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Научни трудове на Съюза на учените в България - Пловдив. Серия Г. Медицина, фармация и дентална медицина т. ХХ. ISSN 1311-9427 (Print), ISSN 2534-9392 (On-line). 2017. Scientific works of the Union of Scientists in Bulgaria-Plovdiv, series G. Medicine, Pharmacy and Dental medicine, Vol. ХХ. ISSN 1311-9427 (Print), ISSN 2534-9392 (On-line). 2017.
СЪВРЕМЕННИ ПОДХОДИ ПРИ АНАСТОМОЗНИ ИНСУФИЦИЕНЦИИ СЛЕД НИСКИ ПРЕДНИ РЕЗЕКЦИИ
НА РЕКТУМА Б. Сакакушев, Б.Атанасов Медицински Университет/ УМБАЛ „Св. Георги" Първа Клиника по Хирургия МБАЛ „Еврохоспитал" Пловдив Хирургично Отделение
MODERN APPROACHES IN ANASTOMOSIS INSUFFICIENCY AFTER LOW ANTERIOR RECTUM RESECTIONS B. Sakakushev, B. Atanasov Medical University/University Hospital"St.George"Plovdiv-General Surgery Department MHAT "Eurohospital" Plovdiv- Surgical Unit
ABSTRACT
The incidence of clinically significant leakage after low anterior resection (LARR) varies between 3% and 21%, but is thought to average 10%, or lower, when patients are operated by a high-volume surgeon. Between 2012 and 2015, 127 patients with low rectal cancer, operated on in the Surgical Unit of Mhat "Eurohospital" and Surgical Department of University Hospital St George" Plovdiv have been retrospectively analyzed. Males were 62.2%/n-79/, females -37.8%/n-48. Patients have been divided into two basic groups, depending on type of operation - conventional/n 68/ or laparoscopic/59/. Subgroups of procedures and techniques performed were separated - those with ARR and TME, neoadjuvant therapy/conventional-21, laparoscopic-59, extra-peritonisation/ conventional-68, laparoscopic-21/, pre-sacral drainage/conventional-68, laparoscopic-0, intra-abdominal drainage/conventional-68, laparoscopic-59/ and protective ileostomy/ conventional-0, laparoscopic-59. Anastomosis insufficiency prolongs hospital stay more than two fold and leads to late complications. Following an algorithm approach results in overcoming this complication and saves sphincter function. Extra-peritonisation of the anastomosis and pre-sacral drainage allow conservative control in more than half of the patients.
Key words: Anastomosis Leakage/AL/, Anterior Rectum Resection/ARR/, Low Anterior Rectum Resection/LARR/, Total Mesorectal Excision/TME/
INTRODUCTION
Anastomosis leakage/takedown, disruption, insufficiency/ is the feculent or gas discharge through and around the anastomosis in the abdominal cavity, pelvis, operative wound and via
drains/1/. Anastomosis insufficiency rate in colorectal surgery varies from 2 to 26% , being higher in low and ultralow rectum resections/2/. Rate of AL after ARR- 1,5-18%/3/. It leads to two fold prolonged hospital stay and higher mortality/4, 5/. The incidence of clinically significant leakage after low anterior resection (LARR) varies between 3% and 21%, but is thought to average 10%, or lower, when patients are operated by a high-volume surgeon/6,7/.
Risk factors for anastomosis leakage like male sex, advanced age, overweight, low rectal cancer /10sm<from ano-rectal line/, 3> CCI/Charlson index/, high ligation of superior mesenteric artery, sepsis, neo-adjuvant chemotherapy, smoking, high ASA score, longer operative time can be stratified by the Colon Leakage Score (CLS)/8,9,10/.
Pre-requisites for better anastomosis healing are:
• intra-operative anastomosis check
• good blood supply
• tension free anastomosis
• meticulous operative technique
Protective ileostomy in low RRA has more advocates than opponents/11/.
PATIENTS AND METHODS
Between 2012 and 2015, 127 patients with low rectal cancer, operated on in the Surgical Unit of Mhat "Eurohospital" and Surgical Department of University Hospital St George" Plovdiv have been retrospectively analyzed. Males were 62.2%/n-79/, females -37.8%/n-48.
Patients have been divided into two basic groups, depending on type of operation -conventional/n 68/ or laparoscopic/59/. Subgroups of procedures and techniques performed were separated - those with ARR and TME, neoadjuvant therapy/conventional-21, laparoscopic-59, extra-peritonization/conventional-68, laparoscopic-21/, pre-sacral drainage/conventional-68, laparoscopic-0, intra-abdominal drainage/conventional-68, laparoscopic-59/ and protective ileostomy/conventional-0, laparoscopic-59. From 127 cases of low and ultralow ARR performed both laparoscopically and conventionally there were 9 anastomosis insufficiencies /7%/, 6 in conventional and 3 in laparoscopic operations.
Anastomosis insufficiency has been treated according to simplified algorithm, where two options existed - first - no peritoneal irritation/n 6/ with conservative or intraoperative over-suturing and second - with peritoneal irritation/ n 3/, where re-laparotomy was done. All 9 cases of anastomosis insufficiency survived/lethality - o/, either conservative/n 6/ or operative treatment/n 3/.
