This document discusses colonic anastomotic leaks. It begins by outlining factors that affect the risk of leaks, including patient characteristics and technical aspects of the surgery. It then defines leaks and describes their reported rates. Common signs and symptoms of leaks are provided. Risk factors for leaks are explored, including preoperative, intraoperative, and postoperative factors. The timing of leaks and relationship between leaks and cancer recurrence is examined. New methods for preventing leaks are briefly outlined. The document concludes by discussing approaches to managing leaks and emerging technologies.
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/
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
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/
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Natural Orifice Transluminal Endoscopic Surgery, NOTES.
"scarless" abdominal surgery with an endoscope passed through a natural orifice (MOUTH, URETHRA, ANUS, VAGINA) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Natural Orifice Transluminal Endoscopic Surgery, NOTES.
"scarless" abdominal surgery with an endoscope passed through a natural orifice (MOUTH, URETHRA, ANUS, VAGINA) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Complications in Surgery- Mr G Williamsjimmystrein
Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.
Adhesions are an important yet often neglected cause of impaired fertility
The use of adhesion prevention agents should be considered in laparoscopic surgeries as well as Open Surgeries, where adhesion formation is expected
Pelvic Fracture managemnt- Case based discussion .pptxKTD Priyadarshani
A case based approach on the management of a pelvic fracture. it is based on ATLS guideline. A brief account on anaesthetic and orthopedic point of view also included.
Similar to Colorectal anastomosis leakeage sorrento 2010 (20)
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
1. Colonic anastomotic leak
No disclosures
JM Enríquez-Navascués
Hospital Donostia
Universidad País Vasco /EHU
San Sebastián. Spain
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. 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. 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. 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)
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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)
35. Colorectal anastomotic leak
• Timing of leaks
• Leaks and cancer recurrence
• New methods for preventing anastomotic leaks
• Management of leaks and the expanding technology
36. 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
37. 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…
39. 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?
Editor's Notes
Anastomotic leaks are responsable of the >33% of surgical colorectal mortality
Experienced colorectal surgeon often quote 3%-6% as an acceptable overall colonic leakeage
Deficition : “leak of luminal contents from from a surgical join between two hollow viscera. Combination of clinical (fever, pain, etc….) radiological and biochemical markers (PCR…)
Leakeage are detected anywhere from 3 to 45th days postoperatively; When clinical leaks occur the media postop day od diagnosis is 7 day; when is made raiographically the media is 16th day; a 10-12% od diasnosis are made >30days after the operation. Close follow-up must be carry out during the firts 40 days after the operation
Impaired general condition, failure of improvement in postop (ie: manteinance of ileus, etc.)
Clinal conditions of the patients (good, mild/moderate disconfort, or severely impaired.
Clinical symtoms ( abdominal or pelvic pain, fever purulent/fecal discharge –drain, wound, vagina and anus-
Laboratory test: leukocytosis, C-reactive protein
Radiological evaluation (contained and small – local complication as an abscess, or generalized complication.
Gender: in rectal multivariate analysis showed male patients with anastomosi <5 cm had higher rate of leaks; some studies show that this is so below the peritoneal reflection; Obesity: almost double the rate of LAR (<5cm); Tobacco: related to microvascular disease; Divericular disease: necessity of mobilization of the splenic angle to avoid an area of muscular hypertrophy ; an ASA >3 is the most important factor for dehiscence, spacifically in left side anastomosis; comorbid conditions such as diabetes, hypertension, and cardiac disease can cause impaired circulation at the microcirculation; Steroid use is associated with an increased risk in the only prospective study (odds ratio 8,7; 95% CI, 1,2-45,1), but not in the retrospective studies. Nutrition: low levels of albumin increase the rate of leaks, so is important to asses the nutritional levels perop. (and the weight loss of > 5kg; Radiation: there is inconclusive data from retrospective only studies. Bevacizumab: (inhibition of angiogenesis, and pre-microthromboembolic disease leading to ischemia) It is advaisable to delay operation for three half live of the drug, or 60 days after the treatment.
