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Anastomotic leakage in colorectal Anastomotic leakage in colorectal cancer surgerycancer surgery
D.Pavalkis, Z.Saladzinskas
Kaunas medical university hospital,
LithuaniaInternational meeting of coloproctology
22 – 24 April, 2004, Hortobagy, Hungary
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Importance of the problemImportance of the problem
Colorectal cancer incidence Increasing numbers of sphincter saving procedures Ageing population Most serious postoperative complications –
anastomotic leakage
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Importance of the problemImportance of the problem
• Anastomotic leakage occurs in 5 - 15% after colorectal surgery
• Leads to substantial morbidity and mortality• Many factors determine AL
– Patient related– Surgery (treatment) related
Soeters/de Zoete /Dejong/Williams/Baeten Dig Surg 2002;19;150-155
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How to manage AL?How to manage AL?
Stoma Drains US drenage Reoperation time
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In what we end with AL?In what we end with AL?
In hospital mortality Local recurrence rate 5 years survival Functional outcome and quality of life
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Causes of ALCauses of AL Bowel preparation Surgical techniques Insufficient blood supply
at the anastomosis Tension on anastomosis Tension on mesentery Protective stoma Presents of inflammation And many other
Elderly Anemia Malnutrition Smoking Obesity Therapeutic diseases
– Cardiovascular– Steroids
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Risk factors for ALRisk factors for AL
Multivariate analysis Male sex increased risk of AL 13 fold in LAR or
PCA Lower than 10 cm anastomoses (3,5 fold increase
compare with higher than 10 cm) ASA group 4 (2,5 fold increase risk of AL to
compare with ASA 1-3
D.Pavalkis, Medicina, 2001, 39:421-425
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Risk factors for ALRisk factors for AL
Multivariate analysis showed that male sex and level of anastomosis were independant risk factors for AL
6,5 times higher for anastomoses less 5 cm 2,7 times higher for man For low anastomoses (5 cm) obesity came as
independant facot for ALRullier E. & all, Brit J Surg, 1998, 85, 355-358
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Obesity and ALObesity and AL
584 elective colorectal surgery for cancer 158 (27%) were obese (BMI>27) Hemicolectomies – no difference AR resulted in AL in 16% of obese and 6% of
nonobese patients (p<0,05) For obese patients in AR group diabetes mellitus
and ASA status were significant risk factors for AL
St.Benoist & all, Am J Surg, 2000, 179, 275-281
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Age and ALAge and AL Prospective multicentric study, 75 German
hospitals, 3756 patients <65; 65-79; >80 Left sided cancers 76.2%, 76.7%, 54.8% AL requiring surgery 4.2%, 3.1%, 1.5% (p>0.05) AL not requiring surgery 1.5%, 2.3%, 1.2%
(p>0.05)
F.Marusch at all, Int J Colorectal Dis, 2002, 17:177-184
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Age and ALAge and AL
Colorectal cancer132 patients >75 and 464 <754 from 132 ( 3.03%) >7518 from 464 (3.87 %) <75
D.Pavalkis, Medicina, 2001, 39:421-425
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Bowel preparationBowel preparation
Mortality and morbidity MBP (n-61) No MBP (n-75)
FET (P<0,05)
Mortality 2(3,2%) 0 NS
Wound infection 4(6,6%) 10(13,3%) NS
Wound dehiscence 2(3,3%) 4(5,3%) NS
Abdominal/pelvic collection
3(4,9%) 2(2,7%) NS
Anastomotic breakdown 5/48(10%) 2/52(3,8%) NS
Memon MA & all Int J Colorectal Dis 1997;12;298-302
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Bowel preparationBowel preparation
• Controversial– Efficient MBP – prerequisite to reduce anastomotic and
septic complicationsHares MM, Alexander-Williams J World J Surg 1982;6;175-181
Ashley SW in Current surgical therapy, 5th edn, Mosby 1985; 210-212
