Gastrointestinal Anastomotic Leaks Research Articles

Mo1704 Risk Factors for Failure of Percutaneous Drainage and Need for Re-Operation Following Symptomatic Gastrointestinal Anastomotic Leak

BACKGROUND: Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks. METHODS: Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD. RESULTS: Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P 5.03) and cancer surgery (P 5.01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/ stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD. CONCLUSIONS: Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Little consensus in either definition or diagnosis of a lower gastro-intestinal anastomotic leak amongst colorectal surgeons

The purposes of this study were to assess the working definition of a colorectal anastomotic leak among colorectal surgeons and to survey the current approach to investigation and management of a patient with a suspected anastomotic leak. Online survey consisting of nine questions regarding the definition, assessment and investigation of anastomotic leaks was conducted. Of the 738 eligible ACP members contacted, 210 responded (28.4%). Results demonstrated that 94.2% of surgeons agreed 'extravasation of contrast on enema' and 91.8% agreed 'faecal material seen in drains/from the wound' constituted a clinical leak. Only 69.2% agreed that a leak was 'intra-abdominal sepsis requiring a laparotomy', and about half agreed that radiological collections constituted a leak when either treated with antibiotics (46.6%) or with percutaneous drainage (51.4%). Serial clinical examination was the perceived most sensitive clinical feature for a leak, with 75% of surgeons ranking this in their top three choices. Surgeons radiologically confirm a leak on average in 80.2% of cases. A CT with rectal contrast for a left-sided leak was selected by 42.9% of respondents. For a right-sided/small bowel anastomosis, 44.5% selected a CT with oral contrast and 43.4% a CT with IV contrast. There is still significant heterogeneity between surgeons in what they define as an anastomotic leak. Most surgeons valued clinical examination as the most sensitive initial tool for leak detection; however, radiology has a major role in the confirmation of clinical leaks in colorectal patients. There is an increasing need to be able to classify and grade anastomotic leaks, both to improve the care of patients and for audit purposes.

Predictors of septic shock following gastrointestinal anastomotic leaks: Only signposts, no destination

Predictors of septic shock following gastrointestinal anastomotic leaks: Only signposts, no destination

Fistula after pyloroplasty - A novel approach to the management of a leak following oesophagectomy.

Management of upper gastrointestinal anastomotic leaks is an inter-disciplinary challenge. We present a case of late pyloroplasty leak following 3-stage oesophagectomy. We describe a novel, combined endoscopic and fluroscopic procedure to introduce a T-tube into the anastomotic leak proving an ideal plug at the site of leak which enabled the patient to consume a normal diet and return home safely.

Small intestinal submucosa for reinforcement of colonic anastomosis

Different materials have been evaluated for anastomotic reinforcement to prevent gastrointestinal anastomotic leakage. In this experimental study, small intestinal submucosa (SIS) was tested as a sealing for stapled colonic anastomosis in a porcine model. The aims of this study were to determine the macroscopic and microscopic outcomes and to evaluate the safety and feasibility of applying SIS for anastomotic sealing. Circular stapled anastomoses were performed in 18 pigs. Standard anastomosis in the control group (n = 8) was compared to an SIS-sealed anastomosis in the study group (n = 10). After 30 days, anastomotic segments were examined for macroscopic and microscopic regeneration and their resistance to mechanical stress. Furthermore, animal survival and clinical course were evaluated. None of the animals developed anastomotic leakage, intraabdominal abscess, or peritonitis. Shrinkage of SIS was evident in nine of ten animals. Encapsulation and displacement of the SIS patches were seen in two animals. Quantity of anastomotic granulation tissue and rate of complete mucosal coverage of anastomotic line were increased in SIS-sealed anastomoses without reaching significance. Moreover, no significant differences were found in the rate of survival of the animals, anastomotic stricture formation, intraabdominal adhesions, anastomotic bursting pressure, and microscopic healing parameters of the anastomosis between stapled colonic standard anastomosis and anastomosis protected by SIS. The results of this study indicate a safe use of SIS for anastomotic reinforcement in a porcine model. Adverse effects like strictures, increased adhesions, and anastomotic abscesses were absent. Promoting effects on colonic wound healing by SIS were microscopically evident. The results argue for a careful clinical evaluation in humans.

Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.

