Management of Anastomotic Leakage of der Lower GI-Tract Professor Dr.med. Dr.h.c. Norbert Runkel...
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Transcript of Management of Anastomotic Leakage of der Lower GI-Tract Professor Dr.med. Dr.h.c. Norbert Runkel...
Management of Anastomotic Leakage of
der Lower GI-Tract
Professor Dr.med. Dr.h.c. Norbert RunkelDepartment of General and Visceral SurgerySchwarzwald-Baar KlinikumTeaching Hospital of the University of Freiburg
Schwarzwald-Baar-Klinikum
Municipal hospital serving 250.000 people Teaching Hospital of University of Freiburg 21 clinical departments 2.700 staff 1.084 beds 41.000 inpatients >80.000 outpatients 200.000.000 € turnover
Center of Excellence/ Certification
Surgical Oncology (Onkologischer Schwerpunkt Schwarzwald-Baar-Heuberg)
Coloproktologie (CACP)Center für Colorectal Cancer (Darmzentrum)Continence-Center Südwest (DKG)Surgical Endoscopie (CAES)Bariatric Surgery CenterMinimal Invasive Surgery Center (Hospitationsklinik
der CAMIC)Wound- and Enterostomy-Center
Department of General and Visceral Surgery
Colorectal Procedures 2007total laparoscopic
Ileocoecalresektion 20 6Hemicolektomie rechts 86 38Transversumresekion 6 -Hemicolektomie links 40 31Sigmaresektion 62 37Segmentresektion 10 1Erweiterte Resektion 10 3Subtotale/totale Colektomie 7 2
Stoma-Anlage 100Stoma-Revision 20Stoma-Rückverlagerung 96
Rektumresektionen 147 93Peranale Excision 19Anteriore Resektion 49 30Tiefe Resektion 69 57Amputation 10 6
total laparoscopic
Ileocoecalresektion 20 6Hemicolektomie rechts 86 38Transversumresekion 6 -Hemicolektomie links 40 31Sigmaresektion 62 37Segmentresektion 10 1Erweiterte Resektion 10 3Subtotale/totale Colektomie 7 2
Stoma-Anlage 100Stoma-Revision 20Stoma-Rückverlagerung 96
Rektumresektionen 147 93Peranale Excision 19Anteriore Resektion 49 30Tiefe Resektion 69 57Amputation 10 6
Colon-Can=116
Mortality 4,3% 5 electiv, 2 emergent
anastomotic leakage: 2re-laparotomy 6wound infection 8
mortality 6,25%anastomotic leakage 11%
conservative 4 xrevision surgery 3 x (1 x enterostomy, 2 x Hartmann)
Rectal Can=64
2006
Sesis-MOF-death 13-66% Rate of intervention 100%
Re-Operation Healing results in scaring/stricture frozen pelvis Increased local tumour recurrences
Management of Leakage
Stomas do not prevent leakagebut
reduce clinical serverity/catastrophy
In high risk patients and situations protect!An ostomy is not a surgical failure!
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
Protective Stoma
Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for
CancerA Randomized Multicenter Trial
Peter Matthiessen, MD, PhD,* Olof Hallböök, MD, PhD,‡ Jörgen Rutegård, MD, PhD,* Göran Simert, MD, PhD,† and Rune Sjödahl, MD, PhD‡
Ann Surg. 2007 August; 246(2): 207–214.
Besonderheiten
1999-2005 intraop. randomisiert 234 PatientenAnastomose < 7 cm
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
Matthiessen et al., Ann Surg. 2007
Protektives Stoma
Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for
CancerA Randomized Multicenter Trial
Peter Matthiessen, MD, PhD,* Olof Hallböök, MD, PhD,‡ Jörgen Rutegård, MD, PhD,* Göran Simert, MD, PhD,† and Rune Sjödahl, MD, PhD‡
Ann Surg. 2007 August; 246(2): 207–214.
Results
Symptomatic Leakage: 10% vs 28%Permanent Stoma 14% vs 17%
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
In all low rectal anastomoses!
Prevention Diagnosis Therapy CasesPrevention
Drainage is not important intraperitoneally
Drainage is essential in extraperitoneal anastomoses
In addition transanal drainage
Drainage
Prevention Diagnosis Therapy CasesPrevention
Fast Tract Rehabilitation
Reduction of averall morbidity from 20% to 7%No reduction of surgical complication rate 17%
leakage rate 3%
Hensel et al. Charite Mitte; Anaesthesist 2006
Fast Tract Surgery
Prevention Diagnosis Therapy CasesPrevention
Peritonealisation of pelvis Peritonealisation of pelvis
Prevented peritonitis after 307 colorectal anastomoses
Eckmann et al., Lübeck Int J Colorectal Dis 2004
Closure of peritoneum
overt: secretion
highly suspicious: peritonitis, septic shock
suspicious: leucocytosis, prolonged paralysis, abdominal
distension and pain
OP!
