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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.

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Präsentation zum Thema: "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."—  Präsentation transkript:

1 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

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3 Schwarzwald-Baar-Klinikum Municipal hospital serving people Teaching Hospital of University of Freiburg 21 clinical departments staff beds inpatients > outpatients € turnover

4 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

5 Colorectal Procedures 2007 total laparoscopic Ileocoecalresektion206 Hemicolektomie rechts8638 Transversumresekion6- Hemicolektomie links4031 Sigmaresektion6237 Segmentresektion101 Erweiterte Resektion103 Subtotale/totale Colektomie72 Stoma-Anlage100 Stoma-Revision20 Stoma-Rückverlagerung96 Rektumresektionen14793 Peranale Excision19 Anteriore Resektion4930 Tiefe Resektion6957 Amputation106

6 Colon-Ca n=116 Mortality 4,3% 5 electiv, 2 emergent anastomotic leakage: 2 re-laparotomy6 wound infection 8 mortality 6,25% anastomotic leakage 11% conservative 4 x revision surgery 3 x (1 x enterostomy, 2 x Hartmann) Rectal Ca n= Sesis-MOF-death13-66% Rate of intervention 100% Re-Operation Healing results in scaring/stricture frozen pelvis Increased local tumour recurrences Management of Leakage

7 Stomas do not prevent leakage but reduce clinical serverity/catastrophy In high risk patients and situations protect! An ostomy is not a surgical failure! PreventionDiagnosisTherapy Cases Prevention Protective Stoma

8 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 August; 246(2): 207–214. Besonderheiten intraop. randomisiert 234 Patienten Anastomose < 7 cm PreventionDiagnosisTherapy Cases Prevention

9 Protective Stoma Matthiessen et al., Ann Surg PreventionDiagnosisTherapy Cases Prevention

10 Protective Stoma Matthiessen et al., Ann Surg PreventionDiagnosisTherapy Cases Prevention

11 Protective Stoma Matthiessen et al., Ann Surg. 2007

12 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 August; 246(2): 207–214. Results Symptomatic Leakage: 10% vs 28% Permanent Stoma 14% vs 17% PreventionDiagnosisTherapy Cases Prevention

13 Protective Stoma In all low rectal anastomoses! PreventionDiagnosisTherapy Cases Prevention

14 Drainage is not important intraperitoneally Drainage is essential in extraperitoneal anastomoses In addition transanal drainage Drainage PreventionDiagnosisTherapy Cases Prevention

15 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 PreventionDiagnosisTherapy Cases Prevention

16 Peritonealisation of pelvis Prevented peritonitis after 307 colorectal anastomoses Eckmann et al., Lübeck Int J Colorectal Dis 2004 Closure of peritoneum

17 overt: secretion highly suspicious: peritonitis, septic shock suspicious: leucocytosis, prolonged paralysis, abdominal distension and pain OP! Diagnosis

18 Sensitivität 96,7% bei 307 colorectalen Anastomosen Eckmann et al., Lübeck Int J Colorectal Dis 2004 Diagnostics: classic and modern

19 Diagnositics: Ultrasonography

20 Diagnostics: Endoscopy

21 Key questions Is the leakage well drained? Signs of SEPSIS? ImplicationPreventionTherapy Cases Therapy Management

22 > conservative therapy grade 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

23 Intraabdominal anastomosis early < 5 dayslate > 5 days Peritonitis/Sepsis conservative Re-Laparotomy Wait, Liquids Interventional drainage antibiotics endoskopic fibrin glue Good general condition Resection, new anastomosis, stoma Poor condition disconnection Therapeutic Algorisms

24 Rectal Anastomosis endoscopy: ischemia of simple leak relaparotomy ileostomy intraop colon washout additional drainages omental flap Hartmann-resection transanale Easyflow-Drainagen without stomawith stoma Transanal Procedures washout debridement decompression using Easyflow drainages Endovac fibrin glue Therapeutic Algorisms

25 Endo-Songe

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27 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

28 Intraabdominal anastomosis early < 5 dayslate > 5 days Peritonitis/Sepsis conservative Re-Laparotomy Therapeutic Algorisms

29 Rectal Anastomosis endoscopy: ischemia of simple leak relaparotomy ileostomy intraop colon washout additional drainages omental flap Hartmann-resection transanale Easyflow-Drainagen without stomawith stoma Transanal Procedures washout debridement decompression using Easyflow drainages Endovac fibrin glue Therapeutic Algorisms

30 Case I Bodo H, geb /2005 peranal bleeding 2/2006 Colonoscopy und polypectomy bei 40 und 56 cm Histology: GII,smII,L1 bei 40 cm endoscopic tatooing lap. Left colectomy

