Anastomotic leakage in Anastomotic leakage in colorectal cancer colorectal cancer surgery surgery D.Pavalkis, Z.Saladzinskas Kaunas medical university hospital, Lithuania International meeting of coloproctology 22 – 24 April, 2004, Hortobagy, Hungary
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Anastomotic leakage in colorectal cancer surgery D.Pavalkis, Z.Saladzinskas Kaunas medical university hospital, Lithuania International meeting of coloproctology.
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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
Importance of the problemImportance of the problem
Colorectal cancer incidence Increasing numbers of sphincter saving procedures Ageing population Most serious postoperative complications –
anastomotic leakage
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
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
Management of ALManagement of AL
Pelvic abscess Non surgical technics (transanal, US, CT) Defunction with stoma? Elementary diet, TPN? Colorectal surgeon = general surgeon
Management of ALManagement of AL
Peritonitis
Emergency surgery
M.Keighley – take down anastomosis
We should try save low anastomoses
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
QL and time after surgeryQL and time after surgery