Management Of Anastomotic Leaks Research Articles

426. TAILORED MANAGEMENT OF ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY IN A SPECIALISED UNIT IN THE ERA OF HYBRID AND ENDOSCOPIC NOVELTIES

Abstract Tailored management of anastomotic leak after esophagectomy in a specialised unit in the era of hybrid and endoscopic novelties. Triantafyllou Alexandra1, Theodoropoulos Charalampos2, Eleni Kitsou1, Saliaris Konstantinos1, Karikis Ioannis1, Pachos Nikolaos1, Katsila Sofia3, Kakounis Konstantinos3, Triantafyllou Tania1, Xiromeritou Vasiliki3, Theodorou Dimitrios1 1. 1st Propaedeutic Surgical Department, Hippocratio General Hospital of Athens, University of Athens, Greece 2. Surgical Department, Tzaneio Hospital, Greece 3. Department of Gastroenterology, Hippocratio General Hospital of Athens, Greece Background Anastomotic leak following esophagectomy remains one of the most dreadful complications with high rates of morbidity and mortality. This study aims to delineate the incidence, therapeutic strategies, and associated outcomes of esophagogastric anastomotic leak in our unit. Methods We retrospectively analyzed prospectively collected data of patients diagnosed with anastomotic leak following esophagectomy. The treatment modalities and the patient outcomes are presented. Results 199 patients underwent esophagectomy between 2019 and 2023. Among them, 21 patients (10.6%) were diagnosed with anastomotic leakage. 17 out of these 21 patients (81.0%) were male, and the mean age was 58.6 years. 14 out of the 21 patients had cervical anastomosis (leak rate: 8.6%) and 7 patients intrathoracic anastomosis (leak rate: 18.9%). Significant reduction of the intrathoracic anastomotic leak rate was recorded within 2013 (0%) following revision of the anastomotic technique. No deaths were observed, and the average time to healing was 29.1 days. Endoscopic stenting was employed in 12 patients (57.1%), reoperation in 5 (23.8%), bedside wound exploration in 7 (4.8%) and one patient was treated conservatively. Besides stenting, 4 patients (19.0%) underwent percutaneous drainage procedures under radiological guidance. Conclusions Managing esophageal anastomotic leakage presents significant challenges. Optimal outcomes for anastomotic healing and patient survival are achieved through a multidisciplinary and individualised approach encompassing interventional radiology or endoscopy and/or reoperation in selected patients.

Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis

BackgroundColorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective.MethodThis observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed.ResultsA total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was − €74,915.28 per patient without anastomotic complications.ConclusionThe incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.

Intraluminal negative pressure wound therapy and rectal anastomotic leak management: regular vac sponge and a nasogastric tube.

Intraluminal negative pressure wound therapy and rectal anastomotic leak management: regular vac sponge and a nasogastric tube.

Endoluminal vacuum therapy using a fenestrated surgical drain for management of anastomotic leak following esophagectomy

Endoluminal vacuum therapy using a fenestrated surgical drain for management of anastomotic leak following esophagectomy

Glycopyrrolate as an Adjunct in the Management of Anastomotic Leak Following Repair of Esophageal Atresia: A Clinicoradiological Perspective.

Anastomotic leak after primary repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a well-known complication and can represent a challenging clinical scenario. The present study aimed to evaluate the role of glycopyrrolate as an adjunct in the treatment of anastomotic leak after primary repair of EA Vogt type 3b. A retrospective study was carried out in our tertiary care teaching institute from January 2015 to December 2022. Neonates with EA with distal TEF with primary repair who had developed anastomotic leak, managed by the author(s), were studied. The study included patients with major, minor, and radiological leaks. Glycopyrrolate was administered in the dose of 4 μg/kg 8 hourly. The outcomes of the study were either resolution or progression of the leak. There were 21 patients who were managed with glycopyrrolate in addition to the classical treatment of the anastomotic leak following repair of EA with distal TEF. The male: female ratio was 1:1.1. All the cases had anastomotic leaks with either clinically detectable in the chest tube (15) or radiological leak (6). The leaks were detected early in patients with major leak (mean = 3.2 ± 0.84 days) compared to minor leak (mean =4.9 ± 1.29 days). Radiological leaks were detected in all the neonates on postoperative day 7. In five patients with major leak, there was a negligible reduction in the amount of chest tube output, and were subjected to diversion procedures. There were a total of three deaths out of five in this group. In 10 patients with minor leak, there was complete resolution of anastomotic leak in eight patients (80%); there was one patient each with mortality and diversion procedure. The patients with a radiological leak (6) did not show any deterioration, and they were fed 1-5 days after the esophagogram. Glycopyrrolate may be an advantageous postoperative adjunct in the management of minor and radiological leak after tracheoesophageal repair.

