tips and tricks of avoiding and management of anastomotic complications

Tips and Tricks of Avoiding and Management of

Anastomotic Complications

Feza H. Remzi, MD, FACS,FASCRS., FTSS (Hon)Chairman Chairman

Department of Colorectal SurgeryDepartment of Colorectal SurgeryProfessor of SurgeryProfessor of Surgery

Rupert B Turnbull Jr,. MD Chair Rupert B Turnbull Jr,. MD Chair Digestive Disease InstituteDigestive Disease Institute

Cleveland Clinic, Cleveland, OHCleveland Clinic, Cleveland, OH

Introduction

• Colorectal / anal

• Ileal Pouch anal anastomosis

• Ileocolic anastomosis

• Small bowel to small bowel

Colorectal / Anal Anastomosis

Acute Management

• Not diverted, – Take back for washout with diverting loop ileostomy

and avoid taking down the colorectal anastomosis

– Drain; I still prefer penrose drains

• Diverted– If leak is proven with CT or GGE; EUA and transanal,

anastomotic drainage through the defect

– If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal

– Prefer mushroom catheter

• IV ATBS, and conservative management and control of sepsis and wait, wait, and wait

Longterm Management of Colorectal / Anal Anastomotic Leak• Wait 6 to 12 months

• Periodic EUA, I & D of cavity, GGE

• If it heals, proceed with ileostomy closure

• If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure

• Incomplete healing / closure of the defect– Ileostomy closure and explain the possibility of recurrence– Presacral sinus with a wide mouth/opening usually

does better– Cavity that got epithelized with mucosa also does well

Turnbull- Cutait Pull Through

Turnbull Cutait

Ileal Pouch Anal Anastomosis

TPC and IPAA

Reach Issues

Difficulty in Reach

Acute Management After IPAA

• Not diverted, – Take back for washout with diverting loop ileostomy

and avoid taking down the colorectal anastomosis

– Drain; I still prefer penrose drains

• Diverted– If leak is proven with CT or GGE; EUA and transanal ,

anastomotic drainage through the defect

– If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal

– Prefer mushroom catheter

• IV ATBS, and conservative management and control of sepsis and wait, wait, and wait

Longterm Management of IPAA Anastomotic Leak

• Wait 6 to 12 months

• Periodic EUA, I & D of cavity, GGE

• If it heals, proceed with ileostomy closure

• If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure

• Incomplete healing / closure of the defect– Ileostomy closure and explain the possibility of recurrence– Presacral sinus with a wide mouth/opening usually

does better– Cavity that got epithelized with mucosa also does well

General Principles

• If not diverted, diverting ileostomy for 3 to 6 months before considering a redo pouch

• Be prepared for the unexpected

• Consenting; permanent ileostomy vs K pouch

• Ureteric stents

• Availability of blood products

• Must excise the pelvic phlegmon to accomplish healing

• Dissection known to unknown, must have exit strategy

• Pelvic dissection; caudal to cranial

Ileocolic Anastomosis

Small Bowel to Small Bowel