Beruflich Dokumente
Kultur Dokumente
Clinical Science
Department of Surgery, Colorectal Unit, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain
KEYWORDS: Abstract
Colorectal BACKGROUND: The aim of this study was to evaluate and compare the morbidity associated with
anastomosis; 2 strategies of treatment of colorectal anastomotic leakage: surgical drainage of anastomosis with loop
Leakage; ileostomy versus anastomotic takedown.
Anastomotic METHODS: An observational study of patients operated on for ileocolic or colorectal anastomotic
takedown; leakage between 2001 and 2009. Patients were classified into 2 groups: group 1, salvage of the
Salvage; anastomosis, and group 2, anastomotic takedown. Mortality and morbidity were assessed. Morbidity
Bowel restoration and mortality of bowel restoration were also evaluated.
RESULTS: Thirty-nine patients were included into group 1 and 54 into group 2. Mortality was 15%
for group 1 and 37% for group 2 (P ⫽ .022). The rate of patients suitable for stoma reversal was 91%
for loop ileostomy and 38% for end stoma (P ⬍ .001). Morbidity was 18% after loop ileostomy closure
and 71% after end stoma reversal (P ⫽ .021). Hospitalization was 10 days and 21 days, respectively
(P ⫽ .009). There was no mortality.
CONCLUSIONS: Salvage of anastomosis with loop ileostomy is an effective strategy to control
peritoneal sepsis for colorectal anastomotic leakage.
© 2012 Elsevier Inc. All rights reserved.
Anastomotic leakage (AL) is the most feared and dread- also result in a poorer functional outcome and increase the
ful specific complication of colorectal surgery, leading to risk of permanent stoma formation.7–9
significant morbidity, increased mortality, and prolonged There is no universally accepted definition of colorectal AL.
hospital stay. There is also a significant increase in the use It may present as diffuse peritonitis requiring abdominal reop-
of hospital resources and costs after AL.1 The reported eration; as fecal discharge from the wound or drain; as a
incidences vary from .5% to over 30%2–5 depending on the localized abscess, which may be amenable to computed to-
inclusion criteria, the case mix, and the definition of leak. mography scan– guided percutaneous drainage; or as extrava-
In emergency colorectal procedures, AL occurs in 2% to sation of radiologic contrast in an otherwise asymptomatic
16% of cases of colonic obstruction and in 6% to 19% of patient, which may only require surveillance.10
cases operated on for colonic peritonitis.6 AL adversely Conventional management of a clinical AL with local or
affects the morbidity and mortality of postoperative patients diffuse peritonitis often requires taking down the anastomo-
with a mortality rate of 25% to 35% in large series. It may sis, with creation of an end colostomy or ileostomy; the
distal bowel is closed and left within the abdominal cavity
* Corresponding author: Tel.: ⫹34-93-260-7485; fax: ⫹34-93-260-7485. or is exteriorized as a mucosal fistula. However, the salvage
E-mail address: sebastianobiondo@yahoo.com of a leaking colorectal or coloanal anastomosis using sur-
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.04.022
672 The American Journal of Surgery, Vol 204, No 5, November 2012
Table 1 Site of anastomosis and treatment Table 3 Patients’ characteristics at the reoperation
and their differences according to the anastomotic
All patients Group 1 Group 2 leakage treatment
93 39 54
Intraperitoneal 79 (84.9) 32 (82.1) 47 (87.0) All patients Group 1 Group 2
Proximal 45 (48.4) 23 (59.0) 22 (40.7) 93 39 54 P value
Distal 34 (36.6) 9 (23.1) 25 (46.3) Hinchey score .329
Extraperitoneal 14 (15.1) Hinchey I–II 15 (16.1) 8 (20.5) 7 (13.0)
Low rectum 14 (15.1) 7 (17.9) 7 (13) Hinchey III-IV 78 (83.9) 31 (79.5) 47 (87.0)
Values in parentheses are percentages. Blood white cells .056
Group 1: salvage of the anastomosis and loop ileostomy, group 2: 4000–10,000 44 (47.3) 23 (59.0) 21 (38.9)
anastomosis takedown. ⬎10,000 49 (52.7) 16 (41.0) 33 (61.1)
Renal failure 29 (31.2) 11 (28.2) 18 (33.3) .598
Respiratory 17 (18.3) 5 (12.8) 12 (22.2) .247
failure
Hemodynamic 18 (19.4) 6 (15.4) 12 (22.2) .410
after anastomotic takedown needed further surgery more failure
frequently than those with salvage of the anastomosis and Type of surgeon .001
loop ileostomy (18.5% vs 7.7%) without statistical differ- Colorectal 48 (51.6) 28 (71.8) 20 (37.0)
ences. General 45 (48.4) 11 (28.2) 34 (63.0)
The overall mortality rate was 28.0% (26/93). Six of 39 Values in parentheses are percentages.
