Disclosure of Affiliations Anastomotic Leak: Management and - PowerPoint PPT Presentation

Disclosure of Affiliations Anastomotic Leak: Management and Prevention • None Thomas E. Read, MD, FACS, FASCRS Professor of Surgery Tufts University School of Medicine Staff Surgeon and Program Director Department of Colon and Rectal Surgery Lahey Clinic Medical Center Burlington, MA, USA Anastomotic Leak Prevention Treatment • Traditional • Non-traditional Ultimate Fate of the Leaking Anastomosis Early Detection 1

Sweet case Sweet case 48 year old woman 48 year old woman • Bulky sigmoid cancer • Bulky sigmoid cancer • Mid rectal cancer in polyp s/p polypectomy + margin • Mid rectal cancer in polyp s/p polypectomy + margin • Body Mass Index = 49 • BMI 49 “I don’t want a • Plan: Low anterior resection poopy bag” • Plan: Low anterior resection OR: Low Anterior Resection Should you construct an anastomosis? Mobilization splenic flexure Margins of resection • Distal descending colon • Mid-Distal Rectum (1 st valve) 2

Not sleeping at night Leaks are Bad Mortality Day of operation Morbidity • Is she bleeding? Re-operation Permanent stoma The next 3 weeks Poor oncologic outcomes • Is she leaking? • increased local recurrence, decreased cancer specific survival and decreased overall survival Implications for the surgeon • Poor technique • Poor judgment Risk Factors 3

Variables Associated with Anastomotic Leak Variables Associated with Anastomotic Leak Problems with the Data • Retrospective Patient factors Intraoperative factors • Selection bias • ASA score • Low rectal anastomosis • Use of diverting stomas • Charlson Comorbidity Index • Adverse events • Underpowered • Poor nutrition Surgeon factors • Multivariate analysis • Smoking • Rule of 10s • Obesity • Surgeon • Lack of standard definition of leak • Steroids • Male sex (pelvic anastomosis) Radiotherapy • Vascular Disease Definition of “Anastomotic Leak” Definition of “Anastomotic Leak” 4

Left colon mobilization Variables Associated with Anastomotic Leak Problems with the Data • Failure to account for other important variables • Tension • Blood supply • Surgeon as variable IMV IMA Anastomotic technique Reinforcing stapled colorectal anastomosis with suture How do you perform colorectal anastomosis? A. Stapled B. Stapled, buttressed C. Hand sewn Madbouly et al. DCR 2010 D. Compression device Courtesy Niti, Inc. 5

Anastomotic internal reinforcement Anastomotic external reinforcement Fibrin - Thrombin Omentoplasty Omentoplasty Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research. Ann Surg. 1998 Feb;227(2):179-86. • No difference in leak rates Omentoplasty in the prevention of anastomotic leakage after colorectal resection: a meta-analysis. Int J Colorectal Dis. 2008 Dec;23(12):1159-65. Hao XY, Yang KH, Guo TK, Ma B, Tian JH, Li HL. • Reduced clinical anastomotic leakage (RR 0.36, 95% CI 0.16 to 0.78) • No difference in: • radiological anastomotic leakage (RR 0.76, 95% CI 0.41 to 1.40) • death (RR 1.01, 95% CI 0.55 to 1.86) • repeat operation (RR 0.60, 95% CI 0.35 to 1.05) 6

Making a Better Anastomosis? Making a Better Anastomosis? Compression devices Internal covering • Coloshield • C-Seal Val-Trac, c. 1992 Murphy button, c. 1892 Nitinol Low anterior resection What is the next step after performing low colorectal anastomosis? A. Loop ileostomy B. Leak test with air or CO2 Courtesy Niti, Inc. C. Leak test with fluid (Betadine, etc.) D. Close the abdomen 7

Air Leak Test Courtesy Sang Lee, MD and Jeffrey Milsom, MD Carbon dioxide video endoscopy Prospective Database • 998 left sided anastomoses without proximal diversion 8

