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Management of Anastomotic Leakage of der Lower GI-Tract. Professor Dr.med. Dr.h.c. Norbert Runkel Department of General and Visceral Surgery Schwarzwald-Baar Klinikum Teaching Hospital of the University of Freiburg. Schwarzwald-Baar-Klinikum. Municipal hospital serving 250.000 people

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slide1
Management of Anastomotic Leakage of der Lower GI-Tract

Professor Dr.med. Dr.h.c. Norbert Runkel

Department of General and Visceral Surgery

Schwarzwald-Baar Klinikum

Teaching Hospital of the University of Freiburg

schwarzwald baar klinikum
Schwarzwald-Baar-Klinikum

Municipal hospital serving 250.000 people

Teaching Hospital of University of Freiburg

21 clinical departments

2.700 staff

1.084 beds

41.000 inpatients

>80.000 outpatients

200.000.000 € turnover

department of general and visceral surgery
Center of Excellence/ Certification

Surgical Oncology (Onkologischer Schwerpunkt Schwarzwald-Baar-Heuberg)

Coloproktologie (CACP)

Center für Colorectal Cancer (Darmzentrum)

Continence-Center Südwest (DKG)

Surgical Endoscopie (CAES)

Bariatric Surgery Center

Minimal Invasive Surgery Center (Hospitationsklinik der CAMIC)

Wound- and Enterostomy-Center

Department of General and Visceral Surgery
colorectal procedures 2007
Colorectal Procedures 2007

total laparoscopic

Ileocoecalresektion 20 6

Hemicolektomie rechts 86 38

Transversumresekion 6 -

Hemicolektomie links 40 31

Sigmaresektion 62 37

Segmentresektion 10 1

Erweiterte Resektion 10 3

Subtotale/totale Colektomie 7 2

Stoma-Anlage 100

Stoma-Revision 20

Stoma-Rückverlagerung 96

Rektumresektionen 147 93

Peranale Excision 19

Anteriore Resektion 49 30

Tiefe Resektion 69 57

Amputation 10 6

colon ca n 116
Colon-Can=116

Mortality 4,3%

5 electiv, 2 emergent

anastomotic leakage: 2

re-laparotomy 6

wound infection 8

2006

Management of Leakage

  • Sesis-MOF-death 13-66% Rate of intervention 100%
  • Re-Operation
  • Healing results in scaring/stricture
  • frozen pelvis
  • Increased local tumour recurrences

mortality 6,25%

anastomotic leakage 11%

conservative 4 x

revision surgery 3 x

(1 x enterostomy, 2 x Hartmann)

Rectal Ca

n=64

slide7
Protective Stoma

Stomas do not prevent leakage

but

reduce clinical serverity/catastrophy

In high risk patients and situations protect!

An ostomy is not a surgical failure!

Prevention

Prevention Diagnosis Therapy Cases

protective stoma
Protective Stoma

Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer

A Randomized Multicenter Trial

Peter Matthiessen, MD, PhD,* Olof Hallböök, MD, PhD,‡ Jörgen Rutegård, MD, PhD,* Göran Simert, MD, PhD,† and Rune Sjödahl, MD, PhD‡

Ann Surg. 2007 August; 246(2): 207–214.

Besonderheiten

1999-2005 intraop. randomisiert 234 Patienten

Anastomose < 7 cm

Prevention

Prevention Diagnosis Therapy Cases

protective stoma9
Protective Stoma

Matthiessen et al., Ann Surg. 2007

Prevention

Prevention Diagnosis Therapy Cases

protective stoma10
Protective Stoma

Matthiessen et al., Ann Surg. 2007

Prevention

Prevention Diagnosis Therapy Cases

protective stoma11
Protective Stoma

Matthiessen et al.,

Ann Surg. 2007

protektives stoma
Protektives Stoma

Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer

A Randomized Multicenter Trial

Peter Matthiessen, MD, PhD,* Olof Hallböök, MD, PhD,‡ Jörgen Rutegård, MD, PhD,* Göran Simert, MD, PhD,† and Rune Sjödahl, MD, PhD‡

Ann Surg. 2007 August; 246(2): 207–214.

Results

Symptomatic Leakage: 10% vs 28%

Permanent Stoma 14% vs 17%

Prevention

Prevention Diagnosis Therapy Cases

protective stoma13
Protective Stoma

In all low rectal anastomoses!

Prevention

Prevention Diagnosis Therapy Cases

slide14
Drainage

Drainage is not important intraperitoneally

Drainage is essential in extraperitoneal anastomoses

In addition transanal drainage

Prevention

Prevention Diagnosis Therapy Cases

slide15
Fast Tract Surgery

Fast Tract Rehabilitation

Reduction of averall morbidity from 20% to 7%

No reduction of surgical complication rate 17%

leakage rate 3%

Hensel et al. Charite Mitte; Anaesthesist 2006

Prevention

Prevention Diagnosis Therapy Cases

slide16
Closure of peritoneum

Peritonealisation of pelvis

Prevented peritonitis after 307 colorectal anastomoses

Eckmann et al., Lübeck

Int J Colorectal Dis 2004

slide17
Diagnosis

overt: secretion

highly suspicious: peritonitis, septic shock

suspicious: leucocytosis, prolonged paralysis, abdominal distension and pain

OP!

slide18
Diagnostics: classic and modern

Sensitivität 96,7% bei 307 colorectalen Anastomosen

Eckmann et al., Lübeck Int J Colorectal Dis 2004

slide21
Management

Key questions

Is the leakage well drained?

