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  Increasing numbers of sphincter saving procedures  Ageing population  Most serious postoperative complications – anastomotic leakage

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

How to manage AL?

 Stoma  Drains  US drenage  Reoperation time

In what we end with AL?

 In hospital mortality  Local recurrence rate  5 years survival  Functional outcome and quality of life

Causes of AL

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

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

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

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

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

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

Bowel preparation

Mortality and morbidity Mortality Wound infection Wound dehiscence Abdominal/pelvic collection Anastomotic breakdown MBP (n-61) 2(3,2%) No MBP (n 75) 0 FET (P<0,05) NS 4(6,6%) 2(3,3%) 3(4,9%) 10(13,3%) 4(5,3%) 2(2,7%) NS NS NS 5/48(10%) 2/52(3,8%) NS Memon MA & all Int J Colorectal Dis 1997;12;298-302

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

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

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

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

Surgical complications (KMUH data)

Complication Wound infection Intraabdominal abscess Pethidine gr 3 (6%) 1 (2%) EA gr.

5 (10%) 3 (6%) 3 (6%) Anastomotic leakage Total: -

4 (8%) 11 (22%)

Other complications (KMUH data)

Complication Chest infection Cardiac arrhythmias Pulmonary embolism Acute renal failure Urinary infection Total: Pethidine 2 (4%) 2 (4%) 1 (2%) † -

5 (10%)

EA gr.

1 (2%) 1 (2%) 1 (2%)

3 (6%)

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)

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

Anastomosis methods

KMUH 1995-1996 Hand sewn, 2 layers 45 Hand sewn, 1 layer 4 1997-1998 46 31 1999-2000 Total 40

131

63

98

Stapled 21 32 64

117

Anastomosis method and AL

 21 Park’s coloanal 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

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

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

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

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)

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

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

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

Suspition of 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

Management of AL

 Pelvic abscess  Non surgical technics (transanal, US, CT)  Defunction with stoma?

 Elementary diet, TPN?

 Colorectal surgeon

=

general surgeon

Management of AL

 Peritonitis  Emergency surgery  M.Keighley – take down anastomosis  We should try save low anastomoses

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

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

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

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

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

Thank you for your attention