1. Tips and Tricks of Avoiding and Management of Anastomotic Complications Feza H. Remzi, MD, FACS,FASCRS., FTSS (Hon)Chairman Department of Colorectal Surgery Professor of Surgery Rupert B Turnbull Jr,. MD Chair Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH

2. Introduction Colorectal / anal Ileal Pouch anal anastomosis Ileocolic anastomosis Small bowel to small bowel

5. Colorectal / Anal Anastomosis

21. Acute Management Not diverted, –Take back for washout with diverting loop ileostomy and avoid taking down the colorectal anastomosis –Drain; I still prefer penrose drains Diverted –If leak is proven with CT or GGE; EUA and transanal, anastomotic drainage through the defect –If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal –Prefer mushroom catheter IV ATBS, and conservative management and control of sepsis and wait, wait, and wait

22. Longterm Management of Colorectal / Anal Anastomotic Leak Wait 6 to 12 months Periodic EUA, I & D of cavity, GGE If it heals, proceed with ileostomy closure If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure Incomplete healing / closure of the defect –Ileostomy closure and explain the possibility of recurrence –Presacral sinus with a wide mouth/opening usually does better –Cavity that got epithelized with mucosa also does well

29. Turnbull- Cutait Pull Through

34. Turnbull Cutait

35. Ileal Pouch Anal Anastomosis

36. TPC and IPAA

45. Reach Issues

46. Difficulty in Reach

55. Acute Management After IPAA Not diverted, –Take back for washout with diverting loop ileostomy and avoid taking down the colorectal anastomosis –Drain; I still prefer penrose drains Diverted –If leak is proven with CT or GGE; EUA and transanal, anastomotic drainage through the defect –If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal –Prefer mushroom catheter IV ATBS, and conservative management and control of sepsis and wait, wait, and wait

56. Longterm Management of IPAA Anastomotic Leak Wait 6 to 12 months Periodic EUA, I & D of cavity, GGE If it heals, proceed with ileostomy closure If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure Incomplete healing / closure of the defect –Ileostomy closure and explain the possibility of recurrence –Presacral sinus with a wide mouth/opening usually does better –Cavity that got epithelized with mucosa also does well

62. General Principles If not diverted, diverting ileostomy for 3 to 6 months before considering a redo pouch Be prepared for the unexpected Consenting; permanent ileostomy vs K pouch Ureteric stents Availability of blood products Must excise the pelvic phlegmon to accomplish healing Dissection known to unknown, must have exit strategy Pelvic dissection; caudal to cranial

71. Ileocolic Anastomosis

73. Small Bowel to Small Bowel