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Incidence of LeakageIncidence of Leakage
Fielding 1980Fielding 1980
Multi-centre prospective audit of 1466 Multi-centre prospective audit of 1466 colorectal anastomosescolorectal anastomoses
Other colonic anastomosesOther colonic anastomoses 3.7%3.7% 2.6%2.6%
OverallOverall 4.9%4.9% 3.4%3.4%
Trent/Wales and Wessex Audits
Incidence of LeakageIncidence of Leakage
ACPGBI Guidelines: 2001ACPGBI Guidelines: 2001
““Surgeons should carefully audit their leak Surgeons should carefully audit their leak rates for colorectal surgery and should expect rates for colorectal surgery and should expect
to achieve an overall leak rate of below 8% to achieve an overall leak rate of below 8% for anterior resection and 4% for other colonic for anterior resection and 4% for other colonic
anastomoses.”anastomoses.”
Incidence of LeakageIncidence of Leakage
Why has the incidence of leakage gone down?Why has the incidence of leakage gone down?
1.1. Widespread use of stapling guns.Widespread use of stapling guns.2.2. Increased sub-specialisation.Increased sub-specialisation.3.3. ?Better patient selection.?Better patient selection.4.4. Widespread use of auditWidespread use of audit
Cause of LeaksCause of Leaks
TechnicalTechnical -- ConstructionConstruction
-- VascularityVascularity
Failure to HealFailure to Heal -- HypoxiaHypoxia
-- Hypo-perfusionHypo-perfusion
-- Co-morbidityCo-morbidity
Vascularity of Left Colonic PedicleVascularity of Left Colonic Pedicle
JD Griffiths: Arris & Gale lecture 1956JD Griffiths: Arris & Gale lecture 1956
““A truly critical point exists at the A truly critical point exists at the splenic flexure where the marginal splenic flexure where the marginal artery is often small --- the terminal artery is often small --- the terminal
branches of the left colonic artery form branches of the left colonic artery form a secondary marginal artery at this a secondary marginal artery at this
Ischaemic heart diseaseIschaemic heart disease Acute and chronic respiratory diseaseAcute and chronic respiratory disease DiabetesDiabetes Old ageOld age Co-existing sepsisCo-existing sepsis Previous radiotherapyPrevious radiotherapy Smoking.Smoking.
What do I doWhat do I do??
Anastomotic LevelsAnastomotic Levels
High High
LowLow
Ultra lowUltra low
What do I doWhat do I do??
OptionsOptions
Anastomosis aloneAnastomosis alone Anastomosis with proximal stomaAnastomosis with proximal stoma End colostomy with closed rectal stump End colostomy with closed rectal stump
(Hartmann’s procedure)(Hartmann’s procedure) End colostomy with full ano-rectal excisionEnd colostomy with full ano-rectal excision
What does a proximal stoma achieveWhat does a proximal stoma achieve??
It doesIt does: - reduce the number of clinical leaks.: - reduce the number of clinical leaks. - reduce the need for further surgery in the - reduce the need for further surgery in the
event of a leak.event of a leak.
It does notIt does not: - prevent breakdown of a poorly: - prevent breakdown of a poorly constructed or poorly perfused anastomosis.constructed or poorly perfused anastomosis.
- provide a guarantee against major - provide a guarantee against major sepsis.sepsis.
Complications of IleostomyComplications of IleostomyFormation and ClosureFormation and Closure
Complications of StomaComplications of Stoma Complications of ClosureComplications of Closure