Endotherapy of Upper GI Anastomotic Leaks Using a Modified Tygon Plastic Stent: Results of a Large Single Center Series

Background: Upper gastrointestinal (GI) anastomotic leaks are associated with significant morbidity and mortality. The risks of repeat surgery are high and further compounded by the possibility of poor anastomotic healing. Endoscopic treatment with self expandable stents (SES) has been reported. SES are costly, and in the absence of associated luminal strictures, there is a high risk of stent migration; in the event of successful placement, SES especially metallic stents may be difficult to remove after fistula resolution. Aim: To examine the feasibility of a modified Tygon plastic stent for the treatment of postoperative upper GI anastomotic leaks. Methods: The clinical data of consecutive patients with upper GI anastomic leaks who were referred for endoscopic treatment with a modified Tygon plastic stent during the period from November 1997 to June 2007 were reviewed. Tygon plastic stents with a diameter ranging from 9-14 mm were individually tailored according to the location of the leaks. After endoscopic placement of a guidewire, the stent was inserted over a bougie without fluoroscopic monitoring. To prevent distal migration, a 7Fr Teflon catheter was attached to the proximal end of the stent and looped around the ear before being fixated with adhesive tape. Results: A total of 40 patients (80% male; mean age 63.5 years) with upper GI anastomotic leaks (post-esophagectomy: 22.5%; post-gastrectomy: 35%; post-esophago-gastrectomy: 37.5%; chronic anastomotic fistula: 5%) were treated with a modified Tygon plastic stent with a mean duration of 32 days (range: 2 - 209) after surgery. Forty percent of these patients had previous unsuccessful treatment with surgery (35%) or endoscopic fibrin glue injection (5%). Stent insertion was technically successful in all patients without any procedure related complications. After stent placement, 30% of patients died from other postoperative complications and severe underlying co-morbidities before resolution of the leaks. Successful resolution of leaks occurred in 96.4% of the remaining cases after stent placement, and the stents were subsequently removed easily without the need for endoscopy after a mean duration of 39 days (range: 17 - 130). Stent dislocation occurred in 15% of cases but successful reinsertion was possible in all instances. No complications occurred after stent placement. Conclusions: Endoscopic temporary placement of a modified Tygon plastic stent is a very effective and safe method for management of upper GI anastomotic leaks.

Perioperative Vasopressors Are Associated with an Increased Risk of Gastrointestinal Anastomotic Leakage

The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown. Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002). Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.

Anastomotic Leaks: What is the Best Diagnostic Imaging Study?

Postoperative anastomotic leaks are one of the most devastating consequences of colorectal surgery. Diagnostic imaging for upper gastrointestinal anastomotic leaks has been evaluated and reported on extensively. No study has compared the utility and effectiveness of CT scans and water-soluble enemas for the identification of postoperative lower gastrointestinal anastomotic leaks. The present study was designed to evaluate and compare these two common radiographic imaging modalities in detecting lower gastrointestinal anastomotic leaks. A retrospective chart review was performed that identified 36 patients during a seven-year period who underwent reoperative surgery for a lower gastrointestinal anastomotic leak. Patient's imaging studies were classified as positive if extravasation of contrast material was demonstrated. When negative, a study was retrospectively reviewed in an attempt to identify findings suggestive of an anastomotic leak. There were 36 patients identified with a postoperative lower gastrointestinal leak requiring surgical intervention. There were 28 of 36 patients (78 percent) re-explored on the basis of a radiologic study demonstrating an anastomotic leak. A total of 27 CT scans were performed, of which 4 (14.8 percent) were considered positive for an anastomotic leak. On review of the remaining negative CT scans, nine (33.3 percent) were considered descriptive positive with a large amount of fluid or air in the peritoneal cavity but without obvious extravasation of contrast. Eighteen patients were evaluated with a water-soluble enema and 15 (83.3 percent) demonstrated extravasation of contrast material. In the 26 patients with a distal anastomotic leak, 17 water-soluble enemas were performed, with 15 (88 percent) demonstrating a leak. In contrast, only 2 of 17 (12 percent) CT scans were positive in this group of patients (P < 0.001). There were ten patients who initially had a CT scan followed by a water-soluble enema. Of these patients, eight of nine (88 percent) initially had a negative CT scan but were considered to be clinically suspicious of having an anastomotic leak and subsequently had a leak demonstrated on a water-soluble enema. Early intervention in patients who develop an anastomotic leak can be shown to improve the ultimate outcome, especially with respect to mortality. It is usually necessary to obtain objective tests of anastomotic integrity because of the nonspecificity of clinical signs. Our study supported the superiority of water-soluble enema to CT imaging in patients in whom both modalities were used. This difference was most pronounced for distal anastomotic leaks, whereas no radiologic imaging study proved effective in evaluating proximal anastomoses.

