 10.1 percent) and a lower rate of mortality (0.9 versus 2.0 percent). •A meta-analysis of four randomized trials including 358 patients undergoing a low anterior resection for rectal cancer found that patients with a protective stoma had significantly fewer anastomotic leaks compared with patients who had no protective stoma (9.6 versus 22.8 percent) [Hüser N, Michalski CW, Erkan M, et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 2008; 248:52.]. Patients with a protective stoma had significantly fewer reoperations for leaks (odds ratio [OR] 0.27, 95% CI 0.17-0.59). •In a randomized controlled trial of 234 patients undergoing a low anterior resection for rectal cancer that was included in the meta-analysis, the rate of anastomotic leakage with a protective stoma was significantly lower compared with no protective stoma in both men (10.0 versus 29.3 percent) and women (10.9 versus 26.7 percent) [Matthiessen P, Hallböök O, Rutegård J, et al. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246:207.].
- •Hand-sewn colorectal anastomosis – Hand-sewn compared with stapled ileocolic anastomoses are associated with a significant increase in leaks [2]. However, whether or not this is true for colorectal anastomoses is unclear [14,38]. •A review of nine prospective trials of 1233 patients with a colorectal anastomosis found no significant difference in overall dehiscence and leaks for a stapled anastomosis compared with a hand-sewn anastomosis (13.0 versus 13.4 percent) [Matos D, Atallah ÁN, Castro AA, Silva Lustosa SA. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2008; ::CD003144.]. •In a prospective, multicenter trial of 732 patients with a colorectal anastomosis, there was an increase in radiographically detected leaks in hand-sewn anastomoses (14.4 versus 5.2 percent) but no difference in clinically detected leak rates [Docherty JG, McGregor JR, Akyol AM, et al. Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group. Ann Surg 1995; 221:176.]. No patient with a radiographic leak without clinical symptoms had an increase in morbidity. There was no difference in morbidity and mortality rates for patients with a hand-sewn or stapled anastomosis. ●Fibrin glue – A retrospective review of 1148 patients with rectal cancer undergoing a sphincter preservation procedure found that use of fibrin glue was an independent predictor of prevention of anastomotic leak (OR 1.94, 95% CI 1.04-3.64). [39]. The anastomotic leak rate in this series was 6.6 percent. ●Laparoscopic procedure – Randomized trials comparing laparoscopic with open colorectal resection for cancer have failed to show any difference in the rate of anastomotic leaks [40,41].
- ●Mechanical bowel preparation – The role of mechanical bowel preparation (MBP) is controversial. A meta-analysis of 13 prospective trials found no significant difference in overall anastomotic leak rate for patients with an MBP compared to those not having an MBP (4.2 versus 3.4 percent). This conclusion applied to both low anterior resection and intraperitoneal anastomosis. ●Nutrition – Nutritional factors, including hypoalbuminemia, alcohol intake, and weight loss, have shown variable and conflicting results [42,43]. ●Perioperative corticosteroids – Data are inconsistent in determining the relationship between perioperative corticosteroid usage and risk of anastomotic leaks [3,24,44-46]. However, a systematic review that included 12 studies demonstrated a significantly higher rate of anastomotic leak for patients who received corticosteroids in the preoperative period compared with those who did not (6.8 versus 3.3 percent) [Eriksen TF, Lassen CB, Gögenur I. Treatment with corticosteroids and the risk of anastomotic leakage following lower gastrointestinal surgery: a literature survey. Colorectal Dis 2014; 16:O154.]. ●Nonsteroidal anti-inflammatory drugs (NSAIDs) – NSAIDs are commonly used for pain control in patients who undergo colorectal surgery. Some data suggest that postoperative use of NSAIDs may increase the risk of anastomotic leak [47,48]. Potential mechanisms include a reduction in prostaglandin-mediated collagen deposition, diminished collagen cross-linking, and increased anastomotic microthrombosis. In a 2016 meta-analysis of 11 retrospective observational studies (>20,000 patients), NSAID use after colorectal surgery was associated with increased anastomotic leak (OR 1.46, 95% CI 1.14-1.86) [49]. The crude incidence of anastomotic leak was 6.9 percent for patients who received NSAIDs and 5.0 percent for controls. In the same study, NSAID use was not associated with increased anastomotic leak (OR 1.96, 95% CI 0.74-5.16) in the meta-analysis of six randomized trials (473 patients). However, the pooled incidence of anastomotic leak of 5.2 percent for NSAID users versus 2.5 percent for nonusers suggested a trend toward a difference; with only 473 patients and 19 events, the randomized trials were likely underpowered to assess for the risk of anastomotic leaks. Intravenous ketorolac is a potent NSAID that is commonly used in enhanced recovery pathways for abdominal surgery. In one study of 398,752 patients, 5 percent of patients received ketorolac after colorectal (55 percent) or other gastrointestinal surgery (45 percent) [50]. Ketorolac use was associated with more readmissions for anastomotic complications (OR 1.20, 95% CI 1.06-1.36). In addition, patients who received ketorolac were more likely to require reintervention (OR 1.20, 95% CI 1.08-1.32), emergency department visit (OR 1.44, 95% CI 1.37-1.51), or readmission (OR 1.11, 95% CI 1.05-1.18) within 30 days of surgery. Another study of patients undergoing colorectal surgery, however, failed to find an association between ketorolac use and anastomotic leak [51].
