management of anastomotic leakage of der lower gi-tract professor dr.med. dr.h.c. norbert runkel...
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Management of Anastomotic Leakage of
der Lower GI-Tract
Professor Dr.med. Dr.h.c. Norbert RunkelDepartment of General and Visceral SurgerySchwarzwald-Baar KlinikumTeaching Hospital of the University of Freiburg
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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
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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 CenterMinimal Invasive Surgery Center (Hospitationsklinik
der CAMIC)Wound- and Enterostomy-Center
Department of General and Visceral Surgery
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Colorectal Procedures 2007total laparoscopic
Ileocoecalresektion 20 6Hemicolektomie rechts 86 38Transversumresekion 6 -Hemicolektomie links 40 31Sigmaresektion 62 37Segmentresektion 10 1Erweiterte Resektion 10 3Subtotale/totale Colektomie 7 2
Stoma-Anlage 100Stoma-Revision 20Stoma-Rückverlagerung 96
Rektumresektionen 147 93Peranale Excision 19Anteriore Resektion 49 30Tiefe Resektion 69 57Amputation 10 6
total laparoscopic
Ileocoecalresektion 20 6Hemicolektomie rechts 86 38Transversumresekion 6 -Hemicolektomie links 40 31Sigmaresektion 62 37Segmentresektion 10 1Erweiterte Resektion 10 3Subtotale/totale Colektomie 7 2
Stoma-Anlage 100Stoma-Revision 20Stoma-Rückverlagerung 96
Rektumresektionen 147 93Peranale Excision 19Anteriore Resektion 49 30Tiefe Resektion 69 57Amputation 10 6
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Colon-Can=116
Mortality 4,3% 5 electiv, 2 emergent
anastomotic leakage: 2re-laparotomy 6wound infection 8
mortality 6,25%anastomotic leakage 11%
conservative 4 xrevision surgery 3 x (1 x enterostomy, 2 x Hartmann)
Rectal Can=64
2006
Sesis-MOF-death 13-66% Rate of intervention 100%
Re-Operation Healing results in scaring/stricture frozen pelvis Increased local tumour recurrences
Management of Leakage
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Stomas do not prevent leakagebut
reduce clinical serverity/catastrophy
In high risk patients and situations protect!An ostomy is not a surgical failure!
Prevention Diagnosis Therapy CasesPrevention
Protective Stoma
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Protective Stoma
Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for
CancerA 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 PatientenAnastomose < 7 cm
Prevention Diagnosis Therapy CasesPrevention
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Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention Diagnosis Therapy CasesPrevention
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Protective Stoma
Matthiessen et al., Ann Surg. 2007
Prevention Diagnosis Therapy CasesPrevention
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Protective Stoma
Matthiessen et al., Ann Surg. 2007
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Protektives Stoma
Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for
CancerA 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 Diagnosis Therapy CasesPrevention
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Protective Stoma
In all low rectal anastomoses!
Prevention Diagnosis Therapy CasesPrevention
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Drainage is not important intraperitoneally
Drainage is essential in extraperitoneal anastomoses
In addition transanal drainage
Drainage
Prevention Diagnosis Therapy CasesPrevention
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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
Fast Tract Surgery
Prevention Diagnosis Therapy CasesPrevention
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Peritonealisation of pelvis Peritonealisation of pelvis
Prevented peritonitis after 307 colorectal anastomoses
Eckmann et al., Lübeck Int J Colorectal Dis 2004
Closure of peritoneum
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overt: secretion
highly suspicious: peritonitis, septic shock
suspicious: leucocytosis, prolonged paralysis, abdominal
distension and pain
OP!
Diagnosis
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Sensitivität 96,7% bei 307 colorectalen AnastomosenEckmann et al., Lübeck Int J Colorectal Dis 2004
Diagnostics: classic and modern
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Diagnositics: Ultrasonography
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Diagnostics: Endoscopy
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Key questions
Is the leakage well drained?
Signs of SEPSIS?
Implication Prevention Therapy CasesTherapy
Management
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> conservative therapygrade I = well drained, no sepsis
grade II = well drained but sepsis
defunctioning stoma
grade III = poorly drained and sepsis
Surgical revision, radical clearing of focus
Stages and Concepts
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Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
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Rectal Anastomosis
endoscopy: ischemia of simple leak
relaparotomy
ileostomy
intraop colon washout
additional drainages
omental flap
Hartmann-resection
transanale Easyflow-Drainagen
without stoma with stoma
Transanal Procedures
washout
debridement
decompression using Easyflow drainages
Endovac
fibrin glue
Therapeutic Algorisms
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Endo-Songe
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Endo-Songe
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dem Patienten erfolgen.Anwendung des Endo-SPONGESystems zur Therapie einergroßen Anastomoseninsuffizienznach tiefer anteriorerRektumresektion mit TMEund J-Pouch AnlageAbb 8: Ausgangssituation zuBeginn der Endo-SPONGE-Therapie:Die Insuffizienz hat eineAusdehnung über 1/3 der Zirkumferenzund ist 20 cm tief mitdem Endoskop einzuspiegeln.Ein Schwammsystem reicht zurTherapie der großen Höhle nichtaus, ein weiteres System wirdanschließend eingelegt.Abb 9: 12 Tage nach Therapiebeginnist die Höhle vollständigvon schmutzigen Fibrinbelägengereinigt und mit sauberemGranulationsgewebe ausgekleidet.Abb 10: Die Höhle kann inzwischenbereits mit nur mehreinem Schwammsystem behandeltwerden.Abb 11: Nach 21 Tagen Therapieist eine deutliche Verkleinerungder Insuffizienzhöhle eingetreten.Die Höhle granuliertaus der Tiefe zu. Das Schwammsystemwird weiter kontinuierlichvon Wechsel zu Wechselverkleinert.Abb 12: Nach 33 Tagen Therapieist nur mehr eine kleineRest-Mulde zu erkennen. DieseMulden heilen in der Regelohne zusätzliche Therapie ab.
