Management of Anastomotic Leaks

Educational Objectives

The goal of this program is to improve the prevention and management of anastomotic leaks (AL). After hearing and assimilating this program, the clinician will be better able to:

1. Characterize the impact of anastomotic leaks on patient health and well-being.

2. Optimize bowel preparation to help reduce rate of AL.

3. List studies assessing the role of indocyanine green fluorescence angiography in reducing the incidence of anastomotic leaks.

Summary

Anastomotic leaks (AL): greatest incidence and severity in the proximal digestive tract (esophageal AL) and great distal digestive tract (rectal AL); 10% to 15% AL rate in patients at high risk for AL; high risk is characterized as ≤10 cm from anal verge in patient that is, eg, irradiated, immunosuppressed, obese, male sex, with multiple AL; AL increases short-term morbidity, long-term functional and oncologic sequelae, and immediate financial burden; studies — Journal of Gastrointestinal Surgery published study in 2014 propensity matching with 6000 US patients reported AL increased cumulative length of stay by 7.3 days, postoperative infections increased 2-fold, and readmissions increased; 2019 retrospective review in Italy found length of stay increased from 9.7 to 29 days and cost increased 4-fold; according to another study, physical scores decreased for 1 yr and mental scores decreased for >1 yr in AL patients; 2015 study found AL reduces overall survival when reoperation is required; other studies found increased recurrence rates and mortality globally

AL prevention: bowel preparation — retrospective studies (Kiran et al [2015]) show only mechanical cathartic bowel preparation combined with oral antibiotic preparation reduces AL rate, surgical site infections and wound dehiscence vs no preparation, mechanical preparation, or antibiotic preparation; level of ligation — Bonnet et al (2012) showed high ligation increased vein length 3-fold with minimal artery lengthening vs low ligation; Cleveland Clinic Florida study showed patients re-operated on because of stricture had intact splenic flexure, intact inferior mesenteric (IM) artery and IM vein; showed that performing high ligations prevented subsequent AL at 24 mo; stapling — crossing staple lines associated with high AL rates; multiple staple firings often required in robotic, laparoscopic, or hybrid surgery, which can create ischemic cross staple points on a distal stump; testing — surgeons tend to test anastomosis via insufflation with betadine or more commonly filling pelvis with water, leading to anastomosis and insufflating air; resolve air-tested AL via diversion or redoing the anastomosis vs suture to reduce postoperative AL; use flexible sigmoidoscope for test and evaluate anastomosis; endoscopy — endoscope for air leak test prevents AL and anastomotic bleeding better than insufflating air, according to study; bioabsorbable staple-line buttressing — 2014 randomized controlled trial showed use of buttressing (Seamguard) in high-risk colorectal anastomoses with neoadjuvant therapy does not reduce AL rates; compression anastomosis — bioresorbable anastomotic ring (Valtrac) contained polyglycolic acid and barium sulfates, but were not successful because there is no mechanism to use it in anastomoses with high AL risk; nitinol flexes with body temperature and with tissue thickness (adjustable by 3%-6% for thin to thick tissue); it can be used in a patient if the proximal bowel had a thinner wall vs distal rectum or as the anastomosis healed; nitinol ring has higher bursting strengths, better circumference, and less adhesions vs standard stapled anastomosis; nitinol has bigger circumference, as anastomosis is formed outside rather than inside the anastomotic device and data showed the compression ring reduced inflammation, scarring, and foreign body reactions vs staplers; according to evidence, nitinol have AL rates of 1.5% to 4.3% for high-risk anastomoses vs 10% to 15% with staples; no longer available

Indocyanine green (ICG) fluorescence angiography: substance used to assess perfusion; considered the most reproductible and cost-effective method to examine the blood supply using near infrared imaging; ICG is administered by anesthetist, typically in a 3.5-mL dosage followed by a 10-mL flush; ≤1 min of administration the bright fluorescent green is visible in perfused areas with an immediate transition to no coloration in nonperfused areas; theoretically, this is used to get a better perfused segment or an optimally perfused segment to use for anastomosis and lower AL rates

PILLAR II trial: multicenter study of perfusion assessment; aimed to assess utility of near infrared fluorescence angiography in creating left-sided anastomoses and to optimize the location of transection to the colon to use as proximal anastomosis; ≤60 sec there is an abrupt cutoff in nearly all patients; 53 high-risk patients identified with anastomoses <10 cm in height and/or with pelvic radiation while low-risk rectal anastomoses were >10 cm and were not irradiated; use of ICG caused surgical plan changes in 6% of low-risk patients and 7.5% of high-risk patients with a median change of 1.5 cm and a mean of 3 cm; first assessment prior to deciding proximal margin, second injection after anastomosis created using custom-designed rigid proctoscope with ICG capability to examine perfusion of mucosa proximal and distal anastomosis; optional third injection before the stapler is fired; ICG can function as “early warning system” and detect suboptimally perfused tissue before it can be detected by the surgeons; can also be teaching tool; clinical AL rate of 1.9% in high-risk group and 1.2% in low-risk group