Clinical Leak vs. Intraoperative Air Leak Testing Clinical Leak vs. Intraoperative Air Leak Testing Circular stapled anastomoses All Anastomoses 40.00% p=0.03 15.00% Clinical Leak 30.00% p=0.04 12.00% Clinical Leak 20.00% 9.00% 21% 6.00% 10.00% 8% 8% 3.00% 5% 0.00% 4% 4% 0.00% Airtight Airleak Untested Airtight Airleak Untested Back to our patient… CO2 flexible sigmoidoscopy Visual inspection of anastomosis State of Washington Leak test with gas insufflation Surgical Care and Outcomes Assessment Program Everything is perfect Left-sided anastomoses Hospitals performing routine anastomotic leak testing (>90% of cases) had fewer anastomotic leaks odds ratio 0.23 (95% CI 0.05-0.99) 9

Low anterior resection What is the next step after performing colorectal anastomosis and negative air leak testing? A. Loop ileostomy B. Loop colostomy C. Fibrin glue around anastomosis D. Close the abdomen Sweet case Sweet case…now with a fever Postoperative course What do you do next? • She does great for 5 days… A. Urinalysis, CBC, CRP, Blood cultures, Chest radiograph • Saturday evening she has fever, dysuria, tachycardia B. Water soluble contrast enema • Minimal abdominal pain and tenderness C. CT D. Laparotomy 10

CT CT CT Anastomotic Leak Prevention Treatment • Traditional • Non-traditional Ultimate Fate of the Leaking Anastomosis Early Detection 11

OR Sweet case…now with a fever and a CT What do you do next? Laparotomy • Intraperitoneal contents appear normal A. Antibiotics • Murky fluid in pelvis posterior to neorectum B. Percutaneous drain C. Laparotomy • Flexible sigmoidoscopy: anastomosis normal; air leak D. Laparoscopy test negative Murky fluid in pelvis posterior to neorectum Flexible sigmoidoscopy: anastomosis normal; air leak test negative What do you do next? A. Close the abdomen B. Pelvic drain C. Proximal fecal diversion + drain D. Hartmann resection Read TE, Kodner IJ. Arch Surg . 1999 Jun;134(6):670-7. 12

Anastomotic Leak Fixing a blown sewer pipe Prevention Treatment • Traditional • Non-traditional Ultimate Fate of the Leaking Anastomosis Early Detection Management of colonic perforation Endoscopic Clips: Bear Claw Endoscopic clips Bear Trap Bear Claw endoscopic clip 13

Endoscopic Clips: Bear Claw Transanal Endoscopic Microsurgery Management of anastomotic leak Video Probe in fistula Anastomotic fistula Clip deployed Endoscopic management of leak Vacuum sponge in leak cavity 17 patients with leak from rectum or rectosigmoid without sepsis Stent Endoscopic lavage of cavity Endoscopic placement of vac sponge into leak cavity 16 did OK Surgery 2008 Mean 5 sponge changes Mean time to healing 53 days Prospective, randomized, pigs 2cm colorectal anastomotic defect Stented group did great Non-stented group: abscesses, fistulae 14

Vacuum sponge in leak cavity Vacuum sponge in leak cavity Novel Treatment of Leak Anastomotic Leak Prevention Problems with the data • Selection bias Treatment • Small numbers • Traditional • Underpowered • Non-traditional Ultimate Fate of the Leaking Anastomosis Early Detection 15

What happens after a leak? What happens after a leak? Prospective database 2001-2007 2627 intestinal operations • 88 clinical leaks (3.3%) in 79 patients • 10% mortality What happens after a leak? What happens after a leak? Management Outcome Mean follow up 32 +/- 26 months 16

Anastomotic Leak Early Detection Drain sampling Prevention • Bacteria • Inflammatory cytokines Treatment • IL-6, IL-10, TNF • Traditional • Non-traditional Ultimate Fate of the Leaking Anastomosis Early Detection C-Reactive Protein C-Reactive Protein Odds Ratios for infectious complications Cutoff: 190 POD 4 Cutoff: 135 17

Anastomotic Leak Optimal Management = Prevention • Good blood supply • No tension • Technically optimal • Good judgment If leak occurs, survival depends on: • Prompt recognition • Tailored treatment 18