- Intraperitoneal anastomotic leak — Management of an intraperitoneal anastomotic leak is dependent upon the patient's clinical condition, the nature of the leak, and, if an exploratory laparotomy is performed, the intraoperative findings. The following treatment options are available, depending upon the clinical stability of the patient, radiographic findings, and feasibility of image-guided percutaneous drainage: ●A subclinical leak, which is defined as a leak detected radiographically in patients with no clinical abdominal findings, can be managed expectantly. ●For patients who present with localized peritonitis and low-grade sepsis, a diagnostic imaging workup is initiated. We perform a computed tomography (CT) scan with oral, intravenous, and rectal contrast. Alternatively, a water-soluble contrast enema may be performed, if available in your institution. If a leak is present, the majority will be localized. •If a free intraperitoneal leak is demonstrated, the patient should be taken to the operating room for surgical management. •If the patient is stable with small, contained abscesses (<3 cm), we recommend conservative management with broad-spectrum antibiotics and bowel rest. •For larger abscesses (>3 cm), multiloculated collections, or multiple collections, an attempt at percutaneous drainage should be made. In those cases where image-guided drainage is not technically feasible or where the patient's clinical condition deteriorates despite drainage, surgical intervention in the form of an exploratory laparotomy should be undertaken as described in the following paragraph. ●Patients who present with generalized peritonitis or high-grade sepsis with hypotension should be resuscitated and brought to the operating room for an exploratory laparotomy on an emergent basis. Surgical management is dependent upon the intraoperative findings. •If an inoperable phlegmon is encountered, the safest approach is to place para-anastomotic drains and perform proximal temporary fecal diversion with either a loop ileostomy or colostomy. ●For patients who have a major anastomotic defect (generally defined as >1 cm or greater than one third the circumference of the anastomosis) [52], the options include resection of the anastomosis with creation of an end stoma with/without mucus fistula, resection of the anastomosis with re-anastomosis and proximal diversion or, rarely, exteriorization of both ends of the stoma. •In selected patients in whom the defect is minor and the tissue quality is adequate, one may consider primary repair of the anastomosis with drain placement and proximal diversion.
- Extraperitoneal anastomotic leak — In most cases, management of an extraperitoneal anastomotic leak is similar to that of an intraperitoneal leak. The following treatment options are available, depending upon the clinical stability of the patient, radiographic findings, and feasibility of image-guided percutaneous drainage: ●For patients with generalized peritonitis and high-grade sepsis, emergent operative management should be performed, as described in the previous section. ●Management of patients with a pelvic abscess depends upon the patient's clinical condition, location of the abscess, and whether or not the abscess is in continuity with a leak. Consideration of proximal diversion is warranted in symptomatic patients. Determination of whether the abscess is contained or is in continuity with the leak can be made by performing a water-soluble contrast enema. •Patients with a contained abscess should be placed on intravenous antibiotics and undergo abscess drainage if the collection is larger than 3 cm. CT-guided drainage via a transabdominal, transvaginal, transanal, or transrectal route should be performed if technically feasible. Rarely, a trans-sciatic or transgluteal approach may be necessary. •For very low pelvic abscesses that are in continuity with the anastomotic leak and that may be anatomically inaccessible by image-guided techniques, we perform an examination under anesthesia with transrectal or trans-anastomotic drainage. This approach is facilitated by making a wide opening in the anastomosis and/or inserting a mushroom-tipped catheter into the abscess cavity.