Colorectal anastomosis leakeage sorrento 2010
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Colorectal anastomosis leakeage sorrento 2010
- 1. Colonic anastomotic leak No disclosures JM Enríquez-Navascués Hospital Donostia Universidad País Vasco /EHU San Sebastián. Spain
- 2. INTESTINAL ANASTOMOSES - Patients general conditions: nutritional and inmunological status, presence of shock, hypovolemia, peritonitis, comorbility… - Local (technical) conditions: irrigation, lack of tension, precise aposition of non inflammed ends…
- 3. Colonic anastomotic leak • Most dreaded complication • Reported rates vary between 1-30% (3%-6%; 8-20%) • Result in increased morbi-mortality,LOS and tumoral recurrence. Definitive stoma (colorectal leak):15-30% • No accepted definition: -Clinical signs -Radiological parameters -Intra-re-operative findings • Timing of the leaks
- 4. Colonic anastomotic leak clinical signs and symptoms: • fever, leukocytosis, C-RP, procalcitonin (PCT) • localized or generalized peritonitis (abdominal/pelvic pain) • gas/purulent/faeces discharge from wound, drain, vagina (rectovaginal fistulae) or anus (pelvic abscess)
- 5. Colorectal anastomotic leak • Definition: - Defect of the intestinal wall integrity at the anastomotic site (and all stapled lines) leading to a communication between the intra and extra luminal compartments. - A pelvic abscess close to anastomosis is also considered as a leak • Grading of severity: A: No active therapy requiered B: Active intervention but not relaparotomy C: Re-laparotomy International Study Group of Rectal Cancer (Surgery, 2010)
- 6. Risk factors for anastomotic leakage • Preoperative patient factors • Preoperative management factors • Operative factors • Postoperative factors
- 7. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 8. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 9. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 10. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 11. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 12. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 13. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 14. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 15. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 16. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 17. Risk factors for anastomotic leakage Preoperative factors: • Gender • Obesity • Tobacco and alcohol use • Diverticular disease • ASA status • Steroids • Nutrition • Radiation • Bevacizumab • Mechanical bowel preparation
- 18. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 19. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 20. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 21. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 22. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 23. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 24. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 25. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 26. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 27. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 28. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 29. Risk factors for anastomotic leakage Intraoperative factors: • Anastomosis height (tumor location) • Obstructive or septic conditions • Duration of operation • Anastomotic ischemia • Use of drains • Stapled vs. handsewn anastomosis • Laparoscopic vs. open • Number of linear stapler firings • Omentum wrapping • Intraoperative testing of the integrity • Role of proximal diversion
- 30. LAR: “chronicle of an announced severe suture failure” • Questionable vascularization after high tie IMA plus TME ? • Deep and sloping pelvic cavity (fluid accumulation) • Insufficient distensible rectal stump below anastomosis, lessening the strong proximal colonic motility (peristalsis), and a closed distal anal sphincters (distal obstacle) • Perianastomotic semiliquid faeces accumulation • Sensitive peritoneum excision: insidious sepsis, minimal symtoms.. CAA (handmade) is not the same than a stapled “ultra” LAR: A true coloanal anastomosis (ie: <3cms) is not intraperitoneal”
- 31. Colo-rectal anastomosis. RISK FACTORS • Anastomoses height : < 6 cm x6 (95% IC: 2,4-17) • ASA III : x3 (95% IC: 2 – 8,8) • Sex : x2,7 > (95% IC: 1,2-6,7). ULAR: 24% vs.12% • Obesity : x2 (95%IC: 0-2) (33% vs.15%) Routine proximal diverting stoma ? or Selective diversion with aggressive follow-up ? (early diagnosis and low threshold to re-operate)
- 32. RICA. LICA. • iso or anisoperistatic ? IRA
- 33. Double stapled anastomosis “ ear dog” “ cross stapling” “ donoughts”
- 35. Colorectal anastomotic leak • Timing of leaks • Leaks and cancer recurrence • New methods for preventing anastomotic leaks • Management of leaks and the expanding technology
- 36. Colorectal anastomotic leak Timing of leaks: • Detected anywhere from 3 to 45 days postop. • Two peaks: - Clinically the median is 7 days postop. - Radiographically the median is 16 days postop. • 12% are diagnosed >30 days after the operation
- 37. Colorectal anastomotic leak Leaks and cancer recurrence: • Many studies have examined this relationship • Leakage has an independent negative association with overall survival and cancer specific survival • Patients with leaks have: 10-20% less OS, and more local recurrences (1,8 HR; 95%CI, 1,2-2,6) • Several explanations: implant and grow of tumor cells present in the colonic lumen?; decreased inmune function?; even selection bias…
- 38. Colorectal anastomotic leak New methods for preventing anastomotic leaks: • Intraluminal tubes: Coloshield® (permanent); SBS tube® (absorbable) • Buttressing material: Fibrin glue (sealing anastomoses, Tissucol®) Bovin pericardial collagen strips (Veritas®) Bioabsorbable stapleline reinforcement (Gore Seamguard®) • Compression anastomoses CAR™27 (Colo-Ring®)
- 39. Colorectal anastomotic leak Management of leaks and the expanding technology Individualized / patient’s needs* Bowel rest + ivf+ abs; observation; percutaneous drainge; colonic stents; surgical revision or diversion + drains RC Re-anastomosis+ drain LC** Anastomotic take down + ostomies R Extensive drains + Proximal diversion •Endostenting? •Endoscopic vacuum devices?
