Anastomotic leaks

Question 1

what is an anastomotic leak

Answer 1

Leak of luminal contents from a surgical join

Can lead to prolonged contamination of the abdomen or chest by the luminal contents, leading to the development of severe sepsis and progression to multi organ failure and death.

Question 2

who should you consider anastomotic leaks in

Answer 2

any patient who is not progressing as expected or who deteriorates after surgery should be considered to have an anastomotic leak until proven otherwise.

Question 3

what are risk factors for anastomotic leaks

Answer 3

Patient based: smoking, obesity or malnutrition, alcohol excess, medications like steroids or immunosuppressant, and diabetes mellitus
Surgical: emergency surgery, prolonged operative time, peritoneal contamination, oesophageal or rectal anastomosis.

Question 4

presentation of anastomotic leaks

Answer 4

Abdominal pain and fever most commonly.
5-7 days post-operatively.
Other features may include delirium or prolonged ileus.
On examination, patients may be pyretic, tachycardic, +/- with signs of peritonism.

Question 5

initial management of anastomotic leaks

Answer 5

Ensure early resuscitation and senior input for any suspected cases
Start broad spec ABX, IV fluids, catheterisation and ensuring the patient is NMB.

Management is with bowel rest, intravenous antibiotics, and potential surgical intervention if a major leak

Question 6

what surgical intervention should be offered to those with a larger anastomotic leak

Answer 6

drained percutaneously if possible
if the patient is septic or has multiple collections then exploratory laparotomy is often required. This generally involves extensive wash outs with large drain insertion; in the case of a leaking Colo-rectal anastomosis, this also usually requires a stoma to be fashioned.