Height: More or less than 6-10 cms (ETM vs EsTM): odds ratio 4,5 (1,8-12,7); almost double incidence of leaks in LAR. Obstruction: wall status. Sepsis: patient hemodynamic status. Duration: 220 minutes (4h) vs. 186 min (3h): more difficult operation (multiresection, relaparotomies, etc.) resection and anastomosis: higher risk of dehiscence. Several attemps to quantify colonic perfusion intraop. Laser Doppler studies reveal that a reduction of 30% in tissue perfusion 2cm proximal to the anastomotic site and 50% at the anastomotic site. In left site sigmoid perfusion is worse that descendong. A consideration has also been given to increasing anastomotic blood flow by performing side to end anastomoses. Drains: Role in evacuating fluid collections, lessening the incidence of abscess formation , or early warning maker of dehiscence. There seems not to be justificable indication to place a drain in resections above the sacral promontory. Hand or staple: Provided the three critical factors when performing an anastomosis are kept (adequate blood supply, no tension an inverted anastomosis) there must be no differences. However subclinical leaks were more frequent in handsewn (14%) compared with stapled (5%) in a RCT. Cochrane found no differences in clinical leaks rate in a review. No differences between lap and open. However the number of firings (more that two shots) is important as a factor of dehiscence in low and left side nastomosis in a prospective consecutive serie of patients with multivariable analysis
Wrapping an anastomosis with omentum confers no protective effect in mitigating nastomotic leaks (RCT with 705 ptes.). A RCT shows that leaks occurred in 4% of the group test performed (air bublles or Betdine filling) compared with 14% of the no-test group. Test should be done after the completion of anastomosis, and repaired in case of positive test to lessen the rate of leaks. Donoughts should also be inspected. Proximal diversion is known does not prevents leaks but lessens the consequences and sequelae should a clinical leak pccur. Stoma are not without inherent complications of their own (retraction, necrosis, prolapse, stricture, etc) and needs an reoperation more risky than was previously thouhgt.
High or low (preserving left colonic arterie) tie of the IMA (mainly the concern is about vascularization of the sigma vs. descent colon)
Distal rectal distensibility is lacking avoiding to cushion the bowel peristalsis)
Perianastomotis faeces accumulation: after mass movement: early diarrhoea is an ominous sign of future dehiscence
LAR: Experienced surgeon is needed for detecting a failure suture: inside the pelvis there is not pain sensitive receptors: no pain, delay in clinical diagnosis
Differences between ACA and LAR
The median time to re-operate after diagnosis of an anastomotic leak must be 0 days !!
The basic principles of adequate blood supply, no tension, and inverted mucosa still apply.
It is more common to occur in a bimodal distribution (with the second group of patients leaking after they have been discharged from the hospital,) than is ussualy appreciated.
Significant clinical indicators of leakeage are: fever (>38º) on day 2, absence of bowel action on day 4, diarrhoea before day 7, >400cc of fluid in abdominal drain on day 3 and leucocytosis on day 7. Fever at 7 days of postop indicate a leak…CT with contrast is superior to contrats enemas, and should be ask for in those situations.
Concern with quicker discharges from the hospital, usually within 5 days, leaks will occur outside of a hospital setting. Patients must be educated as to what signs to look for. Close followup must be carry out during the first 40 days after the operation
*The categorization of leaks as free or contained may not be justified and argues for early re-operation or proximal derivation, according to a study from MGH. Intrabdominal sepsis seems different from a localized abscess, and are trated initially with percutaneous drainage, however most of them (mainly if a communication between the collection and the gi tract is identified) ultimately required surgical intervention, although they requiere less frequent take down of the anastomosis
**: intraperitoneal anastomosis.
In R the anastomosis take down means a permanent stoma and disabled anorectal stump with morbility and frequent unhealed perieum