Notas del editor
- Anastomotic leaks are responsable of the >33% of surgical colorectal mortality Experienced colorectal surgeon often quote 3%-6% as an acceptable overall colonic leakeage Deficition : “leak of luminal contents from from a surgical join between two hollow viscera. Combination of clinical (fever, pain, etc….) radiological and biochemical markers (PCR…) Leakeage are detected anywhere from 3 to 45th days postoperatively; When clinical leaks occur the media postop day od diagnosis is 7 day; when is made raiographically the media is 16th day; a 10-12% od diasnosis are made >30days after the operation. Close follow-up must be carry out during the firts 40 days after the operation
- Impaired general condition, failure of improvement in postop (ie: manteinance of ileus, etc.)
- Clinal conditions of the patients (good, mild/moderate disconfort, or severely impaired. Clinical symtoms ( abdominal or pelvic pain, fever purulent/fecal discharge –drain, wound, vagina and anus- Laboratory test: leukocytosis, C-reactive protein Radiological evaluation (contained and small – local complication as an abscess, or generalized complication.
- Gender: in rectal multivariate analysis showed male patients with anastomosi <5 cm had higher rate of leaks; some studies show that this is so below the peritoneal reflection; Obesity: almost double the rate of LAR (<5cm); Tobacco: related to microvascular disease; Divericular disease: necessity of mobilization of the splenic angle to avoid an area of muscular hypertrophy ; an ASA >3 is the most important factor for dehiscence, spacifically in left side anastomosis; comorbid conditions such as diabetes, hypertension, and cardiac disease can cause impaired circulation at the microcirculation; Steroid use is associated with an increased risk in the only prospective study (odds ratio 8,7; 95% CI, 1,2-45,1), but not in the retrospective studies. Nutrition: low levels of albumin increase the rate of leaks, so is important to asses the nutritional levels perop. (and the weight loss of > 5kg; Radiation: there is inconclusive data from retrospective only studies. Bevacizumab: (inhibition of angiogenesis, and pre-microthromboembolic disease leading to ischemia) It is advaisable to delay operation for three half live of the drug, or 60 days after the treatment.
- Height: More or less than 6-10 cms (ETM vs EsTM): odds ratio 4,5 (1,8-12,7); almost double incidence of leaks in LAR. Obstruction: wall status. Sepsis: patient hemodynamic status. Duration: 220 minutes (4h) vs. 186 min (3h): more difficult operation (multiresection, relaparotomies, etc.) resection and anastomosis: higher risk of dehiscence. Several attemps to quantify colonic perfusion intraop. Laser Doppler studies reveal that a reduction of 30% in tissue perfusion 2cm proximal to the anastomotic site and 50% at the anastomotic site. In left site sigmoid perfusion is worse that descendong. A consideration has also been given to increasing anastomotic blood flow by performing side to end anastomoses. Drains: Role in evacuating fluid collections, lessening the incidence of abscess formation , or early warning maker of dehiscence. There seems not to be justificable indication to place a drain in resections above the sacral promontory. Hand or staple: Provided the three critical factors when performing an anastomosis are kept (adequate blood supply, no tension an inverted anastomosis) there must be no differences. However subclinical leaks were more frequent in handsewn (14%) compared with stapled (5%) in a RCT. Cochrane found no differences in clinical leaks rate in a review. No differences between lap and open. However the number of firings (more that two shots) is important as a factor of dehiscence in low and left side nastomosis in a prospective consecutive serie of patients with multivariable analysis Wrapping an anastomosis with omentum confers no protective effect in mitigating nastomotic leaks (RCT with 705 ptes.). A RCT shows that leaks occurred in 4% of the group test performed (air bublles or Betdine filling) compared with 14% of the no-test group. Test should be done after the completion of anastomosis, and repaired in case of positive test to lessen the rate of leaks. Donoughts should also be inspected. Proximal diversion is known does not prevents leaks but lessens the consequences and sequelae should a clinical leak pccur. Stoma are not without inherent complications of their own (retraction, necrosis, prolapse, stricture, etc) and needs an reoperation more risky than was previously thouhgt.
- High or low (preserving left colonic arterie) tie of the IMA (mainly the concern is about vascularization of the sigma vs. descent colon) Distal rectal distensibility is lacking avoiding to cushion the bowel peristalsis) Perianastomotis faeces accumulation: after mass movement: early diarrhoea is an ominous sign of future dehiscence LAR: Experienced surgeon is needed for detecting a failure suture: inside the pelvis there is not pain sensitive receptors: no pain, delay in clinical diagnosis Differences between ACA and LAR
- The median time to re-operate after diagnosis of an anastomotic leak must be 0 days !!
- The basic principles of adequate blood supply, no tension, and inverted mucosa still apply.
- It is more common to occur in a bimodal distribution (with the second group of patients leaking after they have been discharged from the hospital,) than is ussualy appreciated. Significant clinical indicators of leakeage are: fever (>38º) on day 2, absence of bowel action on day 4, diarrhoea before day 7, >400cc of fluid in abdominal drain on day 3 and leucocytosis on day 7. Fever at 7 days of postop indicate a leak…CT with contrast is superior to contrats enemas, and should be ask for in those situations. Concern with quicker discharges from the hospital, usually within 5 days, leaks will occur outside of a hospital setting. Patients must be educated as to what signs to look for. Close followup must be carry out during the first 40 days after the operation
- Veritas: clinical trial completed; Seamguard: recruiting
- *The categorization of leaks as free or contained may not be justified and argues for early re-operation or proximal derivation, according to a study from MGH. Intrabdominal sepsis seems different from a localized abscess, and are trated initially with percutaneous drainage, however most of them (mainly if a communication between the collection and the gi tract is identified) ultimately required surgical intervention, although they requiere less frequent take down of the anastomosis **: intraperitoneal anastomosis. In R the anastomosis take down means a permanent stoma and disabled anorectal stump with morbility and frequent unhealed perieum