– No beneffit in elective surgeryMietttinen P, et al Digestion 1998;59 suppl;48
– Significant greater incidence of AL in prepared patients versus no preparation 8.1% v.s. 4%
Platell C, Hall J Dis Colon Rectum 1998;41;875-883
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Bowel preparationBowel preparation
Prospective, consecutive 250 patients WITHOUT bowel preparation
Anastomoses were ileocolic in 32%, colocolic in 20,8%, colorectal intraperitoneal 34.4%, extraperit. 12,8%
AL –1,2% - all in extraperitoneal anastomosisvan Geldere D & all, J Am Coll Surg, 2002, 194:40-47
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Anesthesia and ALAnesthesia and AL
Medline search and reviewing literature on
randomized trials
12 trials, 562 pts, 266 epidural resulting in 6%
AL compared with 3,4% receiving opioid based
analgesia (p<0,05)
K.Holte, H.Kehlet, Reg Anesth Pain Med 2001;26:111-117
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Anesthesia and ALAnesthesia and AL
KMUH 100 patients randomized to epidural or
opioid postoperative analgesia
Resectional colorectal surgery for cancer
Postoperative pain management with petidine I/m,
compare with bupivacaine and fentanyl epidurally
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Surgical complications (KMUH data)Surgical complications (KMUH data)
Complication Pethidine gr EA gr.
Wound infection 3 (6%) 5 (10%)
Intraabdominal abscess 1 (2%) 3 (6%)
Anastomotic leakage -3 (6%)
Total: 4 (8%) 11 (22%)
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Other complications (KMUH data)Other complications (KMUH data)
Complication Pethidine EA gr.
Chest infection 2 (4%) 1 (2%)
Cardiac arrhythmias 2 (4%) -
Pulmonary embolism 1 (2%)† -
Acute renal failure - 1 (2%)
Urinary infection - 1 (2%)
Total: 5 (10%) 3 (6%)
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Hand-sewn or stapled?Hand-sewn or stapled?
Supraperitoneal anastomoses 74 hand-sewn and 85 circular stapled.
AL in 4 and 6 patients respectively Mishaps (10 cases) and hemorrhage (5 cases)
occurred in stapled group only Stapled took 8 minutes less to perform Concluded, that there no advantage in stapling in
supraperitoneal anastomosesA.Fingerhut &all, Surgery , 1995, 3: 479-485 (French Association for surgical research)
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Anastomosis techniquesAnastomosis techniques
No issue of whether anastomosis is performed – with one or two layers– Interrupted or continuous sutures– Stapling, biofragmentable ring
Gordon P, Nivatvongs S 1999
Alves A, Panis Y, Trancart D, Regimbeu JM, et al World J Surg 2002;26;499-502
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Anastomosis methodsAnastomosis methods
KMUH Hand sewn,
2 layers
Hand sewn,
1 layer
Stapled
1995-1996 45 4 21
1997-1998 46 31 32
1999-2000 40 63 64
Total 131 98 117
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Anastomosis method and ALAnastomosis method and AL
21 Park’s coloanal anastomosis - 5 (23,8%) 78 LAR - 8 (10,3%) 67 AR - 2 (3%) 103 sigmoid resections - 5 (4,9%)
D.Pavalkis, Medicina, 2001, 39:421-425
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Intraoperative anastomotic testingIntraoperative anastomotic testing
18.1% of patients after rectal resection
demonstrated intraluminal bleeding or leakageO.Schmidt, S.Merkel, W.Hohenberger, Eur J Surg Oncol, 2003, 29:239-243
20,6% leaked on testing, after repair – 3% leaked
on second testingJMD Wheeler, JM Gilbert, Ann Royal Coll Surg Engl, 1999, 51:105-108
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Protective stomaProtective stoma
Consecutive 200 patients with TME 125 defunctioned, 75 – not Reoperation in 8% without stoma, 1% reoperation
– with protective stoma Suggested, that all anastomoses at 6 cm or less
from anal verge should be protected
N.D.Karanjia & all, Br.J.Surg. 1991; 78:196-198
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Colostomy or ileostomy?Colostomy or ileostomy?
