1. The Management of Anastomotic Leak John Hartley Academic Surgical Unit University of Hull

2. 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

3. Anastomotic Leak Anastomoses in Lower Third of Rectum (0-6cm) Leak rate 5 – 20% UKKaranjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196 FranceRuler, Laurent, Premix: BJS, 1998, 85, 355 USASmith: DCR, 1981, 22, 236

4. Anastomotic Leak Leaking Anastomoses in Lower Third of Rectum MORTALITYIncreases by a factor of 20 MORBIDITYHospital stay:10 days 30 days Permanent colostomy > 50%

5. 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

6. 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)

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

8. Anastomotic Leak Clinical signs Depend upon: Severity of leak Degree of localisation Time of leak post op Whether the anastomosis is covered

9. 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

10. Anastomotic Leak Anticipation “Off colour” Failure to diurese Prolonged ileus (diarrhoea) Fever Failure to meet milestones

11. 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

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

13. Anastomotic Leak Faecal Peritonitis – diagnosis Erect chest X-ray Gastrograffin enema ?? CT scan

14. Anastomotic Leak Faecal peritonitis – management Confirm diagnosis Urgent resuscitation - iv fluids - CVP monitoring - Antibiotics - Urinary catheter Urgent re-exploration

15. 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

16. Anastomotic Leak Laparotomy for faecal peritonitis Confirm diagnosis Disconnect anastomosisProximal stoma Mucus fistula Close distal end Wash out abdomen? Drain? Laparostomy

17. 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

18. 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

19. Sealed off leak with abscess Vague localised or general abdominal pain Localised peritoneal signs Temperature, tachycardia Ileus Multi organ failure Jaundice Renal failure ARDS

20. Anastomotic Leak Sealed off major leak with abscess (ill patient) Drainage Nutritional support Antibiotics

21. 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

22. 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

23. Anastomotic Leak Enterocutaneous fistula in clinically well patient Delineate fistulaCT Fistulogram Percutaneous drainage of abscess Exclude distal obstruction / foreign body Correct anaemia, malnutrition, electrolytes Control fistulaskin care suction / bags somatostatin

24. 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

26. Anastomotic Failure Sealed off major leak with abscess Vague localised or general abdominal pain Localised peritoneal signs Temperature, tachycardia Ileus Multi organ failureJaundice Renal failure ARDS

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

28. 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