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