1. 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

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

3. Importance of the problem
Anastomotic leakage occurs in % 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;

4. How to manage AL?
Stoma
Drains
US drenage
Reoperation time

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

6. 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

7. 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:

8. 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,

9. 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,

10. 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:

11. 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:

12. 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;

13. Bowel preparation Controversial
Efficient MBP – prerequisite to reduce anastomotic and septic complications
Hares MM, Alexander-Williams J World J Surg 1982;6;
Ashley SW in Current surgical therapy, 5th edn, Mosby 1985;
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;

14. 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

15. 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:

16. 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

17. 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%)

18. 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%)

19. 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: (French Association for surgical research)

20. 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;

21. Anastomosis methods KMUH Hand sewn, 2 layers 1 layer Stapled 1995-199645 4 21 46 31 32 40 63 64
Total
131 98
117

22. 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:

23. 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:
20,6% leaked on testing, after repair – 3% leaked on second testing
JMD Wheeler, JM Gilbert, Ann Royal Coll Surg Engl, 1999, 51:

24. 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:

25. 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,

26. 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, (Basingstoke)

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. 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:
J.Camilleri-Brennan, British Journal Surgery, 2001, 88,

35. 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:

36. 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,

37. 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

38. Thank you for your attention