31 Bodo H, geb /2005 peranaler Blutabgang 2/2006 Coloskopie und Polypektomie bei 40 und 56 cm Histologie: GII,smII,L1 bei 40 cm Tuschemarkierung lap. Hemicolektomie links Appetitlosigkeit, sauberes Sekret, L 13100; CRP 13, Nahrungskarenz, Antibiose Colon-KE

32 20.3. nil by mouth, antibiotics colonoscopic firbin glue

33 Intraabdominal anastomosis early < 5 dayslate > 5 days Peritonitis/Sepsis conservativeRe-Laparotomy Wait, Liquids Interventional drainage antibiotics endoskopic fibrin glue Good general condition Resection, new anastomosis, stoma Poor condition disconnection Therapeutic Algorisms

34 Case II Gertraud S, /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 dyspnoe, resp. Insufficiency, abdomen not distended ICU, Sepsis, MOF CT Operation: direct drainage of abscess Result stool fistula

35 Case II Gertraud S, /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 dyspnoe, resp. Insufficiency, abdomen not distended ICU, Sepsis, MOF CT Operation Stool fistula

36 Case II CT demission late April

37 Intraabdominal anastomosis early < 5 dayslate > 5 days Peritonitis/Sepsis conservativeRe-Laparotomy Wait, Liquids Interventional drainage antibiotics endoskopic fibrin glue Good general condition Resection, new anastomosis, stoma Poor condition disconnection Therapeutic Algorisms

38 Case III Horst F., Medical history: alcoholism, Korsakow, obesity, sigmoid double cancer with liver metastasis emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy aspiration, subileus; 2 days ICU 6.5. relaparotomie for 4-quadrant peritonitis due to leakage from cecum

39 Case III Horst F., Medical history: alcoholism, Korsakow, obesity, sigmoid double cancer with liver metastasis emergency surgery for acute obstruction: left colectomy, on table-Lavage via appendectomy aspiration, subileus; 2 days ICU 6.5. relaparotomie for 4-quadrant peritonitis due to leakage from cecum: closure and ileostomy, ICU death in MOF

40 Case IV Gisela F., /2005 DVT 9/2005 Colonoscopy: cacer at right flexure CT: liver metastases

41 Case IV Gisela F., right colectomy and liver biopsy postop fever with pneumonia; ICV 6 days L CRP 27; abdomen soft CT Re-laparotomy, drainage and ileostomy No sepsis, ICU 6 days

42 Fallbeispiel IV 1.11 CT (postop day 11) Result: local sepsis and enterocutaneous fistula

43 Case IV

44 Fallbeispiel IV Gisela F., right colectomy and liver biopsy Re-laparotomy, drainage and ileostomy 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 transferal to surgical ward 3.1. demission 1.3. take down of stoma, i.v.-port for chemotherapy

45 Intraabdominal anastomosis early < 5 dayslate > 5 days Peritonitis/Sepsis conservativeRe-Laparotomy Wait, Liquids Interventional drainage antibiotics endoskopic fibrin glue Good general condition Resection, new anastomosis, stoma Poor condition disconnection Therapeutic Algorisms

46 Aachener Algorithmus

47 Risikofaktoren Patient Patientenalter, Geschlecht Patientenalter, Geschlecht Begleiterkrankungen: DM, Tumorerkrankung, CED, Dialyse Begleiterkrankungen: DM, Tumorerkrankung, CED, Dialyse Lifestile: Adipositas, Nikotin, Alkohol Lifestile: Adipositas, Nikotin, Alkohol Adipositas, Nikotin, Alkohol Nickelsen et al., Glostrup, Dänemark; Acta Oncol 2005

48 Risikofaktoren nicht-chirurgisch Neoadjuvante Therapie 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

49 Diskonnektions-Op Hartmann Hartmann Stoma und Schleimfistel Stoma und Schleimfistel Doppelläufiges Anastomosenstoma (Mikulicz- Stoma) Doppelläufiges Anastomosenstoma (Mikulicz- Stoma)

50 Therapeutischer Algorithmus intraabdominelle Anastomose spät > 5 Tage konservativ Abwarten, Tee, Astronautenkost ggf. interventionelle Drainage Somatostatin Antibiose endoskopische Fibrinklebung

51 Therapeutischer Algorithmus intraabdominelle Anastomose früh < 5 Tagespät > 5 Tage Peritonitis/Sepsis Re-Laparotomie Peritonitis-Therapie (Fokussanierung) allg. Sepsis-Therapie Guter Zustand: Resektion, Neuanlage, Stoma schlechter Zustand Diskonnektion


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