Bio-Inspired Self-Healing, Shear-Thinning, and Adhesive Gallic Acid-Conjugated Chitosan/Carbon Black Composite Hydrogels as Suture Support Materials.

The occurrence of leakage from anastomotic sites is a significant issue given its potential undesirable complications. The management of anastomotic leakage after gastrointestinal surgery is particularly crucial because it is directly associated with mortality and morbidity in patients. If adhesive materials could be used to support suturing in surgical procedures, many complications caused by leakage from the anastomosis sites could be prevented. In this study, we have developed self-healing, shear-thinning, tissue-adhesive, carbon-black-containing, gallic acid-conjugated chitosan (CB/Chi-gallol) hydrogels as sealing materials to be used with suturing. The addition of CB into Chi-gallol solution resulted in the formation of a crosslinked hydrogel with instantaneous solidification. In addition, these CB/Chi-gallol hydrogels showed enhancement of the elastic modulus (G') values with increased CB concentration. Furthermore, these hydrogels exhibited excellent self-healing, shear-thinning, and tissue-adhesive properties. Notably, the hydrogels successfully sealed the incision site with suturing, resulting in a significant increase in the bursting pressure. The proposed self-healing and adhesive hydrogels are potentially useful in versatile biomedical applications, particularly as suture support materials for surgical procedures.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience.

Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length ofICU and total hospital stays were 11.5 and 22.5days, respectively. There was no 30-day mortality. The incidence of esophageal ALs at our center is similar to that ofother high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

Commentary on 'Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort' [Int J Surg 2021; 96:106167

Commentary on 'Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort' [Int J Surg 2021; 96:106167

Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers.

(1) Background: A widely accepted algorithm for the management of colorectal anastomotic leakage (CAL) is difficult to establish. The present study aimed to evaluate the current clinical practice on the management of CAL among the German CHIR-Net centers. (2) Methods: An online survey of 38 questions was prepared using the International Study Group of Rectal Cancer (ISREC) grading score of CAL combined with both patient- and surgery-related factors. All CHIR-Net centers received a link to the online questionary in February 2020. (3) Results: Most of the answering centers (55%) were academic hospitals (41%). Only half of them use the ISREC definition and grading for the management of CAL. A preference towards grade B management (no surgical intervention) of CAL was observed in both young and fit as well as elderly and/or frail patients with deviating ostomy and non-ischemic anastomosis. Elderly and/or frail patients without fecal diversion are generally treated as grade C leakage (surgical intervention). A grade C management of CAL is preferred in case of ischemic bowel, irrespective of the presence of an ostomy. Within grade C management, the intestinal continuity is preserved in a subgroup of patients with non-ischemic bowel, with or without ostomy, or young and fit patients with ischemic bowel under ostomy protection. (4) Conclusions: There is no generally accepted therapy algorithm for CAL management within CHIR-Net Centers in Germany. Further effort should be made to increase the application of the ISREC definition and grading of CAL in clinical practice.

Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study.

Management of anastomotic leaks after Ivor-Lewis esophagectomy remains a challenge. Although intracavitary endoscopic vacuum therapy (EVT) has shown great efficacy for large dehiscences, the optimal management of smaller leaks has not been standardized. This study aims to compare EVT versus self-expandable metal stent (SEMS) in the treatment of leaks < 30mm in size, due to the lack of current data on this topic. Patients undergoing EVT (cases) or SEMS (controls) between May 2017 and July 2022 for anastomotic leaks < 3cm following oncologic Ivor-Lewis esophagectomy were enrolled. Controls were matched in a 1:1 ratio based on age (± 3years), BMI (± 3kg/m2) and leak size (± 4mm). Cases (n = 22) and controls (n = 22) showed no difference in baseline characteristics and leak size, as per matching at enrollment. No differences were detected between the two groups in terms of time from surgery to endoscopic treatment (p = 0.11) or total number of procedures per patient (p = 0.05). Remarkably, the two groups showed comparable results in terms of leaks resolution (90.9% vs. 72.7%, p = 0.11). The number of procedures per patient was not significant between the two cohorts (p = 0.05). The most frequent complication in the SEMS group was migration (15.3% of procedures). EVT and SEMS seem to have similar efficacy outcomes in the treatment of anastomotic defects < 30mm after Ivor-Lewis esophagectomy. However, larger studies are needed to corroborate these findings.

