The Management of Anastomotic Leak

John Hartley

Academic Surgical Unit

University of Hull

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

Anastomotic Leak

Anastomoses in Lower Third of Rectum (0-6cm)

Leak rate 5 – 20%

UKUK Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196FranceFrance Ruler, Laurent, Premix: BJS, 1998, 85, 355Ruler, Laurent, Premix: BJS, 1998, 85, 355USAUSA Smith: DCR, 1981, 22, 236 Smith: DCR, 1981, 22, 236

Anastomotic Leak

Leaking Anastomoses in Lower Third of Rectum

MORTALITY Increases by a factor of 20

MORBIDITY Hospital stay:10 days 30 daysPermanent colostomy > 50%

Anastomotic LeakThe 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

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)

Anastomotic Leak

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

Anastomotic Leak

Clinical signs

Depend upon:

• Severity of leak

• Degree of localisation

• Time of leak post op

• Whether the anastomosis is covered

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

Anastomotic Leak

Anticipation

• “Off colour”

• Failure to diurese

• Prolonged ileus

• (diarrhoea)

• Fever

• Failure to meet milestones

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

Anastomotic Leak

Faecal Peritonitis

• Severe abdominal pain

• General tenderness and guarding

• Silent abdomen

• Tachycardia, hypotension

• Oliguria / anuria

• Faecal leakage from drain or wound

Anastomotic Leak

Faecal Peritonitis – diagnosis

• Erect chest X-ray

• Gastrograffin enema

• ?? CT scan

Anastomotic Leak

Faecal peritonitis – management• Confirm diagnosis• Urgent resuscitation

- iv fluids

- CVP monitoring

- Antibiotics

- Urinary catheter• Urgent re-exploration

Anastomotic LeakOptions at re-laparotomy• External Drainage

• Suture DefectSuture Defect with Proximal Diversion

• Proximal DiversionProximal Diversion with Drainage

• Exteriorise Leaking Segment

• Resect Anastomosis with Re-anastomosisResect Anastomosis with end stoma, mucous fistula or Hartmanns

Anastomotic Leak

Laparotomy for faecal peritonitis• Confirm diagnosis• Disconnect anastomosis Proximal stoma

Mucus fistulaClose distal end

• Wash out abdomen?• Drain?• Laparostomy

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

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

Sealed off leak with abscess• Vague localised or general

abdominal pain

• Localised peritoneal signs

• Temperature, tachycardia

• Ileus

• Multi organ failureJaundiceRenal failureARDS

Anastomotic Leak

Sealed off major leak with abscess (ill patient)

S e ttles F is tu la

Im p ro ves

D iv id e A na s to m o s is C o ve ring S to m a & D ra in

L a pa ro to m y

B e com e s W o rse

L e ak

•Drainage•Nutritional support•Antibiotics

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

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

Anastomotic Leak

Enterocutaneous fistula in clinically wellpatient• Delineate fistula CT

Fistulogram• Percutaneous drainage of abscess• Exclude distal obstruction / foreign body• Correct anaemia, malnutrition, electrolytes• Control fistula skin care

suction / bagssomatostatin

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

Anastomotic Failure

Sealed off major leak with abscess• Vague localised or general abdominal pain• Localised peritoneal signs• Temperature, tachycardia• Ileus• Multi organ failure Jaundice

Renal failureARDS

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

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