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%

UK
Karanjia, Corder, Holdsworth, Heald: BJS, 1991, 78, 196
France Ruler, Laurent, Premix: BJS, 1998, 85, 355
USA
Smith: DCR, 1981, 22, 236

Anastomotic Leak
Leaking Anastomoses in Lower Third of Rectum

MORTALITY
MORBIDITY

Increases by a factor of 20
Hospital stay:10 days 30 days
Permanent colostomy > 50%

Anastomotic Leak
The 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
- whos 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 Leak
Options at re-laparotomy
External Drainage

Suture Defect
Suture Defect with Proximal Diversion

Proximal Diversion
Proximal Diversion with Drainage

Exteriorise Leaking Segment

Resect Anastomosis with Re-anastomosis

Resect Anastomosis with end stoma, mucous fistula or Hartmanns

Anastomotic Leak
Laparotomy for faecal peritonitis
Confirm diagnosis
Disconnect anastomosis Proximal stoma
Mucus fistula Close 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 failure
Jaundice
Renal
failure
ARDS

Anastomotic Leak
Sealed off major leak with abscess (ill patient)
Drainage
Nutritional support
Antibiotics

Leak
Im p ro v e s
S e t t le s

B e c o m e s W o rs e
F is t u la

L a p a r o to m y
D i v i d e A n a s t o m o s is

C o v e r i n g S t o m a & D r a in

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 well
patient
Delineate fistula
CT
Fistulogram
Percutaneous drainage of abscess
Exclude distal obstruction / foreign body
Correct anaemia, malnutrition, electrolytes
Control fistula
skin care
suction / bags
somatostatin

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 failure
ARDS

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