Stepping up the management of anastomotic leaks after oesophagectomy: getting a feel through less invasive tentacles.

Stepping up the management of anastomotic leaks after oesophagectomy: getting a feel through less invasive tentacles.

Operative management of anastomotic leak after sigmoid colectomy for left-sided diverticular disease: Ileostomy creation may be as safe as colostomy creation.

The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes. We performed a retrospective cohort study using the NSQIP Colectomy Module (2012-2019) and single-institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak. Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation - 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single-institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies. In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered.

P639 Percutaneous drainage vs surgery as definitive treatment for anastomotic leak after intestinal resection in patients with Crohn’s disease.

Abstract Background Anastomotic leak remains one of the most relevant complications after intestinal resection for Crohn’s disease (CD). While surgery has always been considered the standard treatment for perianastomotic abscess or collection, percutaneous drainage (PD) has been proposed as a potential alternative. The aim of this study was therefore to compare the success rate of percutaneous drainage with that of surgery for the management of anastomotic leak in CD patients. Methods Retrospective, single-centre study including all consecutive patients who were diagnosed with an anastomotic leak as a complication of intestinal resection for CD between 2004 and 2022. Patients requiring emergency surgery due to generalised peritonitis or clinical instability were excluded. Anastomotic leak was defined as a perianastomotic fluid collection confirmed by radiological findings within 30 days from surgery. Patients underwent either PD or surgery as a primary treatment for the complication. The success after PD was defined as the removal of the drainage with clinical and radiological resolution of the complication. The need for further surgical treatment was considered as a failure in both groups. Primary aim: to compare the success rate of PD vs surgery. Secondary aims: to compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication to PD. Results Among the 47 patients included, 25 (53%) underwent PD and 22 (47%) surgery. Table 1 shows the outcomes by the procedure. Success rate was 84% in PD and 95% in surgery group (p=0.20). The median time to success was 14 days after PD (drainage removal) and 12.5 days after surgery (discharge) (p=0.92). Similar rates of post-procedure medical (12% vs 18%, p=0.55) and surgical (24% vs 36%, p=0.62) complications were shown. An ileostomy was required in 91% of surgery cases. At 90 days, similar rates of discharges (100% vs 95%, p=0.28), readmissions (8% vs 0%, p=0.18) and reoperations (16% vs 9%, p=0.48) were observed between PD and surgery cases, respectively. In the multivariate analysis (Table 2), PD was more likely to be performed in patients whose anastomotic leak was diagnosed later after surgery (OR 1.25, 95%CI 1.03-1.53, p=0.027), in those who underwent an ileo-colic anastomosis alone (OR 3.72, 95%CI 2.29-12.45, p=0.034) and in those who were treated after 2016 (OR 6.36, 95%CI 1.04-39.03, p=0.046). Conclusion The present study confirms that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic abscess in CD patients. Surgery, in particular, is associated with a high risk of stoma formation, which would require a subsequent operation. PD should be indicated in all eligible patients as an effective alternative to surgery.

RETRACTED ARTICLE: Changes in diagnosis and management of anastomotic leakage after esophagectomy for underlying malignancy reduce postoperative mortality and improve patient outcome

RETRACTED ARTICLE: Changes in diagnosis and management of anastomotic leakage after esophagectomy for underlying malignancy reduce postoperative mortality and improve patient outcome

Management of anastomotic leakage after robot-assisted minimally invasive esophagectomy with an intrathoracic anastomosis.

