1 / 38

Anastomotic leakage in colorectal cancer surgery

Anastomotic leakage in colorectal cancer surgery. D.Pavalkis , Z.Saladzinskas Kaunas medical university hospital, Lithuania International meeting of coloproctology 22 – 24 April, 2004, Hortobagy, Hungary. Importance of the problem. Colorectal cancer incidence

sai
Download Presentation

Anastomotic leakage in colorectal cancer surgery

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Anastomotic leakage in colorectal cancer surgery D.Pavalkis, Z.Saladzinskas Kaunas medical university hospital, Lithuania International meeting of coloproctology 22 – 24 April, 2004, Hortobagy, Hungary

  2. Importance of the problem • Colorectal cancer incidence • Increasing numbers of sphincter saving procedures • Ageing population • Most serious postoperative complications – anastomotic leakage

  3. Importance of the problem • Anastomotic leakage occurs in 5 - 15% after colorectal surgery • Leads to substantial morbidity and mortality • Many factors determine AL • Patient related • Surgery (treatment) related • Soeters/de Zoete /Dejong/Williams/Baeten Dig Surg 2002;19;150-155

  4. How to manage AL? • Stoma • Drains • US drenage • Reoperation time

  5. In what we end with AL? • In hospital mortality • Local recurrence rate • 5 years survival • Functional outcome and quality of life

  6. Bowel preparation Surgical techniques Insufficient blood supply at the anastomosis Tension on anastomosis Tension on mesentery Protective stoma Presents of inflammation And many other Elderly Anemia Malnutrition Smoking Obesity Therapeutic diseases Cardiovascular Steroids Causes of AL

  7. Risk factors for AL Multivariate analysis • Male sex increased risk of AL 13 fold in LAR or PCA • Lower than 10 cm anastomoses (3,5 fold increase compare with higher than 10 cm) • ASA group 4 (2,5 fold increase risk of AL to compare with ASA 1-3 D.Pavalkis, Medicina,2001, 39:421-425

  8. Risk factors for AL • Multivariate analysis showed that male sex and level of anastomosis were independant risk factors for AL • 6,5 times higher for anastomoses less 5 cm • 2,7 times higher for man • For low anastomoses (5 cm) obesity came as independant facot for AL Rullier E. & all, Brit J Surg, 1998, 85, 355-358

  9. Obesity and AL • 584 elective colorectal surgery for cancer • 158 (27%) were obese (BMI>27) • Hemicolectomies – no difference • AR resulted in AL in 16% of obese and 6% of nonobese patients (p<0,05) • For obese patients in AR group diabetes mellitus and ASA status were significant risk factors for AL St.Benoist & all, Am J Surg, 2000, 179, 275-281

  10. Age and AL • Prospective multicentric study, 75 German hospitals, 3756 patients • <65; 65-79; >80 • Left sided cancers 76.2%, 76.7%, 54.8% • AL requiring surgery 4.2%, 3.1%, 1.5% (p>0.05) • AL not requiring surgery 1.5%, 2.3%, 1.2% (p>0.05) F.Marusch at all, Int J Colorectal Dis, 2002, 17:177-184

  11. Age and AL • Colorectal cancer • 132 patients >75 and 464 <75 • 4 from 132 ( 3.03%) >75 • 18 from 464 (3.87 %) <75 D.Pavalkis, Medicina,2001, 39:421-425

  12. Bowel preparation Memon MA & all Int J Colorectal Dis 1997;12;298-302

  13. Bowel preparation • Controversial • Efficient MBP – prerequisite to reduce anastomotic and septic complications • Hares MM, Alexander-Williams J World J Surg 1982;6;175-181 • Ashley SW in Current surgical therapy, 5th edn, Mosby 1985; 210-212 • No beneffit in elective surgery • Mietttinen P, et al Digestion 1998;59 suppl;48 • Significant greater incidence of AL in prepared patients versus no preparation 8.1% v.s.4% • Platell C, Hall J Dis Colon Rectum 1998;41;875-883

  14. Bowel preparation • Prospective, consecutive 250 patients WITHOUT bowel preparation • Anastomoses were ileocolic in 32%, colocolic in 20,8%, colorectal intraperitoneal 34.4%, extraperit. 12,8% • AL –1,2% - all in extraperitoneal anastomosis van Geldere D & all, J Am Coll Surg, 2002, 194:40-47

  15. Anesthesia and AL • Medline search and reviewing literature on randomized trials • 12 trials, 562 pts, 266 epidural resulting in 6% AL compared with 3,4% receiving opioid based analgesia (p<0,05) K.Holte, H.Kehlet, Reg Anesth Pain Med 2001;26:111-117

  16. Anesthesia and AL • KMUH 100 patients randomized to epidural or opioid postoperative analgesia • Resectional colorectal surgery for cancer • Postoperative pain management with petidine I/m, compare with bupivacaine and fentanyl epidurally

  17. Surgical complications (KMUH data)

  18. Other complications (KMUH data)

  19. Hand-sewn or stapled? • Supraperitoneal anastomoses 74 hand-sewn and 85 circular stapled. • AL in 4 and 6 patients respectively • Mishaps (10 cases) and hemorrhage (5 cases) occurred in stapled group only • Stapled took 8 minutes less to perform • Concluded, that there no advantage in stapling in supraperitoneal anastomoses A.Fingerhut &all, Surgery , 1995, 3: 479-485 (French Association for surgical research)