Diagnosis
Sensitivität 96,7% bei 307 colorectalen AnastomosenEckmann et al., Lübeck Int J Colorectal Dis 2004
Diagnostics: classic and modern
Diagnositics: Ultrasonography
Diagnostics: Endoscopy
Key questions
Is the leakage well drained?
Signs of SEPSIS?
Implication Prevention Therapy CasesTherapy
Management
> conservative therapygrade I = well drained, no sepsis
grade II = well drained but sepsis
defunctioning stoma
grade III = poorly drained and sepsis
Surgical revision, radical clearing of focus
Stages and Concepts
Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
Rectal Anastomosis
endoscopy: ischemia of simple leak
relaparotomy
ileostomy
intraop colon washout
additional drainages
omental flap
Hartmann-resection
transanale Easyflow-Drainagen
without stoma with stoma
Transanal Procedures
washout
debridement
decompression using Easyflow drainages
Endovac
fibrin glue
Therapeutic Algorisms
Endo-Songe
Endo-Songe
dem Patienten erfolgen.Anwendung des Endo-SPONGESystems zur Therapie einergroßen Anastomoseninsuffizienznach tiefer anteriorerRektumresektion mit TMEund J-Pouch AnlageAbb 8: Ausgangssituation zuBeginn der Endo-SPONGE-Therapie:Die Insuffizienz hat eineAusdehnung über 1/3 der Zirkumferenzund ist 20 cm tief mitdem Endoskop einzuspiegeln.Ein Schwammsystem reicht zurTherapie der großen Höhle nichtaus, ein weiteres System wirdanschließend eingelegt.Abb 9: 12 Tage nach Therapiebeginnist die Höhle vollständigvon schmutzigen Fibrinbelägengereinigt und mit sauberemGranulationsgewebe ausgekleidet.Abb 10: Die Höhle kann inzwischenbereits mit nur mehreinem Schwammsystem behandeltwerden.Abb 11: Nach 21 Tagen Therapieist eine deutliche Verkleinerungder Insuffizienzhöhle eingetreten.Die Höhle granuliertaus der Tiefe zu. Das Schwammsystemwird weiter kontinuierlichvon Wechsel zu Wechselverkleinert.Abb 12: Nach 33 Tagen Therapieist nur mehr eine kleineRest-Mulde zu erkennen. DieseMulden heilen in der Regelohne zusätzliche Therapie ab.
Dr. med. Rolf WeidenhagenChirurg Klinikum Großhadern, München
Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Therapeutic Algorisms
Rectal Anastomosis
endoscopy: ischemia of simple leak
relaparotomy
ileostomy
intraop colon washout
additional drainages
omental flap
Hartmann-resection
transanale Easyflow-Drainagen
without stoma with stoma
Transanal Procedures
washout
debridement
decompression using Easyflow drainages
Endovac
fibrin glue
Therapeutic Algorisms
Case I
Bodo H, geb. 1.1.36
12/2005 peranal bleeding
2/2006 Colonoscopy und polypectomy bei 40 und 56 cm
Histology: GII,smII,L1 bei 40 cm
16.3.2006 endoscopic tatooing
17.3.2006 lap. Left colectomy
Bodo H, geb. 1.1.36Bodo H, geb. 1.1.3612/2005 peranaler Blutabgang12/2005 peranaler Blutabgang2/2006 Coloskopie und Polypektomie bei 40 und 56 cm2/2006 Coloskopie und Polypektomie bei 40 und 56 cmHistologie: GII,smII,L1 bei 40 cmHistologie: GII,smII,L1 bei 40 cm16.3.2006 Tuschemarkierung16.3.2006 Tuschemarkierung17.3.2006 lap. Hemicolektomie links17.3.2006 lap. Hemicolektomie links20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP 20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP
13,813,8
20.3. Nahrungskarenz, 20.3. Nahrungskarenz, AntibioseAntibiose21.3. Colon-KE21.3. Colon-KE
20.3. nil by mouth, antibiotics20.3. nil by mouth, antibiotics
23.3. colonoscopic firbin glue23.3. colonoscopic firbin glue
Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
Case II
Gertraud S, 10.2.271/2006 malena, malaise, anemia
medical history: obesity, liver cirrhosis1/2006 colonoscopy: carcinoma at 80cm9.2. left colectomy
postop. pneumonia, SIRS, 4 days ICU19.2. dyspnoe, resp. Insufficiency, abdomen not