Anastomotic leakage is a feared complication after esophagectomy and associated with increased post-operative morbidity and mrotality. The aim of this study was to evaluate the management of leakage after robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis. From a single center prospectively maintained database, all patients with anastomotic leakages defined by the Esophageal Complications Consensus Group between 2016 and 2021 were included. Contained leakage was defined as presence of air or fluid at level of the anastomosis without the involvement of the mediastinum or thorax. Non-contained leakage was defined as mediastinitis and/or mediastinal/pleural fluid collections. The primary outcome was 90-day mortality and the secondary outcome was successful recovery. In this study, 40 patients with anastomotic leakage were included. The 90-day mortality rate was 3% (n = 1). Leakage was considered contained in 29 patients (73%) and non-contained in 11 patients (27%). In the contained group, the majority of the patients were treated non-surgically (n = 27, 93%) and management was successful in 22 patients (76%). In the non-contained group, all patients required a reoperation with thoracic drainage and management was successful in seven patients (64%). Management failed in 11 patients (28%) of whom 7 developed an esophagobronchial fistula, 3 had a disconnection of the anastomosis and 1 died of a septic bleeding. In conclusion, this study demonstrates that the management anastomotic leakage in patients who underwent RAMIE with an intrathoracic anastomosis was successful in 73% of the patients with a 90-day mortality rate of 3%. A differentiated approach for the management of intrathoracic anastomotic leakage is proposed.

Management of anastomotic leaks after oesophagectomy and gastric pull-up.

To evaluate the effectiveness of endoscopic and surgical intervention in treating anastomotic leaks after oesophagectomy. Anastomotic leak after oesophagectomy is a severe complication associated with significant morbidity and mortality. This study aimed to analyse our experience with the management of anastomotic leak after oesophagectomy. A retrospective study evaluated the treatment outcome and duration of treatment in patients with anastomotic dehiscence or conduit necrosis after oesophagectomy from November 2008 to November 2021. The group consists of forty-seven patients. Twenty-one (44.7 %) patients had dehiscence of the neck anastomosis, twenty patients (42.6 %) had dehiscence of the chest anastomosis, and six (12.8 %) patients had conduit necrosis. Nineteen patients with dehiscence were primarily treated by endoscopic insertion of a self-expanding metal stent with perianastomotic drainage; the other patients were primarily treated surgically. Mortality associated with anastomosis dehiscence was 27.7 % (thirteen patients). Stent use in treatment was a statistically significant parameter regarding the length of hospital stay and mortality. Self-expanding metal stents can reduce leak-related morbidity and mortality after oesophagectomy and may be considered a cost-effective treatment alternative (Tab. 2, Fig. 2, Ref. 21).

Early detection of anastomotic leak with C-reactive protein increases the chances of anastomotic salvage.

Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C-reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis. Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010-2013) and 'after' (2016-2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis. Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien-Dindo Grade III to IV, 66.7% vs. 56.9; p= 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p= 0.058) and anastomotic stenosis (p= 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR=2.37 [1.08-5.17]) and increased the number of days out of hospital (p= 0.0002). A CRP-based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay.

Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis.

The present study assessed the factors associated with the maintenance of a functional anastomosis in a large consecutive series of patients with anastomotic leakage (AL). All consecutive patients presenting with AL after colorectal or coloanal anastomosis (2012-2019) were analyzed. The primary end point was a functional anastomosis without a stoma at 1year. A total of 156 patients were included. AL was initially treated by antibiotics (38%), drainage (43%) or urgent surgery (19%). Initial treatment of AL was not adequate in 24.3%, and reintervention in the form of drainage or surgery was required. A total of 60.9% of patients had a functional anastomosis without a stoma 1year after surgery. Factors associated with the risk of anastomotic failure at 1year were diabetes (odds ratio [OR] = 4.24 [95% confidence interval {CI} 1.39-14.24] p = 0.014), neoadjuvant chemoradiotherapy (OR = 3.03 [95% CI 1.14-8.63] p = 0.03) and Grade B (OR = 6.49 [95% CI 2.23-21.74] p = 0.001) or C leak (OR = 35.35 [95% CI 9.36-168.21] p < 0.001). Among patients treated initially by drainage, side-to-end or J-pouch anastomoses were significantly associated with revision of the anastomosis compared to end-to-end (OR = 12.90, p = 0.04). After acute AL following coloanal or colorectal anastomosis, 60.9% of patients had a functional anastomosis without a stoma at the 1year of follow-up. The type of treatment of AL influenced the risk of anastomotic failure.

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus.

BackgroundAnastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons.MethodSeven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon.ResultsThirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks.ConclusionAlthough further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.