RESULTS
From 127 cases of low and ultralow ARR performed both laparoscopically and conventionally there were 9 anastomosis insufficiencies /7%/, 6 in conventional and 3 in laparoscopic operations. Two leakages after open procedures were partial, recognized as stapler misfits, after firing and were over-sutured manually intra-operatively. The first case went uneventfully and leaved the ward 6 days later. The second one developed low pelvic abscess and fistula, postoperative anastomosis stricture, partially resolved by dilatations and strictureplasty in the following 18 months with satisfactory outcome. In 4 patients conservative treatment /drainage and antibiotics/ was successful.
In 3 patients /2 conventional and 1 laparoscopic/ with signs of peritoneal contamination relaparotomy was done. AL/more than / of the circumference/ with fibrinous purulent peritonitis, originating from low pelvis phlegmon was found, requiring Hartmann's obstructive colon resection and stoma.
The treatment of dnastomotic leakage aims at:
• closure of the leakage
• control of infection
• downsizing the cavity
• drainage of the abscess
• de-functioning of the sphincter
This can be achieved by conservative, interventional, endoscopic or surgical approach, depending on the size of the defect, extent of contamination and patient condition.
Anastomosis insufficiency has been treated according to simplified algorithm, where two options existed - first - no peritoneal irritation/n 6/ with conservative or intraoperative over-suturing and second - with peritoneal irritation/ n 3/, where re-laparotomy was done/FigNo 1/. All 9 cases of AL survived/lethality - o/, either after conservative/n 6/ or operative treatment/n 3/.
Fig No 1. Algorytm in Anastomosis Insufficiency
Algorytm in Anastomosis Insufficiency
Control of infection - 6
No peritoneal irritation- 6
Conservative treatment - 6
Lethality - o
I ntra operative tra usa na I ove rsutu ring - 2
Insufficiency-9n
Relaparotomy - 3
With peritoneal irritation - j
DISCUSSION
Mortality after anastomosis leakage varies from 6 to 22%/6/. Our AL rate of 7 %/n- 9/ are comparable with the reported ones of 2-26%/1,2/. Anastomosis leakage after colorectal cancer surgery, though a major surgical problem with medical and social impact on quality of surgical care and patient life, has lowered its rate to the acceptable 3 % in specialized centers, mainly due to increased surgeons experience and technical proficiency, modern diagnostics and risk assessment, turning out itself from an embarrassing fatal disaster in the past to a predictable probability today and hope in the future/12/.
In a multivariate analysis performed by Justin P & alt., the independent risk factors for
insufficiency are ASA>2, preoperative radiotherapy, low anastomosis and males sex/13/.
Prophylaxis of anastomosis leakages aims at lowering the rate of morbidity and mortality
by:
• lowering the risk of their appearance /14/
• intraoperative testing/15/
• drainage
The greater experience of the surgeon with staplers-the lower the rate of the anastomosis leakage/16, 17/. For early diagnosis of anastomosis leakage we use ultrasonography, X-ray, CT, endoscopy, considering, as others CT as the most relevant one/18/.
Low pelvis drainage can serve as an early indicator for anastomosis insufficiency and can reduce the number of re-laparotomies stated Tsuijnaka et alt., applying routine drainage in all 196 patients with ARR, having anastomosis insufficiency in 21 (10, 7%), treated conservatively - 10 (47, 6%)/19/. Our routine practice of extra-peritonization the anastomosis and pre-sacral-perianal drainage usually with 1 or 2 tube drains eliminate the possibility of spreading the infection and fecal leakage after RRA anastomosis insufficiency intra-abdominally, limiting the infection to low pelvic phlegmon and/or local intra-abdominal pelvic infection in overlooked cases.
Current surgical methods for treating AL are the Endo-sponge® procedure, and Endoluminal Vacuum Therapy/20/. The Endo-sponge®procedure is a new minimal invasive endoscopic treatment which transfers of the basic principles of septic wound care to endoscopic wound care - inside the body, thus leading to faster healing than "conservative" treatment, has lower rate of reoperations and higher rate of closed ileostomies. Anastomosis extra-peritonisation and pre-sacral-perianal drainage saves the life of the patient in potential or accidental anastomosis dehiscence, avoiding diffuse fecal peritonitis, having instead a well-drained (by pre-sacral drainage) low pelvis phlegmon.
The absolute number of patients after ARR will grow because of increasing rate of colorectal cancer, growing requirements, increasing of sphincter saving operations with TME and older age of population.
CONCLUSION
Regardless of progress in surgical technique, anastomotic leakage after LARR for distal rectal cancer continues to be a major and challenging clinical problem leading to poor outcome, long hospital stay and late complications. Following an algorithm approach results in less morbidity, mortality and better functional results. Anastomosis extra-peritonisation and pre-sacral drainage are the cornerstone surgical procedures which save patients' life and allow conservative treatment. New minimally invasive endoscopic treatment options are emerging, requiring clinical evidence.
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