patients in group 1 died (15.4%), whereas in group 2 the Group 1: salvage of the anastomosis and loop ileostomy, group 2:
anastomosis takedown.
death rate was 37% (20/54 patients) (P ⫽ .022). The length
of hospital stay was 32.15 days (standard deviation [SD] ⫽
judgment and confidence in the case of a colorectal surgeon the study of Hedrick et al,15 63% of patients managed with
rather than simply technical skill. surgical drainage and proximal diversion had restoration of
Many authors recommend anastomotic resection because intestinal continuity compared with only 33% of the patients
of the high risk of ongoing sepsis caused by the stool who had an end stoma. In the present experience, 91% of
contained in the proximal colon when a leaking anastomosis patients who were treated with salvage of the anastomosis
is left in place. We consider that intraoperative colonic and loop ileostomy have been considered suitable for stoma
lavage performed through the distal opening of the loop closure. By contrast, only 38% of patients with an end
ileostomy decreases the fecal load of the proximal colon and colostomy or end ileostomy were selected for restoration of
may be a useful method to reduce the risk of further sepsis, bowel continuity.
abscess formation, or local peritonitis. The morbidity after loop ileostomy closure in the present
Restoration of bowel continuity after end stoma creation series was 17.6%, which is similar to other reports,24 –27 and
is associated with high morbidity rates, AL rates of 4% to significantly lower than in the end stoma reversal group. No
16%, and mortality rates of up to 4%.17 Major complex death was observed in either group. The length of stay was
surgery is often required with a full midline laparotomy, approximately twice as long for the reversal of end colos-
laborious takedown of adhesions, and difficult pelvic dis- tomy or end ileostomy compared with loop ileostomy. We
section to identify the rectal stump; in these circumstances, think these results should be taken into account because of
the risk of damage of pelvic vessels, ureters, or hypogastric its considerable effect on the use of hospital resources and
nerves is considerable. In many cases, partial or total resec- on overall health costs. Although we have not performed a
tion of the rectum is necessary, and a diverting loop ileos- cost analysis, reducing the length of stay would have con-
tomy is performed to protect the low rectal or coloanal siderable repercussion on the use of hospital resources and
anastomosis. Therefore, because of the high risk of postop- on overall health costs.
erative complications, restoration of intestinal continuity is Given the good results of anastomotic salvage and di-
never accomplished in a significant number of patients, and verting loop ileostomy, the authors propose an algorithm of
only those in a good general condition are selected for management of both intraperitoneal and extraperitoneal AL
stoma reversal.18 Loop ileostomy closure is usually a quite in colorectal surgery (Fig. 2). Patients who have critical
safe procedure, technically straightforward in most cases, hemodynamic conditions during surgery may benefit from a
and quick and often feasible through a small peristomal quick and effective procedure, so drainage of the leaking
incision, with a morbidity rate between 10% and 30% and anastomosis with loop ileostomy may be proposed as a good
mortality between 0% and 2%.19 –22 surgical option to manage a minor dehiscence of an intra-
Other authors have published good long-term results peritoneal anastomosis. In a hemodynamically stable pa-
after proximal diversion without anastomotic takedown in tient, we recommend performing a new anastomosis cov-
the management of colorectal AL. Parc et al23 reported ered by a loop ileostomy.
significant differences in the rate of stoma reversal between In cases of low rectal anastomosis, we begin by checking
patients with a diverting loop stoma (100%, 9 patients) the suture by digital examination. In the presence of major
versus 58% of those treated with Hartmann’s procedure. In disruption (more than half of the circumference) or isch-
676 The American Journal of Surgery, Vol 204, No 5, November 2012
emia, the anastomosis should be resected with the creation 8. Alves A, Panis Y, Pocard M, et al. Management of Anastomotic
of an end stoma. In the presence of minor dehiscence or leakage after nondiverted large bowel resection. J Am Coll Surg
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when firm adhesions make the defect not visible, we rec- 9. Law WL, Choi HK, Lee YM, et al. Anastomotic leakage is associated
ommend performing a loop ileostomy with drainage of the with poor long-term outcome in patients after curative colorectal
leaking anastomosis left in situ. In low rectal anastomoses, resection for malignancy. J Gastrointest Surg 2007;11:8 –15.
we consider it sensible and reasonable to avoid long pelvic 10. Bruce J, Krukowski ZH, Al-Khairy G, et al. Systematic review of the
dissections in an emergency reoperation. Performing a total definition and measurement of anastomotic leak after gastrointestinal
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to a coloanal anastomosis with a higher risk of subsequent leakage in rectal surgery. Colorectal Dis 2001;3:135–7.
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