Incidence of Leakage Fielding 1980 Multi-centre prospective audit of 1466 colorectal anastomoses Leak Rate Intraperitoneal 10.8% Pelvic18.7% Overall 13%

Incidence of Leakage Trent / WalesWessex Anterior resection 7.4%6.9% Other colonic anastomoses 3.7%2.6% Overall4.9%3.4% Trent/Wales and Wessex Audits

Incidence of Leakage ACPGBI Guidelines: 2001 “Surgeons should carefully audit their leak rates for colorectal surgery and should expect to achieve an overall leak rate of below 8% for anterior resection and 4% for other colonic anastomoses.”

Incidence of Leakage Why has the incidence of leakage gone down? 1. Widespread use of stapling guns. 2. Increased sub-specialisation. 3. ?Better patient selection. 4. Widespread use of audit

Cause of Leaks Technical-Construction -Vascularity Failure to Heal-Hypoxia -Hypo-perfusion -Co-morbidity

Vascularity of Left Colonic Pedicle JD Griffiths: Arris & Gale lecture 1956 “A truly critical point exists at the splenic flexure where the marginal artery is often small --- the terminal branches of the left colonic artery form a secondary marginal artery at this point.”

Co-morbidity & Anastomotic Leak  Ischaemic heart disease  Acute and chronic respiratory disease  Diabetes  Old age  Co-existing sepsis  Previous radiotherapy  Smoking.

What do I do? Anastomotic Levels HighLow Ultra low

What do I do? Options  Anastomosis alone  Anastomosis with proximal stoma  End colostomy with closed rectal stump (Hartmann’s procedure) (Hartmann’s procedure)  End colostomy with full ano-rectal excision (abdomino-perineal excision) (abdomino-perineal excision)

What does a proximal stoma achieve? It does: - 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 not: - 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 Ileostomy Formation and Closure Complications of Stoma Complications of Closure  Prolapse  Dehydration  Retraction  Major sepsis Wexner 3% Wexner 3% Hobbiss 4.5% Hobbiss 4.5%

What do I do? No Anastomosis  Dubious blood supply to left colonic pedicle  Major co-morbidity  Pre-existing pelvic sepsis  Residual pelvic tumour

What do I do? High Rectal Anastomosis Anastomosis Alone Anastomosis with Stoma  Uncomplicated surgery  Satisfactory air tight anastomosis. anastomosis.  Minimal co-morbidity  Satisfactory air tight anastomosis anastomosis  Moderate co-morbidity

What do I do? Low Rectal Anastomosis Anastomosis Alone (unusual) Anastomosis with Stoma (majority) No Anastomosis  Long healthy left colonic pedicle. colonic pedicle.  No pelvic dead space. space.  No co-morbidity.  No radiotherapy.  Satisfactory air tight anastomosis. tight anastomosis.  Minor to moderate co-morbidity co-morbidity  Previous radiotherapy. radiotherapy.  Elderly or infirm.  Moderate to severe severe co-morbidity. co-morbidity.

What do I do? Ultra Low Anastomosis Anastomosis Alone (rare) Anastomosis with Stoma (majority) No Anastomosis  Nil  Satisfactory air tight anastomosis tight anastomosis  Mild co-morbidity  Elderly or infirm infirm  Moderate or severe severe co-morbidity co-morbidity