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  2. 2. ANASTOMOSES • Antoine Lembert’s (1802–1851) - Serosal apposition, • William Stewart Halsted (1852–1922) - Mechanical strength & submucosal layer inclusion Combination of • No tension (proper mobilization of bowel). • Good blood supply (pink color, peristaltic bowel with pulsatile mesentery) • Meticulous surgical technique (suturing or stapling) Prof.S.Subbiah et al.
  3. 3. ANASTOMOTIC DEHISCENCE Partial or total loss of continuity in an anastomosis, or very close to the suture line, resulting in a lack of airtightness and communicating the interior of the digestive tract with the extraluminal space. International Multispecialty Anastomotic Leak Global Improvement Exchange Group a defect of continuity localised at the surgical site of the anastomosis, which creates a communication between intra-luminal and extra-luminal compartments Prof.S.Subbiah et al.
  4. 4. CLASSIFICATION Chronologically from the time of surgery • Early - < 3 days after surgery • Intermediate 4-7 days after surgery • Late - developing ≥ 8 days after surgery Prof.S.Subbiah et al.
  5. 5. • Grade A - Leakage with radiological studies with discrete or absent clinical features (no active intervention) • Grade B - Leakage that requires therapeutic intervention (medical management, antibiotic treatment or percutaneous drainage), manageable without surgical intervention • Grade C - with peritonitis and SIRS that require surgical intervention J Gastrointest Oncol 2019;10(6):1229-1237 | http://dx.doi.org/10.21037/jgo.2019.07.07 Prof.S.Subbiah et al.
  6. 6. TECHNIQUES • Suturing (interrupted, continuous, 1/2 layer) end-to-end or end-to- side anastomoses. • Stapler (linear or circumferential) • Factors to consider • Intestinal location, bowel diameter, bowel edema, patient factors, associated peritoneal infection, cancer, contamination, or surgeon preference. Prof.S.Subbiah et al.
  7. 7. • Technique - not associated with major differences in leak rate, (except in specific situations) • Special circumstances- Inflamed, edematous, or thickened bowel (diverticulitis, radiation enteritis, or inflammatory bowel disease) Prof.S.Subbiah et al.
  8. 8. • Technical factors - suture line gaps, misplaced sutures, stapler misfiring, enterotomy, or tear • Distal obstruction, ischemia, and underlying disease - delayed anastomotic leaks (disease related) Prof.S.Subbiah et al.
  9. 9. • Distinct bacterial populations (e.g., Enterococcus faecalis, Bacillus subtilis) - degrade collagen & endanger anastomotic healing • Obligate anaerobes (Clostridum coccoides, Bacteroides fragilis, Bifidobacterium spp & Prevotella spp.) - GI homeostasis & beneficial in anastomotic healing Langenbeck's Archives of Surgery (2021) 406:971–980 https://doi.org/10.1007/s00423-020-01957-1 Prof.S.Subbiah et al.
  10. 10. • Anastomotic integrity -- saline, betadine, or air under pressure to distend the bowel at the site. • Failed staple firing - anastomotic revision • Bowel ischemia or viability - fluorescence vascular angiography • Damage control surgery with a second look & delayed anastomosis DOI: 10.2298/SARH1106333I UDC: 616.348/.35-008-089 Prof.S.Subbiah et al.
  11. 11. Prof.S.Subbiah et al.
  12. 12. virtual ileostomy Langenbeck's Archives of Surgery https://doi.org/10.1007/s00423-019-01776-z Prof.S.Subbiah et al.
  13. 13. SUTURELESS ANASTOMOSES Int J Colorectal Dis DOI 10.1007/s00384-015-2257-z Prof.S.Subbiah et al.
  14. 14. Cellular level issues • Chemotherapy, radiation, and cofactor deficiencies (e.g., vitamins A, C, and E) • In uncontrolled DM (macrophage number and activity are decreased angiogenesis, lymphatic vessel formation, and collagen synthesis causing delayed healing. • Zinc deficiency increases matrix metalloproteinase activity, altering collagen-type ratio, and reducing cellular proliferation. Prof.S.Subbiah et al.
  15. 15. Microcirculatory issues • Heart failure, mesenteric vascular disease, or hemorrhagic or septic shock -- hypoperfusion • Healing is impaired (TaO2) < 35 mm Hg • Angiogenesis, growth factors, and epithelialization impaired < 10 mm Hg. Prof.S.Subbiah et al.
  16. 16. Location • Small bowel anastomoses --“low risk” • Esophageal, Pancreaticoenteric, & colorectal anastomoses “increased risk” • Colorectal anastomoses > ileocolic & colocolic anastomosis. • Rectal surgery - the distance from the anal verge is an independent risk factor • Below the peritoneal reflection (8%–20%) & rectal anastomosis (1%– 9%). Prof.S.Subbiah et al.
  17. 17. • Anastomosis < 10 cm from the anal margin 13.9% vs 3% > 10 cm from the AM. • High ligation of the IMA increased the risk of AD by 3.8 times • Male gender (Pelvis - narrow and technical difficulty) Zeng and Su World Journal of Surgical Oncology (2018) 16:157 https://doi.org/10.1186/s12957-018-1458-7 Gastroenterology Report, 6(2), 2018, 137–143 doi: 10.1093/gastro/gox039 Prof.S.Subbiah et al.
  18. 18. Patient related factors • Protein malnutrition (albumin <3.0–3.5 g/dL), • Weight loss (>10% body weight), diabetes, • Shock, severe blood loss, • Preexisting renal disease • Immune deficiency, • Smoking, Alcohol consumption, • Increased age & Obesity Prof.S.Subbiah et al.
