The Management of Anastomotic Leak

1. The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull

2. The Management of Anastomotic Leak • Surgical disaster • Increased morbidity, mortality, hospital stay, cost etc etc • Best avoided • Will happen • Suspect it (Assume it) • Identify early and treat aggressively

3. Anastomotic LeakAnastomoses in Lower Third of Rectum (0-6cm) Leak rate 5 – 20% UK Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196 France Ruler, Laurent, Premix: BJS, 1998, 85, 355 USA Smith: DCR, 1981, 22, 236

4. Anastomotic LeakLeaking Anastomoses in Lower Third of Rectum MORTALITY Increases by a factor of 20 MORBIDITY Hospital stay:10 days 30 days Permanent colostomy > 50%

5. Anastomotic Leak The value of covering stoma: • 200 patients with low anterior resectionNo defunctioning stoma: 8% peritonitis. Defunctioning stoma: <1% Karanjia et al 1991, BJS 78, 196 • 1115 pts Geneva Multicentre Study: Mortality 0.9% v 3.6% for covered vs not covered Kassler et al, 1993, Int J Colorectal Dis, 8, 158

6. Technical factors Ischaemia of bowel ends Oedema of bowel ends Anastomotic tension Poor suturing technique Haemorrhage Sepsis Patient factors Anaemia Sepsis Malnutrition Steroids Radiotherapy Cardiovascular problems (Bowel preparation) Anastomotic Leak- who’s to blame?

7. Anastomotic Leak Diagnosis • Clinical signs • Leucocytosis • Positive blood cultures • Abdominal/chest X-ray • Gastrograffin enema • CT scan • Labelled white cell scan • Fistulogram

8. Anastomotic Leak Clinical signs Depend upon: • Severity of leak • Degree of localisation • Time of leak post op • Whether the anastomosis is covered

9. Anastomotic Leak Clinical Signs - may be non-specific • Clinical leak in 22 of 379 pts (6%) undergoing surgery for CRC - 7 (32%) obvious peritonitis - 15 (68%) initial misdiagnosis for mean of 4 days (range 0-11), 13 treated for cardiac problems • 30 patients (8%) developed cardiac symptoms of whom 13 had a leak Sutton CD et al. Colorectal Dis 2004;6:21-2

10. Anastomotic Leak Anticipation • “Off colour” • Failure to diurese • Prolonged ileus • (diarrhoea) • Fever • Failure to meet milestones

11. Anastomotic Leak Clinical presentation: • Faecal peritonitis • Clinically ill patient with abscess, no gross abdominal signs • Clinically ill patient without abscess, no gross abdominal signs • Clinically well patient with enterocutaneous fistula

12. Anastomotic Leak Faecal Peritonitis • Severe abdominal pain • General tenderness and guarding • Silent abdomen • Tachycardia, hypotension • Oliguria / anuria • Faecal leakage from drain or wound

13. Anastomotic Leak Faecal Peritonitis – diagnosis • Erect chest X-ray • Gastrograffin enema • ?? CT scan

14. Anastomotic Leak Faecal peritonitis – management • Confirm diagnosis • Urgent resuscitation - iv fluids - CVP monitoring - Antibiotics - Urinary catheter • Urgent re-exploration

15. Anastomotic Leak Options at re-laparotomy • External Drainage • Suture Defect Suture Defect with Proximal Diversion • Proximal Diversion Proximal Diversion with Drainage • Exteriorise Leaking Segment • Resect Anastomosis with Re-anastomosis Resect Anastomosis with end stoma, mucous fistula or Hartmanns

16. Anastomotic Leak Laparotomy for faecal peritonitis • Confirm diagnosis • Disconnect anastomosis Proximal stoma Mucus fistula Close distal end • Wash out abdomen? • Drain? • Laparostomy

17. Anastomotic Leak Laparotomy for leak following anterior resection • 32 pts lavage, drainage, diversion • 22 Hartmans (size of leak, viability of colon, site of anastomosis) - 8 of 19 survivors continuity restored • 10 proximal diversion all had stoma reversed Parc et al. Dis Colon Rectum 2000;43:579-87

18. Anastomotic Leak Clinical presentation: • Faecal peritonitis • Clinically ill patient with abscess, no gross abdominal signs • Clinically ill patient without abscess, no gross abdominal signs • Clinically well patient with enterocutaneous fistula

19. Sealed off leak with abscess • Vague localised or general abdominal pain • Localised peritoneal signs • Temperature, tachycardia • Ileus • Multi organ failure Jaundice Renal failure ARDS

20. Anastomotic Leak Sealed off major leak with abscess (ill patient) • Drainage • Nutritional support • Antibiotics

21. Anastomotic Leak Clinical presentation: • Faecal peritonitis • Clinically ill patient with abscess, no gross abdominal signs • Clinically ill patient without abscess, no gross abdominal signs • Clinically well patient with enterocutaneous fistula

22. Anastomotic Leak Clinical presentation: • Faecal peritonitis • Clinically ill patient with abscess, no gross abdominal signs • Clinically ill patient without abscess, no gross abdominal signs • Clinically well patient with enterocutaneous fistula

23. Anastomotic Leak Enterocutaneous fistula in clinically well patient • Delineate fistula CT Fistulogram • Percutaneous drainage of abscess • Exclude distal obstruction / foreign body • Correct anaemia, malnutrition, electrolytes • Control fistula skin care suction / bags somatostatin

24. Anastomotic Leak Conclusions • Leaks are common • Leaks cause considerable morbidity and mortality • Maintain high index of suspicion • Manage aggressively and safely • Leaks are better avoided than treated: covering stoma

26. Anastomotic Failure Sealed off major leak with abscess • Vague localised or general abdominal pain • Localised peritoneal signs • Temperature, tachycardia • Ileus • Multi organ failure Jaundice Renal failure ARDS

27. Free gas post • Laparotomy • Plane XR almost • always resolved • by 5th day • New gas – worry!

28. Anastomotic Leak Enterocutaneous fistula management • Improve general condition • Feeding line with specialist nursing • Control if possible with stoma or proximal loop • Drain abscess / collection if possible • Intensive attention to input / output • Specialised skin / stoma care • ? Help from fistula unit