Anastamotic Leak

Question 1

What is anastomotic leak?

Answer 1

Leak of luminal contents from a surgical join between two hollow viscera.

Question 2

What are the risk factors for anastomotic leak?

Answer 2

Emergency surgery or longer intra-operative time
Peritoneal cotamination
Oesophargeal-gastric or rectal anastomosis
Medications
Smoking/alcohol excess
Diabetes or obesity/malnutrition

Question 3

What medications cause anastomotic leak?

Answer 3

Corticosteroids
Infliximab (anti-TNF monoclonal antibody) - slows wound healing but no impact on rate of anastomotic leak
Mycophenolate (immunosuppressant) - increases AL risk
Azathiprine (immunosuppressant)
Bevacizumab (VEGF inhibitor)

Question 4

What are the clinical features of anastomotic leak?

Answer 4

Abdo pain
Fever
5-7 days post-op
OE
pyrexial, tachycardia, peritonism or prolonged ileus (painfuls obstruction of intestine)
Important to check for feculent/purulent material or bile in the wound drain or chest drain for oesophageal anastomoses

Question 5

What are the investigations for anastomotic leak?

Answer 5

Urgent bloods = FBC, CRP, U&E, LFT clotting
VBG for tissue perfusion
G&S
definitive diagnosis - CT scan with contrast of abdomen and pelvis for present of extraluminal contents

Question 6

What is initial management of anastomotic leak?

Answer 6

NBM 
Broad spectrum antibiotic cover
Sepsis pathway 
IV fluid therapy 
Insert urinary catheter
Measure fluid balance

Question 7

What is the definitive management of anastomotic leak?

Answer 7

Minor leaks - obs and bowel rest with percutaneous drainage if necessary
Major leak - exploratory laparotomy whereby surgical intervention may involve stoma formation or diversion/stenting with an abdominal washout

Question 8

How long after surgery do anastomotic leaks present?

Answer 8

5-7 days