  19. 19. • Metastatic colorectal cancer- independent risk • Both pre- and postoperative use of the bevacizumab • Bevacizumab - 6 weeks before an elective colorectal anastomosis and 28 days after surgery Ann Surg Oncol DOI 10.1245/s10434-015-4941-1 Prof.S.Subbiah et al.
  20. 20. • Steroid use impairs healing (decreasing TGF-β, IGF-I, and collagen production). • Emergency surgery - multiple reasons _ (malignancy, immunocompromised state, sepsis, hemodynamic instability) • Open abdomens with NPWT - Higher leak rates vs Primary closure Prof.S.Subbiah et al.
  21. 21. ADJUVANT MEASURES ???!!! • Pelvic drains, omental wrapping, or tissue reinforcement - unclear. • Pelvic drains - Prevent the accumulation of blood and fluids, which may become (infected) and suture line dehiscence. • Mixed results - closed suction pelvic drains have fewer anastomotic complications Vs others - independent risk factor Prof.S.Subbiah et al.
  22. 22. Optimization • Smoking cessation, Nutritional optimization (essential nutrients e.g., protein, zinc, and copper) and vitamins (e.g., A, C, and E). • Risk stratification & optimization of cardiac and respiratory illness. • Sleep apnea with continuous positive airway pressure ventilation, preoperative beta blockade or afterload reduction, improving glycemic control Prof.S.Subbiah et al.
  23. 23. • The combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics reduce the risk of SSI in elective colorectal surgery Ambe et al. World Journal of Surgical Oncology (2019) 17:20 https://doi.org/10.1186/s12957-019-1563-2 Prof.S.Subbiah et al.
  24. 24. PRESENTATION & DIAGNOSIS Variable depending on • Intestinal location, • Size of the leak, • Degree and spread of contamination • Timing (early vs. late) Prof.S.Subbiah et al.
  25. 25. • Intraabdominal leaks: • Fever, tachycardia, increasing abdominal pain, elevated WBC count, decreased urine output & shortness of breath • Early (severe symptoms) • Sepsis, MODS if intestinal contents are disseminated throughout the peritoneal cavity. • Late (subtle) • vague abdominal pain, prolonged ileus, “walled off” abscess. • Intra-abdominal drains or as SSIs with ECFs from skin incision. Prof.S.Subbiah et al.
  26. 26. TIMING • GJ leaks after bypass surgery usually present early (<24 hours) • Small bowel or Colon between 5 and 7 days after surgery. • Obvious clinical signs of peritonitis/severe sepsis, exploratory laparotomy or diagnostic laparoscopy. • Complete blood test, C-reactive protein, procalcitonin may be elevated -nonspecific. Prof.S.Subbiah et al.
  27. 27. DULK Score: • uses 13 parameters • scores > or equal to 4 identifies the leak Modified DULK Score: • uses 4 variables ( Clinical condition, RR, Abdominal pain & CRP level); >1 or equal used Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e528–e533 doi:10.1111/codi.12379 Prof.S.Subbiah et al.
  28. 28. IMAGING • MC techniques - water-soluble contrast studies & CT scans. • Fluoroscopic contrast studies -- for proximal GI or distal colorectal anastomoses. • Abdomen-pelvic CT scans with oral or rectal contrast • Interventional radiology sampling or drainage treat a small or contained leak. Prof.S.Subbiah et al.
  29. 29. • Local inflammation (Stranding, Thickened bowel) • Large amounts of fluid (>300 mL) around the anastomosis ± free air Prof.S.Subbiah et al.
  30. 30. MANAGEMENT • Asymptomatic, Leaks identified through imaging - No treatment. • Localized abscesses (not toxic) - Abscess drainage, broad spectrum antibiotics, and/or bowel rest. • A contained leak with abdominal or pelvic abscess + clinical signs of sepsis = abscess drainage + broad spectrum antibiotic coverage • Surgical intervention - absence of clinical improvement or deterioration, sepsis, or diffuse peritonitis Prof.S.Subbiah et al.
  31. 31. • Small leaks from a low colorectal anastomosis - Pelvic drains and a diverting loop ileostomy. • Protective stomas are not just limited to rectal surgery but are applicable to all anastomoses • Proximal diverting stoma - reduce the clinical impact of anastomotic failure by diverting the fecal stream. Prof.S.Subbiah et al.
  32. 32. • SEMS or covered stents • Stent migration - issue • Reduced by endoclip placement Prof.S.Subbiah et al.
  33. 33. ENDOSCOPIC TECHNIQUES • fistula closure- • Placing conventional endoscopic clips or special bear-trap clips OVESCO (over the scope) • Drainage and obliteration of the para-anastomotic spaces _ suction-assisted endoscopic drainage application, (sponge in the para-anastomotic sinus with suction assisted drainage) Prof.S.Subbiah et al.
  34. 34. NiTi CAR 27 (compression ring) is equivalent to that of the conventional circular staplers. Prof.S.Subbiah et al.
  35. 35. Anastomotic biomarkers • Implantable sensors placed intra- operatively; • Continuously monitor peri- anastomotic biomarkers such as O2, pH, C-reactive protein, lactate and pyruvate levels. Prof.S.Subbiah et al.
  36. 36. For colon cancer, leakage was not associated with increased LR & decreased DFS. For rectal cancer, an increase in LR (13.3% vs 4.6%) & decrease of DFS (53.6% vs 70.9% at 5-year follow-up Annals of Surgery: February 2022 - Volume 275 - Issue 2 - p e420-e427 doi: 10.1097/SLA.0000000000003889 Prof.S.Subbiah et al.
  37. 37. THANK YOU... Prof.S.Subbiah et al.