Umesh Ramachandra Kakade

Assistant Professor, Department of General Surgery, Bharati Hospital and Medical College, Sangli. Bharati Vidyapeeth Deemed to be University, Sangli. INDIA.

Email: umeshkakade66@rediffmail.com

Table 1: General characteristics

In presents study risk factors for anastomotic leakage (AL) were Age -≥ 50 years, Male gender, BMI - ≥ 25 kg/m2, ASA classification ≥ III, Hemoglobin < 8 gm% on admission, Diabetes mellites, Emergency surgery, Colo-colic anastomosis, Colonic obstruction, Contamination Of peritoneal cavity, Duration of surgery ( > 2 hours), Time for anastomosis (> 30 min), Intraoperative blood transfusion. Significant mortality was noted in anastomotic leakage (AL) patients.

Table 2: Risk factors studied

In present study, complications observed in anastomotic leak patients were surgical site infection (53.85 %), septicemia (38.46 %), abdominal wound dehiscence (burst abdomen) (30.77 %), acute renal failure (15.38 %) and respiratory complications (15.38 %).

Table 3: Complications observed in Anastomotic Leak patients

DISCUSSION

Despite the “perfect patient,” healthy bowel, and meticulous techniques, some anastomosis continue to leak after intestinal surgery. According to severity and clinical presentation, Anastomotic Leak (AL) can be classified into one of three grades.⁵

1. Grade A leaks are managed without an invasive intervention,
2. grade B leaks are managed with invasive intervention other than repeat surgical intervention (e.g., percutaneous drainage), and
3. grade C leaks require repeat surgical intervention and often diversion.

Classic presentations of AL are severe abdominal pain, diffuse muscle guarding with positive peritoneal signs, and hemodynamic instability. Besides, the positive predictive value of abnormal vital signs after bowel resection is only 4% to 11%.⁶ Drains placed intraoperatively may provide early clues to a leak if fecal material is seen to exit, but drains are not always reliable.⁷

Various risk factors are associated with AL which can be subdivided into systemic and local factors; both entities contribute to poor healing and failure of anastomosis.⁸ Systemic conditions include anemia, diabetes mellitus (DM), malnutrition, hypoalbuminemia, and prolonged steroid therapy. Local factors comprise local irradiation of bowel, diseased bowel as in Crohn’s disease, and intestinal ischemia. In addition, high ligation of inferior mesenteric artery is considered a unique risk factor for disruption of colonic anastomosis.⁹ Many risk factors have been identified and one of the strongest is the position of anastomosis. Especially low anastomosis (within 5 or 6 cm from the anal verge) show high risk of AL. Other known factors are age, gender, smoking, steroid therapy and more.^10,11,12 Patients with intra-abdominal sepsis, anemia, old age and patients treated with perioperative corticosteroids for pulmonary disease carry a substantial risk for anastomotic dehiscence and in these patients it is advised that anastomosis must be protected by a diverting stoma.¹³ The factors which are known to contribute for leakage of anastomosis include hypoalbuminemia, advanced age, presence of intra-abdominal sepsis, male sex, rectal location of the disease, hyponatremia, ASA grade 2 or above, perioperative blood transfusion and anaemia.^14,15,16 Shanker V et al.,¹⁷ studied 80 patients, post-operative anastomotic leaks were present in 10% and associated mortality was 100%. Increasing age was associated with leakage and 75% patients with leaks were male. Significant risk factors associated with anastomotic dehiscence: diabetes mellitus (p=0.05), low hemoglobin, altered TLC count, low serum protein (albumin) (p=0.001), longer operative time. Other predisposing factors like serum creatinine, hyperbilirubinemia, elective/emergency surgeries, contamination of peritoneal cavity and time taken to perform the anastomosis were insignificant statistically. Ahmad Sakr et al.,¹⁸ studied risk factors associated with AL after small intestinal and colonic anastomosis, 224 patients (126 males) with intestinal anastomosis of a median age of 44 years were reviewed. Independent factors associated with AL were male gender, chronic liver disease(CLD), more than one associated comorbidity, anastomosis conducted as emergency, colonic anastomosis, preoperative leukocytosis, and intraoperative blood transfusion. Predicative factors significantly associated with AL were male gender, CLD, multiple comorbidities, emergent anastomosis, colonic anastomosis, preoperative leukocytosis, and intraoperative blood transfusion. Choudhuri AH et al.,¹⁹ studied, potential non‑surgical factors that can influence anastomotic leakage, 1246 patients who developed anastomotic leak were analyzed, factors found to be independently associated with increased risk of anastomotic leak were albumin <3.5 g/dl, anemia <8 g/dl, hypotension, use of inotropes, and blood transfusion. The risk for anastomotic leak was four times more in patients who required inotropic support in the perioperative period and three times more in patients who developed hypotension. To prevent anastomotic leakage, tension-free anastomosis with maintained circulation is important. Karanjia et al.,²⁰ reported that the patient group without mobilization of the splenic flexure had a greater anastomotic leakage rate than the group with mobilization (22% vs. 9%). They insisted that complete splenic flexure mobilization needs to be done thoroughly before anastomosis or stapling. There is no convincing evidence that mechanical bowel preparation results in a decrease in anastomotic leakage rates, and this might even be detrimental. Besides the skill and technique involved during surgery various non‑surgical factors are believed to influence the occurrence of anastomotic failure and leakage. They include male sex, ASA score, emergency surgery, obesity, smoking and alcohol abuse, perioperative fluid management, blood transfusion among the many. Besides the obvious improvements that can be made regarding pre-operative risk assessment, the post-operative recognition and management of AL has also proven to be challenging. The timing of AL diagnosis varies greatly, from post-operative day 3 to beyond 30 days, with a mean of 12.7 days post-operatively.²¹ An adequate blood supply is important for safe colorectal anastomosis in colorectal cancer surgery. Anastomotic healing defects, including anastomotic leakage (AL), are critical complications that may have a fatal impact on the patient after resection of colorectal cancer. In many cases, AL causes sepsis and requires percutaneous drainage or additional surgery. The occurrence of AL increases the length of hospital stay, the medical cost, and postoperative morbidity and mortality.^22,23,24 Early resuscitation to avoid septic shock is the key to avoiding multisystem organ failure and even death following AL. High suspicion, early recognition with an aggressive approach and intervention, prior to development of contamination and subsequent sepsis, are important.

CONCLUSION

Age ≥ 50 years, male gender, BMI - ≥ 25 kg/m2, ASA grade ≥ III, hemoglobin < 8 gm%, diabetes mellites, emergency surgery, colo-colic anastomosis, presence of colonic obstruction, contamination of peritoneal cavity, duration of surgery ( > 2 hours) were predictive factors for small intestinal and colonic anastomotic leak noted in present study.

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