Anastomotic leakage in colorectal cancer surgery D.Pavalkis, Z.Saladzinskas Kaunas medical university hospital, Lithuania International meeting of coloproctology 22 – 24 April, 2004, Hortobagy, Hungary

Importance of the problem Colorectal cancer incidence Increasing numbers of sphincter saving procedures Ageing population Most serious postoperative complications – anastomotic leakage

Importance 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? Stoma Drains US drenage Reoperation time

In what we end with AL? In hospital mortality Local recurrence rate 5 years survival Functional outcome and quality of life

Causes of AL Bowel preparation Elderly Surgical techniques Anemia 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 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 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 AL Rullier E. & all, Brit J Surg, 1998, 85, 355-358

Obesity 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 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 AL Colorectal cancer 132 patients >75 and 464 <75 4 from 132 ( 3.03%) >75 18 from 464 (3.87 %) <75 D.Pavalkis, Medicina, 2001, 39:421-425

Bowel preparation Mortality and morbidity MBP (n-61) No MBP (n-75) FET (P<0,05) Mortality 2(3,2%) NS Wound infection 4(6,6%) 10(13,3%) Wound dehiscence 2(3,3%) 4(5,3%) Abdominal/pelvic collection 3(4,9%) 2(2,7%) Anastomotic breakdown 5/48(10%) 2/52(3,8%) Memon MA & all Int J Colorectal Dis 1997;12;298-302

Bowel preparation Controversial Efficient MBP – prerequisite to reduce anastomotic and septic complications Hares 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 surgery Mietttinen 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 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 anastomosis van Geldere D & all, J Am Coll Surg, 2002, 194:40-47

Anesthesia 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 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) Pethidine gr EA gr. Wound infection 3 (6%) 5 (10%) Intraabdominal abscess 1 (2%) Anastomotic leakage - Total: 4 (8%) 11 (22%)

Other complications (KMUH data) Pethidine EA gr. Chest infection 2 (4%) 1 (2%) Cardiac arrhythmias - Pulmonary embolism 1 (2%)† Acute renal failure Urinary infection Total: 5 (10%) 3 (6%)

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 anastomoses A.Fingerhut &all, Surgery , 1995, 3: 479-485 (French Association for surgical research)

Anastomosis 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 methods KMUH Hand sewn, 2 layers 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 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 testing 18.1% of patients after rectal resection demonstrated intraluminal bleeding or leakage O.Schmidt, S.Merkel, W.Hohenberger, Eur J Surg Oncol, 2003, 29:239-243 20,6% leaked on testing, after repair – 3% leaked on second testing JMD Wheeler, JM Gilbert, Ann Royal Coll Surg Engl, 1999, 51:105-108

Protective 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? 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? 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 anastomosis 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 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 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

Suspition 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 AL Pelvic abscess Non surgical technics (transanal, US, CT) Defunction with stoma? Elementary diet, TPN? Colorectal surgeon = general surgeon

Management of AL Peritonitis Emergency surgery M.Keighley – take down anastomosis We should try save low anastomoses

AL 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 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 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 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

Conclusions 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 attention