Anastomotic Leak Flashcards
What are anastomotic leaks defined as?
A leak of luminal contents from a surgical join
How important are of anastomotic leaks?
They are the most important complication to recognise following GI surgery
What is key with anastomotic leaks?
Early diagnosis, resuscitation, and treatment
What does delay in recognition and management of anastomotic leaks lead to?
Prolonged contamination of the abdomen or chest by luminal contents, leading to development of severe sepsis and progression to multi-organ failure and death
Who should be considered to have an anastomotic leak until proven otherwise?
Any patient who is not progressing as expected or deteriorates after surgery
What are the risk factors for anastomotic leak divided into?
- Patient factors
- Surgical factors
What are the patient risk factors for anastomotic leak?
- Medication
- Smoking or alcohol excess
- Diabetes
- Obesity or malnutrition
What medication can increase the risk of anastomotic leak?
- Corticosteroids
- Immunosuppressants
What surgical factors can increase the risk of anastomotic leak?
- Emergency surgery
- Longer intra-operative time
- Peritoneal contamination
- Oesophageal-gastric or rectal anastomosis
What are the most common clinical features of anastomotic leak?
- Abdominal pain
- Fever
When do the symptoms of anastomotic leak present?
5-7 days post-op
What are the other clinical features of anastomotic leak?
- Delirium
- Prolonged ileus
What may be found on examination in anastomotic leak?
- Pyrexia
- Tachycardia
- Peritonism
What is it important to check for in examination for suspected anastomotic leak?
Faeculent/purulent material or bile in any drains
What is the definitive investigation for a suspected anastomotic leak?
CT with contrast or abdomen and pelvis (or CAP for an intra-thoracic anastomosis)
Why is CT with contrast the investigation of choice for suspected anastomotic leak?
Will demonstrate the presence of any extraluminal contents
What is important to ensure in any suspected case of anastomotic leak?
Early resuscitation and senior input
What other initial investigations should be done in suspected anastomotic leak?
- Urgent blood tests
- VBG
- G&S
What urgent bloods should be done in suspected anastomotic leak?
- FBC
- CRP
- LFTs
- Clotting screen
Why should a VBG be done in suspected anastomotic leak?
Assess degree of tissue perfusion
Why should a G&S be done in suspected anastomotic leak?
Needed for possible surgery or radiological drainage
What do the key immediate principles of anastomotic leak relate to?
Treatment of potential contamination and resultant sepsis
What does any suspected anastomotic leak require in terms of review?
Urgent senior review
What is involved in the initial management of anastomotic leak?
- Ensure patient is NBM
- Start broad spectrum antibiotic cover
- Start IV fluid therapy
- Insert urinary catheter (to enable monitoring of fluid balance)
What does the definitive management of anastomotic leak depend on?
- Extent of leak
- Extent of contamination
- Physiological status of patient
How can minor anastomotic leaks be managed?
Conservatively
What is involved in the conservative management of anastomotic leaks?
IV antibiotics
When can anastomotic leaks be managed with IV antibiotics?
Collections <5cm
What may be required for larger anastomotic leaks?
Percutaneous drainage
What may be required for anastomotic leaks if the patient is septic or has multiple collections?
Exploratory lapatotomy
What does an exploratory laparotomy for anastomotic leaks usually involve?
Extensive wash outs with large drain insertion
What is usually required in the case of a colorectal anastomotic leak if septic/multiple collections?
Stoma insertion
What is it important to pay close attention to, if the leak is managed surgically or conservatively?
Patient’s nutrition
What may be required nutritionally for patients with anastomotic leaks?
Act pre-emptively, including considering parenteral nutrition if the patient is likely to be NBM for an extended period of time