Dr. med. Rolf WeidenhagenChirurg Klinikum Großhadern, München
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Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Therapeutic Algorisms
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Rectal Anastomosis
endoscopy: ischemia of simple leak
relaparotomy
ileostomy
intraop colon washout
additional drainages
omental flap
Hartmann-resection
transanale Easyflow-Drainagen
without stoma with stoma
Transanal Procedures
washout
debridement
decompression using Easyflow drainages
Endovac
fibrin glue
Therapeutic Algorisms
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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
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Bodo H, geb. 1.1.36Bodo H, geb. 1.1.3612/2005 peranaler Blutabgang12/2005 peranaler Blutabgang2/2006 Coloskopie und Polypektomie bei 40 und 56 cm2/2006 Coloskopie und Polypektomie bei 40 und 56 cmHistologie: GII,smII,L1 bei 40 cmHistologie: GII,smII,L1 bei 40 cm16.3.2006 Tuschemarkierung16.3.2006 Tuschemarkierung17.3.2006 lap. Hemicolektomie links17.3.2006 lap. Hemicolektomie links20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP 20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP
13,813,8
20.3. Nahrungskarenz, 20.3. Nahrungskarenz, AntibioseAntibiose21.3. Colon-KE21.3. Colon-KE
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20.3. nil by mouth, antibiotics20.3. nil by mouth, antibiotics
23.3. colonoscopic firbin glue23.3. colonoscopic firbin glue
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Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
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Case II
Gertraud S, 10.2.271/2006 malena, malaise, anemia
medical history: obesity, liver cirrhosis1/2006 colonoscopy: carcinoma at 80cm9.2. left colectomy
postop. pneumonia, SIRS, 4 days ICU19.2. dyspnoe, resp. Insufficiency, abdomen not
distended20.2. ICU, Sepsis, MOF
20.2. CTOperation: direct drainage of abscessResult stool fistula
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Case II
Gertraud S, 10.2.271/2006 malena, malaise, anemia
medical history: obesity, liver cirrhosis1/2006 colonoscopy: carcinoma at 80cm9.2. left colectomy
postop. pneumonia, SIRS, 4 days ICU19.2. dyspnoe, resp. Insufficiency, abdomen not
distended20.2. ICU, Sepsis, MOF
20.2. CT
20.2. Operation22.2. Stool fistula
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Case II
20.3. CT demission late April20.3. CT demission late April
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Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
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Case III
Horst F., 26.11.26Medical 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 ICU6.5. relaparotomie for 4-quadrant peritonitis due to
leakage from cecum
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Case III
Horst F., 26.11.26Medical 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 ICU6.5. relaparotomie for 4-quadrant peritonitis due to
leakage from cecum: closure and ileostomy, ICU 13.5. death in MOF
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Case IV
Gisela F., 20.2.459/2005 DVT9/2005 Colonoscopy: cacer at right flexure
CT: liver metastases
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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
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Fallbeispiel IV
1.11 CT (postop day 11)
Result: local sepsis and enterocutaneous fistula
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Case IV
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Fallbeispiel IVGisela 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
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Intraabdominal anastomosis
early < 5 days late > 5 days
Peritonitis/Sepsis
conservativeRe-Laparotomy
Wait, LiquidsInterventional drainageantibioticsendoskopic fibrin glue
Good general conditionResection, new anastomosis, stoma
Poor conditiondisconnection
Therapeutic Algorisms
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Aachener AlgorithmusAachener Algorithmus
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RisikofaktorenPatient
Patientenalter, GeschlechtPatientenalter, GeschlechtBegleiterkrankungen: DM, Begleiterkrankungen: DM,
Tumorerkrankung, CED, DialyseTumorerkrankung, CED, DialyseLifestile: Adipositas, Nikotin, AlkoholLifestile: Adipositas, Nikotin, Alkohol
Adipositas, Nikotin, Alkohol Nickelsen et al., Glostrup, Dänemark; Acta Oncol 2005
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RisikofaktorenRisikofaktorennicht-chirurgischnicht-chirurgisch
Neoadjuvante TherapieNeoadjuvante Therapie
N=246 TME, konv. Radiochemotherapie, retrospektiv93 (28 mit vs 65 ohne RXT) Anastomose < 6 cmInsuffizienz 18% vs 6%RXT einziger unabhängiger Faktor in multivariater Analyse Buie et al., Calgary, Dis Colon Rectum 2005
n=924 TME, Kurz-Radiotherapie, randomisiert-retrospektivsymptomatische Insuffizienz 11,6%Peeters et al Dutch Coloretal Cancer GroupBr J Surg 2205
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Diskonnektions-OpDiskonnektions-Op
HartmannHartmannStoma und SchleimfistelStoma und SchleimfistelDoppelläufiges Anastomosenstoma Doppelläufiges Anastomosenstoma
(Mikulicz-Stoma)(Mikulicz-Stoma)
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Therapeutischer AlgorithmusTherapeutischer Algorithmus
intraabdominelle Anastomose
spät > 5 Tage
konservativ
Abwarten, Tee, Astronautenkostggf. interventionelle DrainageSomatostatinAntibioseendoskopische Fibrinklebung
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Therapeutischer AlgorithmusTherapeutischer Algorithmusintraabdominelle Anastomose
früh < 5 Tage spät > 5 Tage
Peritonitis/Sepsis
Re-Laparotomie
Peritonitis-Therapie (Fokussanierung)allg. Sepsis-Therapie
Guter Zustand:Resektion, Neuanlage, Stoma
schlechter ZustandDiskonnektion