Signs of SEPSIS?

Therapy

Implication Prevention Therapy Cases

slide22
Stages and Concepts

grade I = well drained, no sepsis

> conservative therapy

grade II = well drained but sepsis

  • defunctioning stoma

grade III = poorly drained and sepsis

  • Surgical revision,

radical clearing of focus

slide23
Therapeutic Algorisms

Intraabdominal anastomosis

early < 5 days

late > 5 days

Peritonitis/Sepsis

Re-Laparotomy

conservative

Good general condition

Resection, new anastomosis, stoma

Wait, Liquids

Interventional drainage

antibiotics

endoskopic fibrin glue

Poor condition

disconnection

slide24
Therapeutic Algorisms

Rectal Anastomosis

without stoma

with stoma

endoscopy: ischemia of simple leak

relaparotomy

ileostomy

intraop colon washout

additional drainages

omental flap

Hartmann-resection

transanale Easyflow-Drainagen

Transanal Procedures

washout

debridement

decompression using Easyflow drainages

Endovac

fibrin glue

slide27
dem Patienten erfolgen.

Anwendung des Endo-SPONGE

Systems zur Therapie einer

großen Anastomoseninsuffizienz

nach tiefer anteriorer

Rektumresektion mit TME

und J-Pouch Anlage

Abb 8: Ausgangssituation zu

Beginn der Endo-SPONGE-Therapie:

Die Insuffizienz hat eine

Ausdehnung über 1/3 der Zirkumferenz

und ist 20 cm tief mit

dem Endoskop einzuspiegeln.

Ein Schwammsystem reicht zur

Therapie der großen Höhle nicht

aus, ein weiteres System wird

anschließend eingelegt.

Abb 9: 12 Tage nach Therapiebeginn

ist die Höhle vollständig

von schmutzigen Fibrinbelägen

gereinigt und mit sauberem

Granulationsgewebe ausgekleidet.

Abb 10: Die Höhle kann inzwischen

bereits mit nur mehr

einem Schwammsystem behandelt

werden.

Abb 11: Nach 21 Tagen Therapie

ist eine deutliche Verkleinerung

der Insuffizienzhöhle eingetreten.

Die Höhle granuliert

aus der Tiefe zu. Das Schwammsystem

wird weiter kontinuierlich

von Wechsel zu Wechsel

verkleinert.

Abb 12: Nach 33 Tagen Therapie

ist nur mehr eine kleine

Rest-Mulde zu erkennen. Diese

Mulden heilen in der Regel

ohne zusätzliche Therapie ab.