Randomized, 42 patients protected with loop ileostomy and 38 – with loop transverse colostomy
Postoperative intestinal obstruction from creation to closure 6 pts with ileostomy, 1 with colotomy
Transverse colostomy was recommended
W.L.Law,K.W. Chu, H.K.Choi, Br.J.Surg.2002, 89, 704-708
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Colostomy or ileostomy?Colostomy or ileostomy?
Comparison was made regarding the difficulty of stoma formation and closure, recovery after stoma closure and stoma-related complications
No difference in in the difficulty of formation or closure
Colostomy resulted in 1 faecal fistula, 2 stoma prolaps, 2 parastomal hernia and 5 incisional hernia in stoma site
Both methods provide satisfactory protection, but Ileostomy is preferable
D.P.Edwards & all, Br.J.Surg., 2001,88,360-363 (Basingstoke)
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Principles of good colorectal Principles of good colorectal anastomosisanastomosis
Good exposure Adequate blood supply Prevention of local contamination Sutures or staples placed properly No tension (release splenic flexure) Prevent distal obstruction Good bowel preparation
M.R.B. Keigley, N.S.Williams, 1993
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Suspition of leakSuspition of leak
• Wounds draining sero-sanguinolent fluid or pus• Adynamic ileus• Pain• Malaise• No stool passage• Fever and leucocytosis• Cardiorespiratory complications in the first 7-10 d
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Suspition of ALSuspition of AL
655 patients; 39 AL (6%) Fever>38 degrees C on day 2 Absence of bowel action on day 4 Diarrhea before day 7 Collection more than 400 ml fluids 0-3 day Renal failure on day 3 Leukocytosis after day 7
Alves A & all, J AM Coll Surg, 1999, 189:554-9
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SuspitionSuspition of AL
Combination of signs observed before day 5
– If 2 – leakage 18%
– If 3 – leakage 67%
Reoperated after day 5 (5 of 23 patients) death 22% versus 0% reoperated before day 5 (0 of 11 patients)
Alves A & all, J AM Coll Surg, 1999, 189:554-9
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Management of ALManagement of AL
Pelvic abscess Non surgical technics (transanal, US, CT) Defunction with stoma? Elementary diet, TPN? Colorectal surgeon = general surgeon
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Management of ALManagement of AL
Peritonitis
Emergency surgery
M.Keighley – take down anastomosis
We should try save low anastomoses
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AL and functional outcomeAL and functional outcome
Comparison 19 pts with AL with 19 pts without 30 months postoperatively No differences in anal pressures Difference in neorectal volume with associated
urge incontinence Frequency of bowel movements
O. Hallbook, R.Sjodahl, Brit J Surg, 1996; 83:60-62
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QL and time after surgeryQL and time after surgery
Data from studies exists showing that QL changes
with time after operation and tends to come to
baseline after 6 moths after surgery
M.Koller, Langenback’s Arch Surg. 1998, 383:427-436
J.Camilleri-Brennan, British Journal Surgery, 2001, 88,1517-1622
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Influence of AL on QLInfluence of AL on QL
Anastomotic leakage in this patient resulted in very low global QL
Specific deficits included physical functioning, pain and fatigue
M.Koller and W.Lorentz, Langenbek’s Arch Surg, 1998, 383:427-436
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AL and local reccurenceAL and local reccurence
814 currative AR with 89 (10,9%) AL Local reccurences – 13,6% AL group – 22% reccurences, withouth AL –
12,5% (p<0,05) Multivariate analysis – AL independent factor for
local reccurence 5 years survival in AL group 69,6%, withouth –
77,8% (p<0,0035)S.Merkel & all, Colorectal Disease, 2001, 3, 154-160
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ConclusionsConclusions
AL remains most important postoperative
complication after sphincter saving surgery
Surgeons should know risk factors for AL
Less risky operations with defunctioning
ileostomy are preferable in high risk for AL
patients group
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Thank you for your attentionThank you for your attention