Multicenter phase II trial: evaluated patients with low risk for pelvic AL (191), and patients who had Hartmann reversal (29), low anterior resection (90), ileoanal anastomosis surgery (12), ileorectal anastomosis surgery (11), and small bowel resection (28); use of ICG added 4 min to procedure, as it included 2 assessments, each requiring 2 min; resection changed from 0.5 to 5 cm in 6% of cases and this resulted in zero AL in altered cases; overall AL rate was 2.4%, right hemicolectomy AL rate was 2.8%, high anterior resection AL rate was 2.3%, and high-risk anastomosis AL rate was 3.3%; subsequent retrospective review of literature showed overall AL rate was reduced from 5.8% to 2.4% using ICG, ileocolic AL rate had no significant changes, and high-risk anastomosis decreased from 10.7% to 3.3%

Luigi series (Boni et al [2017]): compared 42 patients with fluorescence angiography vs 38 control patients; AL rate of zero using ICG vs 5% in controls; 4.5% of patients had change in anticipation or planned resection margin because of ICG findings

ICG with robotics: study evaluated ICG during sphincter-saving surgery in patients undergoing robotic rectal cancer surgery found ICG use reduced AL rates from 5.2% in control group to 0.6%

Supportive studies: other studies show ICG changes proximal margin in 16% of cases with a median length change of 2 cm ranging from 1 to 6.5 cm; ICG usage during low anterior resection reduced AL rate from 6.7% to 0%; for transanal total mesorectal excision, ICG led to a change in surgical plan in 22.7% of patients, and this may be related to compression of vessels through levators in the anus

Quadruple assessment: there is no panacea for leaks and no way to prevent all AL; in every patient, when the stapler is fired and then removed, the tissue doughnuts are examined using endoscopic visualization to assess for any bleeding as well as viability of the anastomosis; ICG can be added to assess the mucosa during air leak test; quadruple assessment is doughnuts, endoscopic visualization, air leak test, ICG

Reverse leak test: used in case of transanal total mesorectal excision in colorectal anastomosis, if anastomosis is at the dentate line and hand-sewn; during this test, the patient is laparoscopically placed in a head-up position, the pelvis is filled with water, insufflation is occurring and an anoscope is used to assess hand-sewn coloanal anastomosis; this releases small effervescent “champagne bubbles” between sutures that need reinforcement; cannot perform a standard air test when the anastomosis is at the endoderm or lower, making this test necessary; ICG is not panacea but is helpful; systemic review and meta-analysis found ICG perfusion assessment in rectal anastomosis resulted in a lower rate of AL vs control; Delphi analysis found concordance among surgeons who routinely used ICG for checking anastomosis

Summary: employ air test anastomosis, assess tissue doughnuts, consider redoing anastomosis or diverting if leak is detected; 10% of patients with ileostomies are readmitted for dehydration; AL at stoma closure sites occur at 2% to 3% rate; there are sometimes increased adhesions because of surgery and formation of traumatized sites; hernias at stoma sites can occur throughout patient lifetime and require hernia repair; minimize AL incidence using oral mechanical cathartic and an oral antibiotic bowel preparation with parenteral antibiotics at time of surgery, include mobilizing the splenic flexure during surgery and ligating the IM artery within 1 cm of aorta and IM vein at the inferior border of the pancreas; include a tension-free anastomosis in which vascularity and tissue doughnuts are assessed along with ICG; for high-risk anastomosis, consider fecal diversion

Readings

2017 European Society of Coloproctology (ESCP) collaborating group. Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi-centre, prospective audit. Colorectal Dis. 2018;20:15-32; doi: 10.1111/codi.14362; Chan DKH et al. Indocyanine green fluorescence angiography decreases the risk of colorectal anastomotic leakage: Systematic review and meta-analysis. Surgery. 2020;168:1128-1137; doi: 10.1016/j.surg.2020.08.024; Emile SH et al. Quadruple assessment of colorectal anastomoses: a technique to reduce the incidence of anastomotic leakage. Colorectal Dis. 2020;22:102-103; doi: 10.1111/codi.14844; Meyer J et al. Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges. World J Gastroenterol. 2019;25:5017-5025; doi: 10.3748/wjg.v25.i34.5017; Platell C et al. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis. 2007;9:71-79; doi: 10.1111/j.1463-1318.2006.01002.x; Shen R et al. Indocyanine green fluorescence angiography and the incidence of anastomotic leak after colorectal resection for colorectal cancer: a meta-analysis. Dis Colon Rectum. 2018;61:1228-1234; doi: 10.1097/DCR.0000000000001123; Watanabe J et al. Indocyanine green fluorescence imaging to reduce the risk of anastomotic leakage in laparoscopic low anterior resection for rectal cancer: a propensity score-matched cohort study. Surg Endosc. 2020;34:202-208; doi: 10.1007/s00464-019-06751-9.

Disclosures

For this program, the following has been disclosed: Dr. Wexner receives royalties from Intuitive Surgical, Medtronic, and Karl Storz endoscopy; is a consultant for Intuitive Surgical, Medtronic, Takeda, Baxter, Astellas, and Stryker. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Wexner was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks the speakers and Keck Medicine of USC for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS681201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.