Dr. med. Rolf Weidenhagen

Chirurg Klinikum Großhadern, München

slide28
Intraabdominal anastomosis

Therapeutic Algorisms

early < 5 days

late > 5 days

Peritonitis/Sepsis

Re-Laparotomy

conservative

slide29
Rectal Anastomosis

Therapeutic Algorisms

without stoma

with stoma

endoscopy: ischemia of simple leak

relaparotomy

ileostomy

intraop colon washout

additional drainages

omental flap

Hartmann-resection

transanale Easyflow-Drainagen

Transanal Procedures

washout

debridement

decompression using Easyflow drainages

Endovac

fibrin glue

case i
Case I

Bodo H, geb. 1.1.36

12/2005 peranal bleeding

2/2006 Colonoscopy und polypectomy bei 40 und 56 cm

Histology: GII,smII,L1 bei 40 cm

16.3.2006 endoscopic tatooing

17.3.2006 lap. Left colectomy

slide31
Bodo H, geb. 1.1.36

12/2005 peranaler Blutabgang

2/2006 Coloskopie und Polypektomie bei 40 und 56 cm

Histologie: GII,smII,L1 bei 40 cm

16.3.2006 Tuschemarkierung

17.3.2006 lap. Hemicolektomie links

20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP 13,8

20.3. Nahrungskarenz, Antibiose

21.3. Colon-KE

slide32
20.3. nil by mouth, antibiotics

23.3. colonoscopic firbin glue

slide33
Intraabdominal anastomosis

Therapeutic Algorisms

early < 5 days

late > 5 days

Peritonitis/Sepsis

Re-Laparotomy

conservative

Good general condition

Resection, new anastomosis, stoma

Wait, Liquids

Interventional drainage

antibiotics

endoskopic fibrin glue

Poor condition

disconnection

case ii
Case II

Gertraud S, 10.2.27

1/2006 malena, malaise, anemia

medical history: obesity, liver cirrhosis

1/2006 colonoscopy: carcinoma at 80cm

9.2. left colectomy

postop. pneumonia, SIRS, 4 days ICU

19.2. dyspnoe, resp. Insufficiency, abdomen not distended

20.2. ICU, Sepsis, MOF

20.2. CT

Operation: direct drainage of abscess

Result stool fistula

case ii35
Case II

Gertraud S, 10.2.27

1/2006 malena, malaise, anemia

medical history: obesity, liver cirrhosis

1/2006 colonoscopy: carcinoma at 80cm

9.2. left colectomy

postop. pneumonia, SIRS, 4 days ICU

19.2. dyspnoe, resp. Insufficiency, abdomen not distended

20.2. ICU, Sepsis, MOF

20.2. CT

20.2. Operation

22.2. Stool fistula

case ii36
Case II

20.3. CT demission late April

slide37
Intraabdominal anastomosis

Therapeutic Algorisms

early < 5 days

late > 5 days

Peritonitis/Sepsis

Re-Laparotomy

conservative

Good general condition

Resection, new anastomosis, stoma

Wait, Liquids

Interventional drainage

antibiotics

endoskopic fibrin glue

Poor condition

disconnection

case iii
Case III

Horst F., 26.11.26

Medical history: alcoholism, Korsakow, obesity, sigmoid double cancer with liver metastasis

25.4.2005 emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy

29.4. aspiration, subileus; 2 days ICU

6.5. relaparotomie for 4-quadrant peritonitis due to leakage from cecum

case iii39
Case III

Horst F., 26.11.26

Medical history: alcoholism, Korsakow, obesity, sigmoid double cancer with liver metastasis

25.4.2005 emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy

29.4. aspiration, subileus; 2 days ICU

6.5. relaparotomie for 4-quadrant peritonitis due to leakage from cecum: closure and ileostomy, ICU

13.5. death in MOF

case iv
Case IV

Gisela F., 20.2.45

9/2005 DVT

9/2005 Colonoscopy: cacer at right flexure

CT: liver metastases

case iv41
Case IV

Gisela F., 20.2.45

4.10. right colectomy and liver biopsy

postop fever with pneumonia; ICV 6 days

20.10. L 15600. CRP 27; abdomen soft

20.10. CT

20.10. Re-laparotomy, drainage and ileostomy

No sepsis, ICU 6 days

fallbeispiel iv
Fallbeispiel IV

1.11 CT (postop day 11)

Result: local sepsis and enterocutaneous fistula

fallbeispiel iv44
Fallbeispiel IV

Gisela F., 20.2.45

4.10. right colectomy and liver biopsy

20.10. Re-laparotomy, drainage and ileostomy

29.11. Re-laparotomy for short bowel syndrom, intraabdominal abszess and fistulation:

Debridenemnt, drainage, resction of anastomosis and ileostoma-take down

6.12 Re-laparotomy for enterocutaneous fistula and wound dehiscence: anastomotic stoma

16.12 transferal to surgical ward

3.1. demission

1.3. take down of stoma, i.v.-port for chemotherapy

slide45
Intraabdominal anastomosis

Therapeutic Algorisms

early < 5 days

late > 5 days

Peritonitis/Sepsis

Re-Laparotomy

conservative

Good general condition

Resection, new anastomosis, stoma

Wait, Liquids

Interventional drainage

antibiotics

endoskopic fibrin glue

Poor condition

disconnection

risikofaktoren patient
RisikofaktorenPatient
  • Patientenalter, Geschlecht
  • Begleiterkrankungen: DM, Tumorerkrankung, CED, Dialyse
  • Lifestile: Adipositas, Nikotin, Alkohol

Adipositas, Nikotin, Alkohol

Nickelsen et al., Glostrup, Dänemark; Acta Oncol 2005

risikofaktoren nicht chirurgisch
Risikofaktorennicht-chirurgisch
  • Neoadjuvante Therapie

N=246 TME, konv. Radiochemotherapie, retrospektiv

93 (28 mit vs 65 ohne RXT) Anastomose < 6 cm

Insuffizienz 18% vs 6%

RXT einziger unabhängiger Faktor in multivariater Analyse

Buie et al., Calgary, Dis Colon Rectum 2005

n=924 TME, Kurz-Radiotherapie, randomisiert-retrospektiv

symptomatische Insuffizienz 11,6%

Peeters et al Dutch Coloretal Cancer Group

Br J Surg 2205

diskonnektions op
Diskonnektions-Op
  • Hartmann
  • Stoma und Schleimfistel
  • Doppelläufiges Anastomosenstoma (Mikulicz-Stoma)
therapeutischer algorithmus
Therapeutischer Algorithmus

intraabdominelle Anastomose

spät > 5 Tage

Abwarten, Tee, Astronautenkost

ggf. interventionelle Drainage

Somatostatin

Antibiose

endoskopische Fibrinklebung

konservativ

therapeutischer algorithmus51
Therapeutischer Algorithmus

intraabdominelle Anastomose

früh < 5 Tage

spät > 5 Tage

Peritonitis/Sepsis

Re-Laparotomie

Guter Zustand:

Resektion, Neuanlage, Stoma

schlechter Zustand

Diskonnektion

Peritonitis-Therapie (Fokussanierung)

allg. Sepsis-Therapie

ad