Bowel injury 2013

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Bowel injury 2013

  1. 1. Bringing cutting edge to daily practice in gynecological cancer surgery January 2013 Murad Aljiffry MD, MSc, FRCSC HPB and Transplant Surgery General Surgery Bowel Injury and Bowel Anastomosis
  2. 2. Objectives ¨  Introduction ¨  Preoperative preparation ¨  Operative management ¤  Small bowel ¤  Colorectal ¨  Current techniques of bowel anastomosis
  3. 3. Background ¨  The incidence of intestinal injury in gynecologic surgery is 0.1–0.7% ¨  The commonest site of injury is small bowel (60-70%) ¨  Most injuries are minor with uncomplicated clinical outcome ¨  Immediate VS delayed presentation (15-40% delayed) Vilos GA, J Obstet Gynaecol Can Erratum, Am J Obstet Gynecol
  4. 4. Background ¨  Risks: ¤  Previous surgery ¤  Prior infection ¤  Radiation ¤  Endometriosis ¤  Obesity ¨  Commonly during entrance into the peritoneal cavity (45%), adhesiolysis (35%) and pelvic dissection (10%) RVan der Voort, Br J Surg Alan Lam, Best Practice & Research Clinical Obstetrics and Gynaecology
  5. 5. Background ¨  Mechanisms: ¤  Sharp ¤  Rough handling of tissue (tear) ¤  Thermal (25%) à usually late Michael J, Rev Obstet Gynecol. Diamantis T, Surg Today.
  6. 6. Background ¨  An open entry technique has not been shown to reduce the incidence of entry related bowel injury ¨  BUT allow immediate recognition of the bowel injuries Ahmad G, Cochrane Database Syst Rev. Penfield AJ, J Reprod Med Hashizume M , Surg Endosc
  7. 7. Recognition ¨  Return of bowel contents ¨  Foul-smelling gas ¨  Serosal tears ¨  Hematomas wall or mesentery ¨  Laparoscopy à high insufflation pressures, asymmetric distension ¨  Good exercise to run the bowel after extensive dissection
  8. 8. Delayed diagnosis ¨  The later the diagnosis, the higher the morbidity and mortality associated with bowel injury ¨  Time of recognition is variable depends on type: ¤  Small bowel 4 days ¤  Colon 5.5 days ¨  Presentation range from septic shock to localized abscess Brosens I, J Am Assoc Gynecol Laparosc. BishoffJT, J Urol
  9. 9. Background ¨  Early diagnosis is critical ¨  If suspecting bowel injury: ¤  Admit pt for close monitoring ¤  Use blood test and CT when indicated ¤  Low threshold for exploration ¤  Ask for help if not clear
  10. 10. Don t let the abdominal wall stand between you and the diagnosis
  11. 11. Preparation ¨  Multidisciplinary approach for complex cases ¨  Proper pt education and communication ¨  Prophylactic antibiotics (within 30 min)
  12. 12. Mechanical bowel prep (MBP) ¨  Bottom line no need ¨  Paucity of literature specific to gynecologic surgery, it is reasonable to extrapolate from the colorectal data against MBP Sarah L. Cohen, Rev Obstet Gynecol. 2011
  13. 13. No Statistically Significant Difference Between MBP and No-MBP 2003 No Difference 2005 Statistically Significant Increase in Anastomotic Leak with MBP 2009 No Difference 14 RCTs with > 4500 Pts Primary outcome anastomotic leakage Secondary outcome measures surgical site infection Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
  14. 14. Mechanical bowel prep (MBP) ¨  There is sufficient evidence to abandon MBP ¨  MBP Has Been Shown to be harmful in few studies ¨  No-MBP is (or becoming) the standard for colorectal surgery ¨  Side Does Not Matter (Right v. Left, Colon v. Rectum) Sarah L. Cohen, Rev Obstet Gynecol. 2011
  15. 15. Mechanical bowel prep (MBP) At Least From the Patients Perspective MBP Should Be Abandoned ¨  Quality of life and patient preference ¨  Dehydration and electrolyte disturbance ¨  Bacterial translocation ¨  Spillage with Bowel Prep (17%) v. NO Bowel Prep (12%) Mahajna A, Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005 Slim K, Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009
