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GI Anastomosis

GI Anastomosis. Dr Siu Wing Tai Department of Surgery PWH. Anastomosis. Connection between 2 tubular structures Surgical anastomosis Pathological anastomosis / fistula. Pathphysiology. Lag phase (Day 0-4) Acute inflammatory response Fibroplasia phase (Day 3-14)

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GI Anastomosis

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  1. GI Anastomosis Dr Siu Wing Tai Department of Surgery PWH

  2. Anastomosis • Connection between 2 tubular structures • Surgical anastomosis • Pathological anastomosis / fistula

  3. Pathphysiology • Lag phase (Day 0-4) • Acute inflammatory response • Fibroplasia phase (Day 3-14) • Fibroplasts proliferation • Immature collage is laid down • Maturation phase (> Day 10) • Collage is remodeled • Strength of anastomosis is increased

  4. Principles • Appropriate indications • Bowel preparation / prophylatic antibiotics • Extent of resection • Anastomosis / defunctioning stoma • Adequate exposure / assessment • Preparation of bowel for anastomosis • Vascularity, healthy tissue, tension, alignment • Technique of Anastomosis • Protection against contamination • Drainage • Proximal defunctioning stoma

  5. Techniques • Sutured • Interrupted, continuous • single- / double-layer • Bowel edges are approximated & inverted • Watertight anastomosis with adequate lumen

  6. Techniques • Stapled GIA TA EEA

  7. Techniques • Sutured • Interrupted, continuous • single- / double-layer • Bowel edges are approximated & inverted • Watertight anastomosis with adequate lumen • Stapled • Unconventional • Compression rings • Tissue glue • Laser welding

  8. Configurations • End-to-end • End-to-side • Side-to-side

  9. Configurations • End-to-end • End-to-side • Side-to-side

  10. Configurations • End-to-end • End-to-side • Side-to-side

  11. Configurations • End-to-end • End-to-side • Side-to-side

  12. Factors affecting Anastomotic Healing • Intrinsic factors • Hypotension, hypoxia • Jaundice, uraemia • Malnutrition, immunocompromise • Steroid, cytotoxic drugs • Previous irradiation • Peri-anastomosis sepsis, haematoma • Distal obstruction • Surgical techniques • Blood supply • Appropriate alignment • No tension • Maintenance of apposition

  13. Post-operative Care • Vigilant for signs of anastomotic leakage • +/- water soluble contrast study / imaging • Obvious signs • Abnormal content in drainage bag, peritonitis, high fever • Obscure signs • Unexplained pyrexia, leucocytosis, prolonged ileus, chest infection, effusion

  14. Group A • A 75-y-o retired cook post-operative day 5right hemicolectomy for carcinoma of caecum. • Known IHD, DM, COPD FU medics. Noted “faculent” discharge in the abdominal drain. • How would you assess/manage the situation?

  15. Group B • 60 y.o. male post-operative day 4Ivor-Lewis oesophagectomy for carcinoma of distal oesophagus. • Past health: HT, chronic smoker, drinke • Running low grade fever, CXR diffuse hazziness in right side • How would you manage the patient?

  16. Group C • A 65-y-o woman admitted because of large bowel obstruction. Diagnosed to have obstructing recto-sigmoid tumor by contrast enema. • She underwent emergency anterior resection with primary anastomosis by mechanical stapler. • Post-operative D6, running a temp of 38.5oC, c/o left- sided abdominal pain. Then noted large amount of turbid fluid discharging from the midline wound. • How wound you treat the lady?

  17. GI Fistulas Dr Siu Wing Tai Department of Surgery PWH

  18. Intestinal Fistulas • An abnormal communication between two epithelialized surfaces. • GI fistulas • Congential / acquired • Primary (underlying gut disease) / Secondary (injury to normal gut) • Enterocutaneous / enteroenteral • Simple (short & direct tract) / complex (long & multiple tracks via an abscess cavity) • Low / high output (>500ml /day)

  19. Primary Fistulas • Malignancy • Crohn’s disease • Colonic diverticular disease • Necrotizing pancreatitis • Radiation enteritis

  20. Secondary Fistulas • Risk factors for anastomotic failure • Unrecognized enteric injury • Breakdown of repaired serosal tear • Laparostomy for severe widespread abdominal sepsis • Mesh application

  21. Management • Manage according to the degree of associated sepsis • Resuscitation • Airway, breathing, circulation • Peritonitis for operation • Drain abscess, exteriorized bowel ends, resect ischemic gut • Stable patient • Correct fluid / electrolyte imbalance • Eliminate sepsis- antibiotic, drain abscess • Wound / skin care • Nutrition • Imaging delineation of fistula anatomy • Plan for surgical correction / wait for spontaneous closure • Rehabilitation

  22. Factors affecting Fistulas Closure • Discontinuity of bowel ends • Distal obstruction • Damaged / diseased residual intestine • Intervening abscess / ongoing sepsis • Mucocutaneous continuity of the fistula with skin • Malnutrition • Foreign bodies / mesh • Malignancy

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