The Management of Anastomotic Leak

John Hartley Academic Surgical Unit University of Hull

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

Anastomotic Leak

Anastomoses 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

Anastomotic Leak

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

Anastomotic Leak

The value of covering stoma: • 200 patients with low anterior resection No 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

Anastomotic Leak - who’s to blame?

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

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

Anastomotic Leak

Clinical signs Depend upon: • Severity of leak • Degree of localisation • • Time of leak post op

Whether the anastomosis is covered

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

Anastomotic Leak

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

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

Anastomotic Leak

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

Anastomotic Leak

Faecal Peritonitis – diagnosis • Erect chest X-ray • Gastrograffin enema • ?? CT scan

Anastomotic Leak

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

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

Anastomotic Leak

Laparotomy for faecal peritonitis • Confirm diagnosis • Disconnect anastomosis Proximal stoma Mucus fistula Close distal end • Wash out abdomen?

• Drain?

• Laparostomy

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

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

Sealed off leak with abscess

• Vague localised or general abdominal pain • Localised peritoneal signs • Temperature, tachycardia • Ileus • Multi organ failure Jaundice Renal failure ARDS

Anastomotic Leak

Sealed off major leak with abscess (ill patient) •Drainage •Nutritional support •Antibiotics Leak Improves Settles Becomes Worse Fistula Laparotomy Divide Anastomosis Covering Stoma & Drain

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

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

Anastomotic Leak

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

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

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

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

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