  16. 16. Mechanical bowel prep (MBP) So, Who Should we Prep? ¨  Inadequate localization or possibility of intra-op Colonoscopy ¨  Defunctionalized anastomoses? ¨  Low-level rectal resections?
  17. 17. Measures may reduce bowel injuries ¨  When entering the abdomen in high-risk patients: ¤  Watch for adhesions to abdominal wall ¤  Extending the previous scar ¨  Routine inspection of the bowel below the entry ¨  Minimize bowel handling
  18. 18. Measures may reduce bowel injuries ¨  Use atraumatic instruments for bowel handling ¨  Careful tissue dissection under vision ¨  Limit adhesiolysis to clinically indicated cases only ¨  Limit the use of thermal energy when working close to or on bowel wall
  19. 19. Management ¨  The management of bowel injuries depends on the following: ¤  The timing of the diagnosis ¤  The patient s clinical status ¤  Type and site of injury ¤  The available experties
  20. 20. Small bowel injuries ¨  Control contamination and assess ¨  Close enterotomies and serosal tears (transversely) ¨  Resection and anastomosis: ¤  >½ diameter ¤  Multiple injuries in a small segment ¤  Devascularized ¨  Avoid multiple resections
  21. 21. Colon injuries ¨  Control contamination and assess ¨  Depends on type of injury ¤  (destructive VS non-destructive) ¨  Generally two options: ¤  Primary repair (The Standard) ¤  Resection with anastomosis or diversion ¨  Exteriorization is abandoned à failure and complications
  22. 22. Colon injuries Trauma literature ¨  Numerous large retrospective and several prospective studies have demonstrated that primary repair is safe and effective in the majority of patients with penetrating injuries ¨  1% failure rate for all primary repairs The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  23. 23. Colon injuries Trauma literature ¨  5-8% failure rate for resection anastomosis ¨  Most failures with resection in: ¤  Significant associated injuries ¤  Hemodynamic unstability ¤  Delayed presentation (peritonitis) ¤  Significant underlying disease The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  24. 24. Colon injuries ¨  Primary repair of all repairable injuries: ¤  The decreased morbidity associated with avoidance of colostomy, the disability associated with the interval from creation to closure of the colostomy all support primary repair of non-destructive colon injuries The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  25. 25. Colon injuries ¨  Resect all non-repairable injuries ¨  Anastomosis if favorable general condition ¨  Resection + proximal diversion: ¤  Shock (massive transfusion > 6 units) ¤  Significant underlying disease ¤  Significant associated injuries (> 2) ¤  Delay of operation (>12hrs) The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  26. 26. Rectal injury ¨  Intraperitoneal ¤  Similar to colonic injuries ¨  Extraperitoneal ¤  Repair if feasible, avoid unnecessary dissection ¤  Diversion ¤  Drainage ¤  Distal Washout
  27. 27. Bowel anastomosis ¨  Pillars of of technically successful anastomosis: ¤  Healthy edges ¤  Adequate blood supply ¤  No tension ¨  Overall suturing or stapling are equally safe in bowel surgery (as long as done properly) ¨  Currently most are done stapled Cochrane Database Syst Rev. 2011 Cochrane Database Syst Rev. 2012
  28. 28. Anatomical Side-To-Side / Functional End-To-End Anastomosis
  29. 29. Circular Anastomosis
  30. 30. Summary ¨  Be familiar with general principles of bowel surgery ¨  Call for help when needed ¨  High index of suspicion in complex cases ¨  No need for routine MBP ¨  Primary repair or resection/anastomosis is the Role ¨  Diversion is the Exception
  31. 31. Questions

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