Management of Anastomotic Leakage of der Lower GI-Tract

Präsentation zum Thema: "Management of Anastomotic Leakage of der Lower GI-Tract"—  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

2

3 Schwarzwald-Baar-Klinikum
Municipal hospital serving people Teaching Hospital of University of Freiburg 21 clinical departments 2.700 staff 1.084 beds inpatients > outpatients € turnover

4 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

5 Colorectal Procedures 2007
total laparoscopic Ileocoecalresektion Hemicolektomie rechts Transversumresekion 6 - Hemicolektomie links Sigmaresektion Segmentresektion Erweiterte Resektion Subtotale/totale Colektomie 7 2 Stoma-Anlage Stoma-Revision 20 Stoma-Rückverlagerung 96 Rektumresektionen Peranale Excision 19 Anteriore Resektion Tiefe Resektion Amputation

6 2006 Management of Leakage Colon-Ca n=116 Rectal Ca n=64
Mortality ,3% 5 electiv, 2 emergent anastomotic leakage: 2 re-laparotomy 6 wound infection 8 Colon-Ca n=116 Sesis-MOF-death % Rate of intervention 100% Re-Operation Healing results in scaring/stricture frozen pelvis Increased local tumour recurrences mortality ,25% anastomotic leakage % conservative 4 x revision surgery 3 x (1 x enterostomy, 2 x Hartmann) Rectal Ca n=64

7 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

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

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

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

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

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

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

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

15 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

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

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

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

19 Diagnositics: Ultrasonography

20 Diagnostics: Endoscopy

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

22 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

23 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

24 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

25 Endo-Songe

26 Endo-Songe

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

29 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

30 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 endoscopic tatooing lap. Left colectomy

31 Bodo H, geb 12/2005 peranaler Blutabgang 2/2006 Coloskopie und Polypektomie bei 40 und 56 cm Histologie: GII,smII,L1 bei 40 cm Tuschemarkierung lap. Hemicolektomie links 20.3. Appetitlosigkeit, sauberes Sekret, L 13100; CRP 13,8 20.3. Nahrungskarenz, Antibiose 21.3. Colon-KE

32 20.3. nil by mouth, antibiotics
23.3. colonoscopic firbin glue

33 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

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

35 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 dyspnoe, resp. Insufficiency, abdomen not distended ICU, Sepsis, MOF CT Operation Stool fistula

36 Case II 20.3. CT demission late April

37 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

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

41 Case IV Gisela F., 20.2.45 4.10. 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., 20.2.45
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 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

46 Aachener Algorithmus

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

48 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

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

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

51 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