Colonic anastomotic leak

JM Enríquez-NavascuésHospital DonostiaUniversidad País Vasco /EHUSan Sebastián. Spain

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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…

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

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)

Colonic anastomotic leak

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)

Risk factors for anastomotic leakage

• Preoperative patient factors

• Preoperative management factors

• Operative factors

• Postoperative factors

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakage

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Preoperative factors:

• Gender• Obesity• Tobacco and alcohol use• Diverticular disease• ASA status• Steroids• Nutrition• Radiation• Bevacizumab• Mechanical bowel preparation

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

Risk factors for anastomotic leakageIntraoperative 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

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”

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)

RICA. LICA.

IRA• iso or anisoperistatic ?

Double stapled anastomosis

“ ear dog”“ cross stapling”“ donoughts”

Colorectal anastomotic leak

• Timing of leaks

• Leaks and cancer recurrence

• New methods for preventing anastomotic leaks

• Management of leaks and the expanding technology

Colorectal anastomotic leak

• 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

Timing of leaks:

Colorectal anastomotic leakLeaks 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…

Colorectal anastomotic leakNew 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 anastomosesCAR™27 (Colo-Ring®)

Colorectal anastomotic leakManagement of leaks and the expanding technology

Bowel rest + ivf+ abs; observation; percutaneous drainge; colonic stents;

surgical revision or diversion + drains

Individualized / patient’s needs*

RC

Re-anastomosis+drain

LC**

Anastomotic take down +ostomies

R

Extensive drains +Proximal diversion

•Endostenting?

•Endoscopic vacuum devices?