CT assessment of anastomotic bowel leak

To evaluate the predictors of clinically important gastrointestinal anastomotic leaks using multidetector computed tomography (CT). Ninety-nine patients, 73 with clinical suspicion of anastomotic bowel leak and 26 non-bowel surgery controls underwent CT to investigate postoperative sepsis. Fifty patients had undergone large bowel and 23 small bowel anastomoses. The time interval from surgery was 3-30 days (mean 10+/-5.9 SD) for the anastomotic group and 3-40 days (mean 14+/-11 SD) for the control group (p=0.3). Two radiologists blinded to the final results reviewed the CT examinations in consensus and recorded the presence of peri-anastomotic air, fluid or combination of the two; distant loculated fluid or combination of fluid and air; free air or fluid; and intestinal contrast leak. Final diagnosis of clinically important anastomotic leak (CIAL) was confirmed at surgery or by chart review of predetermined clinical and laboratory criteria. The prevalence of CIAL in the group undergoing CT was 31.5% (23/73). The CT examinations with documented leak were performed 5-28 (mean; 11.4+/-6 SD) days after surgery. Nine patients required repeat operation, 10 percutaneous abscess drainage, two percutaneous drainage followed by surgery, and two prolonged antibiotic treatment and total parenteral nutrition (TPN). Of the CT features examined, only peri-anastomotic loculated fluid containing air was more frequently seen in the CIAL group as opposed to the no leak group (p=0.04). There was no intestinal contrast leakage in this cohort. Free air was present up to 9 days and loculated air up to 26 days without CIAL. Most postoperative CT features overlap between patients with and without CIAL. The only feature seen statistically more frequently with CIAL is peri-anastomotic loculated fluid containing air.

Endoscopic Treatment of a Large Upper Gastrointestinal Anastomotic Leak Using a Prolene Plug and Cyanoacrylate

Endoscopic Treatment of a Large Upper Gastrointestinal Anastomotic Leak Using a Prolene Plug and Cyanoacrylate

Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks

The adoption of advanced laparoscopic techniques for complex surgical procedures has raised the concern that the leak rate might be higher than for open surgery, particularly in the surgeon's early experience or in difficult cases. In this study, the sealing effect of fibrin glue on leaking gastrointestinal anastomoses was evaluated in an experimental swine model. A standardized gastrojejunostomy was performed on 20 female pigs (mean weight, 47.7 +/- 5.7 kg). A leak was created on the anterior surface of the anastomosis. The animals were randomized to either fibrin glue or no treatment of the leak. Clinical conditions and vital signs, including body temperature, heart rate and, respiratory rate, were collected three times a day. Preoperative and postoperative complete and differential blood count and lactate dehydrogenase levels were determined. Postmortem analysis was performed when the animals were killed. Clinical signs of peritonitis developed in the control animals by the second or third postoperative day. Findings that confirmed the presence of an anastomotic leak at the postmortem examination were the presence of food or gastrojejunal juices in the abdominal cavity, a localized abscess, or a positive air leak test. Fibrin glue treatment prevented the development of peritonitis in all the animals. Complete sealing of the leak was observed on postoperative day 7 in all treated animals, except one in which an asymptomatic contained leak developed. The postoperative total white blood count was significantly increased in the untreated group (24.69 +/- 5.5 vs 12.74 +/- 3.7 10(3)/ul p < 0.001, paired t-test), as compared with the treated group (15. 55 +/- 2.4 vs 14.89 +/- 2.7 10(3)/ul; p = 0.24). In this study, fibrin glue showed reproducible sealing effects on leaking gastrojejunal anastomoses. Fibrin glue application may be a valuable approach for the treatment of gastrointestinal anastomotic leaks.

The efficacy of fibrin sealant in prevention of gastrointestinal anastomotic leak

Introduction: Anastomotic leak, although low in frequency (1–2%), is a dreaded complication after Roux-en-Y gastric bypass (GBP). Clinical uses of fibrin sealant for prevention of gastrointestinal (GI) leak have been reported; however, its efficacy has not been demonstrated. The aims of this study were to 1) develop an anastomotic leak animal model, 2) examine the efficacy of the tissue sealing property of fibrin sealant, and 3) review our experience in the use of fibrin sealant in 42 patients who underwent laparoscopic GBP. Methods: This study was performed in three phases. In phase 1, laparoscopic GI anastomosis was performed in adult swine with disruption of the staple-line starting at a 6F opening and sequentially increased in size until a leak model was developed. A leak model was developed at a 12F opening. In phase 2, ten animals (study group) underwent laparoscopic gastrojejunostomy with a 12F disruption of the anastomosis and received 2-mL of fibrin sealant (Tisseel, Baxter Healthcare Corp) applied on the disrupted area. The control animals (n = 6) did not receive the fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed. The primary endpoint was sealing of the disrupted anastomosis at sacrifice and secondary endpoint was evaluation for the presence of intraabdominal abscess. In phase 3, fibrin sealant was used clinically in 42 laparoscopic GBP patients. Results: In phase 2, persistent anastomotic leak was identified in 2 of 6 control animals (both required early sacrifice due to peritonitis). Three of 6 control animals had intraabdominal abscess discovered at sacrifice on postoperative day 5 without persistent leak and 1 animal in the control group did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice. None of the animals had evidence of intraabdominal abscess or persistent leak at sacrifice. Leak or abscess occurred in 83% of control animals compared to 0% in the study animals (p < 0.01, Fischer’s Exact test). Clinically, there was no leak or intraabdominal abscess in the 42 patients who underwent laparoscopic GBP. Conclusions: The use of fibrin sealant in an animal leak model significantly reduces leak and abscess complication. Our results support the efficacy of tissue sealing property of fibrin sealant and its use on high-risk GI anastomosis.