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

– Patient related– Surgery (treatment) related

Soeters/de Zoete /Dejong/Williams/Baeten Dig Surg 2002;19;150-155

How to manage AL?How to manage AL?

Stoma Drains US drenage Reoperation time

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

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

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

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

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

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%)

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%)

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)

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

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

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

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

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

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

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)

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

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

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

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

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

Thank you for your attentionThank you for your attention