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Incidence of Leakage. Fielding 1980 Multi-centre prospective audit of 1466 colorectal anastomoses Leak Rate Intraperitoneal 10.8% Pelvic18.7% Overall 13%. Trent/Wales and Wessex Audits. Incidence of Leakage. Incidence of Leakage. ACPGBI Guidelines: 2001 - PowerPoint PPT Presentation
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Incidence of LeakageIncidence of Leakage
Fielding 1980Fielding 1980
Multi-centre prospective audit of 1466 Multi-centre prospective audit of 1466 colorectal anastomosescolorectal anastomoses
Leak RateLeak Rate
Intraperitoneal Intraperitoneal 10.8%10.8%
PelvicPelvic 18.7%18.7%
Overall Overall 13%13%
Incidence of LeakageIncidence of Leakage
Trent /Trent /
WalesWales
WessexWessex
Anterior resectionAnterior resection 7.4%7.4% 6.9%6.9%
Other colonic anastomosesOther colonic anastomoses 3.7%3.7% 2.6%2.6%
OverallOverall 4.9%4.9% 3.4%3.4%
Trent/Wales and Wessex Audits
Incidence of LeakageIncidence of Leakage
ACPGBI Guidelines: 2001ACPGBI Guidelines: 2001
““Surgeons should carefully audit their leak Surgeons should carefully audit their leak rates for colorectal surgery and should expect rates for colorectal surgery and should expect
to achieve an overall leak rate of below 8% to achieve an overall leak rate of below 8% for anterior resection and 4% for other colonic for anterior resection and 4% for other colonic
anastomoses.”anastomoses.”
Incidence of LeakageIncidence of Leakage
Why has the incidence of leakage gone down?Why has the incidence of leakage gone down?
1.1. Widespread use of stapling guns.Widespread use of stapling guns.2.2. Increased sub-specialisation.Increased sub-specialisation.3.3. ?Better patient selection.?Better patient selection.4.4. Widespread use of auditWidespread use of audit
Cause of LeaksCause of Leaks
TechnicalTechnical -- ConstructionConstruction
-- VascularityVascularity
Failure to HealFailure to Heal -- HypoxiaHypoxia
-- Hypo-perfusionHypo-perfusion
-- Co-morbidityCo-morbidity
Vascularity of Left Colonic PedicleVascularity of Left Colonic Pedicle
JD Griffiths: Arris & Gale lecture 1956JD Griffiths: Arris & Gale lecture 1956
““A truly critical point exists at the A truly critical point exists at the splenic flexure where the marginal splenic flexure where the marginal artery is often small --- the terminal artery is often small --- the terminal
branches of the left colonic artery form branches of the left colonic artery form a secondary marginal artery at this a secondary marginal artery at this
point.”point.”
Co-morbidity & Anastomotic LeakCo-morbidity & Anastomotic Leak
Ischaemic heart diseaseIschaemic heart disease Acute and chronic respiratory diseaseAcute and chronic respiratory disease DiabetesDiabetes Old ageOld age Co-existing sepsisCo-existing sepsis Previous radiotherapyPrevious radiotherapy Smoking.Smoking.
What do I doWhat do I do??
Anastomotic LevelsAnastomotic Levels
High High
LowLow
Ultra lowUltra low
What do I doWhat do I do??
OptionsOptions
Anastomosis aloneAnastomosis alone Anastomosis with proximal stomaAnastomosis with proximal stoma End colostomy with closed rectal stump End colostomy with closed rectal stump
(Hartmann’s procedure)(Hartmann’s procedure) End colostomy with full ano-rectal excisionEnd colostomy with full ano-rectal excision
(abdomino-perineal excision)(abdomino-perineal excision)
What does a proximal stoma achieveWhat does a proximal stoma achieve??
It doesIt does: - reduce the number of clinical leaks.: - reduce the number of clinical leaks. - reduce the need for further surgery in the - reduce the need for further surgery in the
event of a leak.event of a leak.
It does notIt does not: - prevent breakdown of a poorly: - prevent breakdown of a poorly constructed or poorly perfused anastomosis.constructed or poorly perfused anastomosis.
- provide a guarantee against major - provide a guarantee against major sepsis.sepsis.
Complications of IleostomyComplications of IleostomyFormation and ClosureFormation and Closure
Complications of StomaComplications of Stoma Complications of ClosureComplications of Closure
ProlapseProlapse DehydrationDehydration RetractionRetraction
Major sepsisMajor sepsis
Wexner 3%Wexner 3%
Hobbiss 4.5%Hobbiss 4.5%
What do I doWhat do I do??
No AnastomosisNo Anastomosis
Dubious blood supply to left colonic pedicleDubious blood supply to left colonic pedicle Major co-morbidityMajor co-morbidity Pre-existing pelvic sepsisPre-existing pelvic sepsis Residual pelvic tumourResidual pelvic tumour
What do I doWhat do I do??
High Rectal AnastomosisHigh Rectal Anastomosis
Anastomosis Alone Anastomosis Alone Anastomosis with StomaAnastomosis with Stoma
Uncomplicated surgeryUncomplicated surgery
Satisfactory air tight Satisfactory air tight
anastomosis.anastomosis.
Minimal co-morbidityMinimal co-morbidity
Satisfactory air tightSatisfactory air tight
anastomosisanastomosis
Moderate co-morbidityModerate co-morbidity
What do I do?What do I do?Low Rectal AnastomosisLow Rectal Anastomosis
Anastomosis Alone Anastomosis Alone (unusual)(unusual)
Anastomosis with Stoma Anastomosis with Stoma (majority)(majority)
No AnastomosisNo Anastomosis
Long healthy left Long healthy left
colonic pedicle.colonic pedicle.
No pelvic dead No pelvic dead
space.space.
No co-morbidity.No co-morbidity.
No radiotherapy.No radiotherapy.
Satisfactory air Satisfactory air
tight anastomosis.tight anastomosis.
Minor to moderateMinor to moderate
co-morbidityco-morbidity
Previous Previous
radiotherapy.radiotherapy.
Elderly or infirm.Elderly or infirm.
Moderate toModerate to
severesevere
co-morbidity.co-morbidity.
What do I doWhat do I do??
Ultra LUltra Low Anastomosisow Anastomosis
Anastomosis Alone Anastomosis Alone (rare)(rare)
Anastomosis with Stoma Anastomosis with Stoma (majority)(majority)
No AnastomosisNo Anastomosis
NilNil Satisfactory air Satisfactory air
tight anastomosistight anastomosis
Mild co-morbidityMild co-morbidity
Elderly or Elderly or
infirminfirm
Moderate or Moderate or
severe severe
co-morbidityco-morbidity