Anastomotic leak

Question 1

What is an anastomotic leak?

Answer 1

• Leak of luminal contents from surgical join
• Important post GI surgery complication when anastomosis used

Question 2

Consequences of anastomotic leak

Answer 2

• Contamination of abdominal cavity (or thoracic in oesophagus)
• Sepsis
• –> multi organ failure and even death

Question 3

RF for anastomtic leak - patient factors

Answer 3

• Medication - corticosteroids, immunosupressants
• Smoking or alcohol excess
• Diabetes mellitus
• Obesity or malnutrition

Question 4

RF for anastomotic leak - surgical factors

Answer 4

• Emergency
• Extended operative time
• Peritoneal contamination (eg pus, faeces)
• Oesophageal-gastric anastomosis or colo-rectal anastomosis

Question 5

Symptoms of anastomotic leak

Answer 5

• Usually post op day 3-5 (but can before/after)
• Worsening abdominal pain
• Symptoms of sepsis

Question 6

More subtle presentations of anastomotic leak

Answer 6

• Can be prolonged ileus
• Any patient not progressing appropriately post op with an anastomosis = consider leak

Question 7

Examination of anastomotic leak

Answer 7

• Tender abdomen
• Localised or generalised +/- signs of peritonism - depends on contamination
• If untreated - may be signs of sepsis

Question 8

Investigations for suspected anastomotic leak - bedside and bloods

Answer 8

• Urgent bloods - FBC, CRP, clotting screen
• ABG - pH and lactate
• sepsis 6 if septic too

Question 9

Imaging for anastomotic leak

Answer 9

• CT scan + IV contrast - assess for presence of gas or enteric contents outside lumen
• Can supplement with oral or contrast enema so if contrast outside bowel = +ve diagnosis
  *

Question 10

Initial management of anastomotic leak

Answer 10

• Make patient NBM
• Start broad spec IV abx
• IV fluids
• Insert catheter for fluid balance monitoring
• Ensure nutritional support is considered - if operative or not as some may need TPN

Question 11

Definitive management of minor anastomotic leaks

Answer 11

Conservative:
* If systemically well
* IV abx
* Bowel rest
* Percutaneous drains if needed

Question 12

When can endoluminal vaccum therapy be used? (eg EndoSPONGE)

Answer 12

• Select patients with certain leaks
• eg small leak in low rectal anastomosis

Question 13

Management of patients who are systemically unwell, signs of peritonism +/- large leaks

Answer 13

• Surgical intervention
• Laparotomy + washout of contamination
• Refashioning anastomosis +/- formation of defunctioning proximal stoma