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