distended20.2. ICU, Sepsis, MOF
20.2. CTOperation: direct drainage of abscessResult stool fistula
Case II
Gertraud S, 10.2.271/2006 malena, malaise, anemia
medical history: obesity, liver cirrhosis1/2006 colonoscopy: carcinoma at 80cm9.2. left colectomy
postop. pneumonia, SIRS, 4 days ICU19.2. dyspnoe, resp. Insufficiency, abdomen not
distended20.2. ICU, Sepsis, MOF
20.2. CT
20.2. Operation22.2. Stool fistula
Case II
20.3. CT demission late April20.3. CT demission late April
Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
Case III
Horst F., 26.11.26Medical history: alcoholism, Korsakow, obesity, sigmoid
double cancer with liver metastasis
25.4.2005 emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy
29.4. aspiration, subileus; 2 days ICU6.5. relaparotomie for 4-quadrant peritonitis due to
leakage from cecum
Case III
Horst F., 26.11.26Medical history: alcoholism, Korsakow, obesity, sigmoid
double cancer with liver metastasis
25.4.2005 emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy
29.4. aspiration, subileus; 2 days ICU6.5. relaparotomie for 4-quadrant peritonitis due to
leakage from cecum: closure and ileostomy, ICU 13.5. death in MOF
Case IV
Gisela F., 20.2.459/2005 DVT9/2005 Colonoscopy: cacer at right flexure
CT: liver metastases
Case IV
Gisela F., 20.2.45
4.10. right colectomy and liver biopsy
postop fever with pneumonia; ICV 6 days
20.10. L 15600. CRP 27; abdomen soft
20.10. CT
20.10. Re-laparotomy, drainage and ileostomy
No sepsis, ICU 6 days
Fallbeispiel IV
1.11 CT (postop day 11)
Result: local sepsis and enterocutaneous fistula
Case IV
Fallbeispiel IVGisela F., 20.2.45
4.10. right colectomy and liver biopsy
20.10. Re-laparotomy, drainage and ileostomy
29.11. Re-laparotomy for short bowel syndrom, intraabdominal abszess and fistulation:
Debridenemnt, drainage, resction of anastomosis and ileostoma-take down
6.12 Re-laparotomy for enterocutaneous fistula and wound dehiscence: anastomotic stoma
16.12 transferal to surgical ward
3.1. demission
1.3. take down of stoma, i.v.-port for chemotherapy
Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
Aachener AlgorithmusAachener Algorithmus
RisikofaktorenPatient
Patientenalter, GeschlechtPatientenalter, GeschlechtBegleiterkrankungen: DM, Begleiterkrankungen: DM,
Tumorerkrankung, CED, DialyseTumorerkrankung, CED, DialyseLifestile: Adipositas, Nikotin, AlkoholLifestile: Adipositas, Nikotin, Alkohol
Adipositas, Nikotin, Alkohol Nickelsen et al., Glostrup, Dänemark; Acta Oncol 2005
RisikofaktorenRisikofaktorennicht-chirurgischnicht-chirurgisch
Neoadjuvante TherapieNeoadjuvante Therapie
N=246 TME, konv. Radiochemotherapie, retrospektiv93 (28 mit vs 65 ohne RXT) Anastomose < 6 cmInsuffizienz 18% vs 6%RXT einziger unabhängiger Faktor in multivariater Analyse Buie et al., Calgary, Dis Colon Rectum 2005
n=924 TME, Kurz-Radiotherapie, randomisiert-retrospektivsymptomatische Insuffizienz 11,6%Peeters et al Dutch Coloretal Cancer GroupBr J Surg 2205
Diskonnektions-OpDiskonnektions-Op
HartmannHartmannStoma und SchleimfistelStoma und SchleimfistelDoppelläufiges Anastomosenstoma Doppelläufiges Anastomosenstoma
(Mikulicz-Stoma)(Mikulicz-Stoma)
Therapeutischer AlgorithmusTherapeutischer Algorithmus
intraabdominelle Anastomose
spät > 5 Tage
konservativ
Abwarten, Tee, Astronautenkostggf. interventionelle DrainageSomatostatinAntibioseendoskopische Fibrinklebung
Therapeutischer AlgorithmusTherapeutischer Algorithmusintraabdominelle Anastomose
früh < 5 Tage spät > 5 Tage
Peritonitis/Sepsis
Re-Laparotomie
Peritonitis-Therapie (Fokussanierung)allg. Sepsis-Therapie
Guter Zustand:Resektion, Neuanlage, Stoma
schlechter ZustandDiskonnektion