  20. Anastomosis techniques • No issue of whether anastomosis is performed • with one or two layers • Interrupted or continuous sutures • Stapling, biofragmentable ring • Gordon P, Nivatvongs S 1999 • Alves A, Panis Y, Trancart D, Regimbeu JM, et al World J Surg 2002;26;499-502

  21. Anastomosis methods

  22. Anastomosis method and AL • 21Park’scoloanal anastomosis - 5 (23,8%) • 78 LAR - 8 (10,3%) • 67 AR - 2 (3%) • 103 sigmoid resections - 5 (4,9%) D.Pavalkis, Medicina,2001, 39:421-425

  23. Intraoperative anastomotic testing • 18.1% of patients after rectal resection demonstrated intraluminal bleeding or leakage O.Schmidt, S.Merkel, W.Hohenberger, Eur J Surg Oncol, 2003, 29:239-243 • 20,6% leaked on testing, after repair – 3% leaked on second testing JMD Wheeler, JM Gilbert, Ann Royal Coll Surg Engl, 1999, 51:105-108

  24. Protective stoma • Consecutive 200 patients with TME • 125 defunctioned, 75 – not • Reoperation in 8% without stoma, 1% reoperation – with protective stoma • Suggested, that all anastomoses at 6 cm or less from anal verge should be protected N.D.Karanjia & all, Br.J.Surg. 1991; 78:196-198

  25. Colostomy or ileostomy? • Randomized, 42 patients protected with loop ileostomy and 38 – with loop transverse colostomy • Postoperative intestinal obstruction from creation to closure 6 pts with ileostomy, 1 with colotomy • Transverse colostomy was recommended W.L.Law,K.W. Chu, H.K.Choi, Br.J.Surg.2002, 89, 704-708

  26. Colostomy or ileostomy? • Comparison was made regarding the difficulty of stoma formation and closure, recovery after stoma closure and stoma-related complications • No difference in in the difficulty of formation or closure • Colostomy resulted in 1 faecal fistula, 2 stoma prolaps, 2 parastomal hernia and 5 incisional hernia in stoma site • Both methods provide satisfactory protection, but Ileostomy is preferable D.P.Edwards & all, Br.J.Surg., 2001,88,360-363 (Basingstoke)

  27. Principles of good colorectal anastomosis • Good exposure • Adequate blood supply • Prevention of local contamination • Sutures or staples placed properly • No tension (release splenic flexure) • Prevent distal obstruction • Good bowel preparation M.R.B. Keigley, N.S.Williams, 1993

  28. Suspition of leak • Wounds draining sero-sanguinolent fluid or pus • Adynamic ileus • Pain • Malaise • No stool passage • Fever and leucocytosis • Cardiorespiratory complications in the first 7-10 d

  29. Suspition of AL • 655 patients; 39 AL (6%) • Fever>38 degrees C on day 2 • Absence of bowel action on day 4 • Diarrhea before day 7 • Collection more than 400 ml fluids 0-3 day • Renal failure on day 3 • Leukocytosis after day 7 Alves A & all, J AM Coll Surg, 1999, 189:554-9

  30. Suspitionof AL • Combination of signs observed before day 5 • If 2 – leakage 18% • If 3 – leakage 67% Reoperated after day 5 (5 of 23 patients) death 22% versus 0% reoperated before day 5 (0 of 11 patients) Alves A & all, J AM Coll Surg, 1999, 189:554-9

  31. Management of AL • Pelvic abscess • Non surgical technics (transanal, US, CT) • Defunction with stoma? • Elementary diet, TPN? • Colorectal surgeon = general surgeon

  32. Management of AL • Peritonitis • Emergency surgery • M.Keighley – take down anastomosis • We should try save low anastomoses

  33. AL and functional outcome • Comparison 19 pts with AL with 19 pts without • 30 months postoperatively • No differences in anal pressures • Difference in neorectal volume with associated • urge incontinence • Frequency of bowel movements O. Hallbook, R.Sjodahl, Brit J Surg, 1996; 83:60-62

  34. QL and time after surgery • Data from studies exists showing that QL changes with time after operation and tends to come to baseline after 6 moths after surgery M.Koller, Langenback’s Arch Surg. 1998, 383:427-436 J.Camilleri-Brennan, British Journal Surgery, 2001, 88,1517-1622

  35. Influence of AL on QL • Anastomotic leakage in this patient resulted in very low global QL • Specific deficits included physical functioning, pain and fatigue M.Koller and W.Lorentz, Langenbek’s Arch Surg, 1998, 383:427-436

  36. AL and local reccurence • 814 currative AR with 89 (10,9%) AL • Local reccurences – 13,6% • AL group – 22% reccurences, withouth AL – 12,5% (p<0,05) • Multivariate analysis – AL independent factor for local reccurence • 5 years survival in AL group 69,6%, withouth – 77,8% (p<0,0035) S.Merkel & all, Colorectal Disease, 2001, 3, 154-160

  37. Conclusions • AL remains most important postoperative complication after sphincter saving surgery • Surgeons should know risk factors for AL • Less risky operations with defunctioning ileostomy are preferable in high risk for AL patients group

  38. Thank you for your attention

More Related