tips and tricks of avoiding and management of anastomotic complications
DESCRIPTION
Tips and Tricks of Avoiding and Management of Anastomotic Complications. Feza H. Remzi, MD, FACS,FASCRS., FTSS (Hon) Chairman Department of Colorectal Surgery Professor of Surgery Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH. Introduction. - PowerPoint PPT PresentationTRANSCRIPT
Tips and Tricks of Avoiding and Management of
Anastomotic Complications
Feza H. Remzi, MD, FACS,FASCRS., FTSS (Hon)Chairman Chairman
Department of Colorectal SurgeryDepartment of Colorectal SurgeryProfessor of SurgeryProfessor of Surgery
Rupert B Turnbull Jr,. MD Chair Rupert B Turnbull Jr,. MD Chair Digestive Disease InstituteDigestive Disease Institute
Cleveland Clinic, Cleveland, OHCleveland Clinic, Cleveland, OH
Introduction
• Colorectal / anal
• Ileal Pouch anal anastomosis
• Ileocolic anastomosis
• Small bowel to small bowel
Colorectal / Anal Anastomosis
Acute Management
• Not diverted, – Take back for washout with diverting loop ileostomy
and avoid taking down the colorectal anastomosis
– Drain; I still prefer penrose drains
• Diverted– If leak is proven with CT or GGE; EUA and transanal,
anastomotic drainage through the defect
– If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal
– Prefer mushroom catheter
• IV ATBS, and conservative management and control of sepsis and wait, wait, and wait
Longterm Management of Colorectal / Anal Anastomotic Leak• Wait 6 to 12 months
• Periodic EUA, I & D of cavity, GGE
• If it heals, proceed with ileostomy closure
• If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure
• Incomplete healing / closure of the defect– Ileostomy closure and explain the possibility of recurrence– Presacral sinus with a wide mouth/opening usually
does better– Cavity that got epithelized with mucosa also does well
Turnbull- Cutait Pull Through
Turnbull Cutait
Ileal Pouch Anal Anastomosis
TPC and IPAA
Reach Issues
Difficulty in Reach
Acute Management After IPAA
• Not diverted, – Take back for washout with diverting loop ileostomy
and avoid taking down the colorectal anastomosis
– Drain; I still prefer penrose drains
• Diverted– If leak is proven with CT or GGE; EUA and transanal ,
anastomotic drainage through the defect
– If leak is not proven with CT or GGE; CT guided drainage. Drain injection study before removal
– Prefer mushroom catheter
• IV ATBS, and conservative management and control of sepsis and wait, wait, and wait
Longterm Management of IPAA Anastomotic Leak
• Wait 6 to 12 months
• Periodic EUA, I & D of cavity, GGE
• If it heals, proceed with ileostomy closure
• If there is still a persistent large cavity with drainage of pus……. Redo coloanal / Turnbull Cutait pull through procedure
• Incomplete healing / closure of the defect– Ileostomy closure and explain the possibility of recurrence– Presacral sinus with a wide mouth/opening usually
does better– Cavity that got epithelized with mucosa also does well
General Principles
• If not diverted, diverting ileostomy for 3 to 6 months before considering a redo pouch
• Be prepared for the unexpected
• Consenting; permanent ileostomy vs K pouch
• Ureteric stents
• Availability of blood products
• Must excise the pelvic phlegmon to accomplish healing
• Dissection known to unknown, must have exit strategy
• Pelvic dissection; caudal to cranial
Ileocolic Anastomosis
Small Bowel to Small Bowel