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 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

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

2006 Management of Leakage Colon-Ca n=116 Rectal Ca n=64 Mortality 4,3% 5 electiv, 2 emergent anastomotic leakage: 2 re-laparotomy 6 wound infection 8 Colon-Ca n=116 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

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 Diagnosis Therapy Cases Prevention

A Randomized Multicenter Trial 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 Stoma Prevention Prevention Diagnosis Therapy Cases Matthiessen et al., Ann Surg. 2007 Prevention Prevention Diagnosis Therapy Cases

Protective Stoma Prevention Prevention Diagnosis Therapy Cases Matthiessen et al., Ann Surg. 2007 Prevention Prevention Diagnosis Therapy Cases

Protective Stoma Matthiessen et al., Ann Surg. 2007

A Randomized Multicenter Trial 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

In all low rectal anastomoses! Protective Stoma In all low rectal anastomoses! Prevention Prevention Diagnosis Therapy Cases

Drainage Drainage is not important intraperitoneally Drainage is essential in extraperitoneal anastomoses In addition transanal drainage Prevention Prevention Diagnosis Therapy Cases

Fast Tract Rehabilitation 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

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

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

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

Diagnositics: Ultrasonography

Diagnostics: Endoscopy

Is the leakage well drained? Management Key questions Is the leakage well drained? Signs of SEPSIS? Implication Prevention Therapy Cases Therapy

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

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

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

Endo-Songe

Endo-Songe

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

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

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

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

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

20.3. nil by mouth, antibiotics 23.3. colonoscopic firbin glue

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

Case II Operation: direct drainage of abscess Result stool fistula 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 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 II 20.3. CT demission late April

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

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 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 Gisela F., 20.2.45 9/2005 DVT 9/2005 Colonoscopy: cacer at right flexure CT: liver metastases

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

Case IV

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

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

Aachener Algorithmus

Risikofaktoren Patient 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 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 Hartmann Stoma und Schleimfistel Doppelläufiges Anastomosenstoma (Mikulicz-Stoma)

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

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