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