Anastomotic Leaks John M Roberts

Anastamotic Leaks Affect 2-10% of GI surgery “inevitable complications” Serious 20-30% morbidity 7-12% mortality

Diagnosis Clinically Average 7.5 days postoperatively (3-45 days) 42% occur after discharge Pain, peritonitis, fever, tachycardia Contrast imaging

Treatment Depends on severity of leak Options Observation, bowel rest Drainage Reexploration, repair, possible diversion

Contributing Factors Tension at anastamosis Vascular supply Distal obstruction

Contributing Factors? Comorbidities Nutrition IBD Intraop blood loss Bowel Prep Omental butress Suture vs Staple Chemotherapeutic agents Fancy new strategies

Comorbidities Diabetes Steroid Use CAD Inflammatory bowel disease ASA score

Comorbidities Prospective case controlled study 90 pts over 5 years (02-07), Mt Sinai Pts undergoing colorectal surgery for a variety of indications 180 case/surgeon controls

Comorbidities Does not contribute DiseaseControlALP value DM11.99 Steroids* CAD Crohns

Comorbidites However, separate multivariate analysis 1400 colon resections ASA 3-5 and emergent surgery only 2 statistically significant RF ASA class is a gestalt of comorbidity

Nutritional Status Measured by Albumin

Nutritional Status YES Preop albumin levels of <3.5 have an odds ratio of 2.5 for leak ControlALPvalue Albumin

IBD Crohns Ulcerative colitis

IBD No However, if margins involved disease by pathology, YES OR 2.7 ControlALPvalue Margins with IBD involvement 21%43%.02

Intraoperative variables Blood loss Transfusion requirements Operative time

Intraoperative variables Yes to all! ControlALPvalue OR time157 min204 min<.001 Blood loss150 cc290 cc<.001 Transfusions11%22%.03

Intraoperative variables Increasing risk OR > 200 mins: OR 3.4 Blood loss >200 cc: OR 3.1 Intraoperative transfusion: OR 2.3 All 3: OR % PPV for AL None of the three: OR 0.28

Study drawbacks Wide variety of procedures and surgeons Did not asess severity of leak

Bowel Prep

No Vanderbuilt Childrens Hospital, pts underwent distal small bowel procedures: 33 no prep, 110 controls 1/33 leak vs 2/110. p= 0.58

Omentoplasty The omentum can be tacked around the anastamosis to provide mechanical support

Omentoplasty No! French group, Mehrad Prospective randomized trial 705 patients No difference in leak or severity Leak rate 4.7% in omentoplasy vs 5.2% Rates of mortality, reoperation for leak (6 each group) equal

Suture vs Staples

NO Review article 652 randomized patients No difference in clinically significant leak (4.4% both groups) However, radiographical leak in 14% of handsewn anastamosis vs 5% in stapled: significance unkown

Chemotherapeutic Agents

YES Bevacizumab Vascular endothelial growth factor inhibitor Arterial microemboli Wound healing complications up to 56 days after treatment

Areas of Controversy Radiation: data both ways Drains: general consensus is that they are not needed in intraperitoneal anastamosis Testing anastamosis: One prospective randomized study (colon, 145 pts): 4% leak rate in group where testing performed vs 14% when not performed

Not enough time to discuss End to side anastamosis: doppler studies suggest better blood flow Laprascopic vs open: 52 articles reviewed by chapman, no difference

Fancy New Stuff Regenerated oxidized cellulose reinforcement (Surgicel) Low ant rsx (high leak rates 10-15%): 108 pts randomized prospectively: Alexandria, Egypt Leak in 6/38 with no surgicel. 3 with peritonitis 2/33 with surgicel. No peritonitis.

Fancy New Stuff Bioglue (Bovine albumin + glutaraldehyde) Animal study at Weill Medical college, NY Stapled gastrojejunostomies performed on explanted, ex-vivo pig tripe Burst pressures recorded Increased from 27 mmHg to 59 mmHg Small defect introduced Increased from 1.2 mmHg to 42 mmHg (criticism: average time to leak 7 days)

Review Tension at anastamosis Vascular supply Distal obstruction Nutritional status OR time Intraoperative blood loss Active crohns Bevacizumab

Review Tension at anastamosis Vascular supply Distal obstruction Nutritional status OR time Intraoperative blood loss Active crohns Bevacizumab

Diversion Some controversy over standardized diversion Diversion does not prevent leaks, but lessens terrible sequela Diversion is not without risks: necrosis, retraction, prolapse, hernia, and disuse stricture of a distal anastomosis

Practical guidelines Avoid OR on patients with albumin <3.5 If a patient has long OR time, with significant blood loss, and needs a transfusion, consider diversion. Check to make sure mucosa is pink