Prevention and Treatment of Anastomotic Leakage
Prevention and Treatment of Anastomotic Leakage
At present, efficient treatments or drugs to prevent the onset of AL are still not available.
In the specific case of mid or low rectal cancers or when a combination of high-risk variables for AL are present, surgeons can rely only on some surgical methods to reduce the clinical impact of AL. In fact, the improved surgical techniques together with the realization of a defunctioning stoma for fecal diversion allowed a significant decrease of the severity of the clinical sequelae and an easier management of this complication. Defunctioning stoma are created in up to 73% of the patients treated for rectal cancer to avoid complications due to anastomotic dehiscence. Neverthless, clinical leakage may occur in up to 32% of these patients.
Indeed, the use of a diverting stoma seems not to decrease the leakage rate, but it does reduce the risk of reoperation and post-operative death if leakage is present. However, the presence of a temporary ileostomy sometimes can add other clinical complications, such as tendency to dehydration and electrolytes' imbalance, especially in elderly patients. The diverting stoma is generally maintained for 2 months, a contrast enema radiography is then planned to rule out a distal leakage and at this point the patient needs a second operation. During this operation the ileostomy is resected, a new ileal anastomosis is performed and the skin is closed. Closure of a defunctioning stoma in patients who had an anastomotic leakage can result in long-term anorectal disfunction. The amount of resources to diagnose and manage AL is enormous: almost all patients developing a leakage will undergo a close clinical monitoring, a contrast enema followed by a CT-scan; some cases might need a colonoscopy study. The type of treatment depends on the severity of the clinical conditions, the height and the flow volume of the leakage. The treatment can range from the percutaneous drainage of the peri-anastomotic collection under ultrasound or CT-guidance to a major reintervention. A portion of patients with AL can be managed conservatively, but this approach very often leads to very long hospitalization. In a retrospective study conduced on 67 patients affected by anastomotic leakage after rectal cancer surgery, only 1.5% had a conservative treatment, 1.5% underwent a surgical lavage and drainage operation with the creation of a diverting stoma not previously performed; in 67.2% of patients a re-resection with a new anastomosis was performed. In 11.9% of cases there was a recurrent leakage rate. In general, the re-operation of a pelvis where a low-flow chronic leakage is present, is technically much more difficult and longer, because of the fibrosis developed by the tissues. In the same paper, a more demolitive operation such as Hartmann's resection was needed in almost 30% of patients.
This operation consists in a detachment of the former anastomosis, closure of the distal rectal stump and creation of an end-colostomy. According to the age and general conditions of the patient, a subsequent new major abdominal operation called "reversal of Hartmann" can be proposed, carrying again all the high morbidity and mortality mentioned for colorectal surgery, especially in old and multi-morbid patients. The restoration of continuity after Hartmann's procedure is done in only 57-63% of cases, leading a large number of patients to keep the colostomy all life long. Finally, in a very small group of patients developing a life-threatening peritonitis with sepsis and multi organ failure, an emergency life-saving surgery as laparostomy can be needed. In this setting the abdomen is kept open in order to allow a reduction of the intra-abdominal pressure and repeated surgical lavage and drainages in the OR. The patient needs a longer stay in the Intensive Care Unit period and an enormous amount of resources. Following recovery, morbidity will be additionally accompanied by restoration of bowel continuity or abdominal wall reconstruction after laparostomy. .
These surgical methods are very invasive, physically and psychologically debilitating and painful for the patient. Moreover these methods are not fully efficient; therefore the prognosis and the health care of this pathology have not known any considerable improvement recently.
Additional resources need to be considered for the recovery of elderly patients, who almost always require a post-operative motor rehabilitation physiotherapy and a "protected" discharge in Geriatric Structures or Nursing Homes to be helped and assisted.
Concluding, despite the clinical importance of AL and the substantial morbidity and mortality, at the moment the practicing surgeon has few available options to reduce the rate of anastomotic leaks.