The Anastomotic Leak Syndrome Earl Belle Smith, MD Pittsburgh, Pennsylvania
To evaluate the mechanisms, diagnosis, treatment, and prevention of the anastomotic complex, 151 anastomotic disruptions (representing a 20-year-study) were analyzed from records of St. Frances General Hospital, Pittsburgh. These leaks are serious postoperative problems which require individualized treatment. Prevention should be the main approach to controlling the syndrome.
An anastomotic dehiscence is a postoperative complication which portrays increased surgical morbidity and mortality.1-9 In order to evaluate the mechanisms, diagnosis, treatment, and prevention of the anastomotic leak complex, 151 anastomotic disruptions were analyzed. The latter occurred during a 20-year period from July 1, 1957 to June 30, 1977 at St. Francis General Hospital, a 745-bed University-affiliated community facility. The main purposes of this paper are to: (1) review the clinical material; (2) analyze the animal research data; and (3) discuss
Dr. Smith is Chairman, Department of Surgery, St. Francis General Hospital, Pittsburgh, Pennsylvania. Requests for reprints should be addressed to Dr. Earl Belle Smith, Department of Surgery, St. Francis General Hospital, 408 45th Street, Pittsburgh, PA 15201.
the clinical aspects of anastomotic leaks.
nique resulted in an effective and strong anastomosis.
Clinical Material
Experimental Data In 1967, 12 mongrel dogs, ranging in weight from 20 to 26 kg, were anesthesized with pentobarbital (Nembutal). Numerous anastomotic techniques were utilized upon the esophagus, stomach, and small and large intestines. The suture techniques performed upon these animals included: (1) Standard-double inverting; (2) Halsted-single inverting; (3) Navysingle everting; and (4) Gambeesingle-through and through inverting. There was an inversion cuff, avascular necrosis, and abscess formation in the Standard and Halsted techniques. There was evidence of leakage in all anastomoses, particularly in the Standard and Halsted techniques. The Standard technique required the longest operating time. Experimentally, it was our opinion that a single-layer anastomosis was more effective than the conventional double-layer technique. In addition, the Gambee tech-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 1, 1978
During the aforementioned study period, there were 151 anastomotic leaks with an organ distribution noted in Table 1. Anastomoses which involved the colon and rectum numbered 87 cases or 71 percent. In contrast, there were 662 anastomoses involving the gastrointestinal tract with a 22.8 percent leak incidence. The anastomotic sites are listed in Table 2. There were five deaths in our series of anastomotic disruptions resulting in a mortality of 3.3 percent. Clinically, anastomotic leaks may be divided into major, moderate, and minor breakdowns. A major leak is more than 5 cm in diameter which results in peritonitis and subsequent septicemia. A moderate leak is less than 5 cm in diameter with localized peritonitis. A minor leak is one in which there is fecal or gastrointestinal material in the drainage tube with no evidence of local or generalized peritonitis. Approximately 20 percent 49
of the anastomotic leaks in this series were of the major type.
Table 1. Anastomotic Leaks
Organ
Discussion
Number of Leaks
Esophagus
9
Stomach
21
Small intestine
32
Colon
62
Rectum
25
Anus
The prime etiological reasons for anastomotic dehiscences are as follows: age, anatomic sites, bowel distension, intraluminal and extraluminal infections, inadequate blood supply, inadequate preoperative bowel preparation, techniques of anastomoses, multiple anastomoses, tension, and malignancy. The clinical features of anatomic leaks are signs and symptoms of localized and/or generalized
2
Table 2. Anastomotic Sites
Esophagojejunostomy
19
Esophagogastrostomy
8
Gastrojejunostomy Pancreaticocystogastrostomy
Gastroduodenostomy
50
118 5
102
Jejunojejunostomy
22
lleoileostomy
14
Jejunoileostomy
10
Duodenojejunostomy
6
Pancreaticojejunostomy
9
Cholecystojejunostomy
23
Choledochojejunostomy
18
Choledochoduodenostomy
11
Colocolostomy
155
Ileocolostomy
22
Jejunocolostomy
6
Coloproctostomy
44
I leoproctostomy
4
Coloanastomy
4
peritonitis, intraperitoneal abscesses, intestinal fistulas, and wound infections. In the latter, bacteriologic and chemical analyses of the exudate may be the clues to an anastomotic leak. The resultant effects of anastomotic breakdowns are systemic and local sepsis, partial and complete intestinal obstruction, secondary anemia, hypoproteinemia, electrolyte imbalance, avitaminosis, deficiency of trace metals and fatty acids, and increased collagenolytic activity. The aforementioned sequellae result in increased mortality and morbidity, prolongation of hospital stays, increased hospital costs, prolonged convalescence, and lost manpower hours and wages. The diagnosis of an anastomotic leak can be substantiated by an evaluation of the clinical symptoms and signs, analysis of sump drainage materials, digital anorectal examinations, proctosigmoidoscopy, colonoscopy, barium enema, and other radiological techniques. The management of anastomotic leaks may vary with each individual case; however, proximal intestinal defunctionalization, intestinal bypass, intestinal resection, turn-in procedures, patch graft procedures, intraperitoneal sump drainage, metabolic corrections and support, and parenteral and enteral hyperalimentation are contemplated approaches. It is our opinion that prevention is the effective approach to solve or minimize these surgical problems. Effective measures are as follows: 1. Preoperative intestinal decompression 2. Careful and thorough intraabdominal exploration 3. Antibiotics 4. Positive nitrogen balance 5. Adequate circulatory blood volume
6. Intraoperative aseptic intestinal decompression 7. Intraperitoneal irrigation and instillation with antibiotic solutions 8. Meticulous operative technique 9. Effective sump drainage 10. Complementary proximal colostomy 11. Postoperative intestinal decompression 12. Single layer anastomoses 13. Types of suture materials
Conclusions Anastomotic dehiscences or leaks are serious postoperative complications which are dependent upon numerous factors. Specific treatment has to be individualized; however, the main approach should be preventive.
Literature Cited 1. Adams YG, Volk H, State D: Low colorectal anastomosis after resection for cancer. Surg Gynec Obstet 125:1259-1268, 1967 2. Cole W, Petit R, Bernard H: Factors affecting incidence of anastomotic leak following esophagogastrectomy. Ann Thoracic Surg 6:396-399, 1968 3. Cronin K, Jackson DS, Dunphy JE: Specific activity of hydroxyprolive-tritium in the healing colon. Surg Gynec Obstet 126:10611065, 1968 4. Inberg MV, Linva Ml, Schernin TM, et al: Anastomotic leakage after excision of esophageal and high gastric carcinoma. Am J Surg 122:540-544, 1971 5. Garnjobst W, Hardwick C: Further criteria for anastomosis in diverticulitis of the sigmoid colon. Am J Surg 120:264-270, 1970 6. Goligher JC, Graham NG, DeDombal FT: Anastomotic dehiscence. Br J Surg 57:109-119, 1970 7. Oberless D, Seymour TK, Lenaghan R, et al: Effect of zinc deficiency on wound healing in rats. Am J Surg 121:566-568, 1971 8. Miller D, Wechein WA: Perforated sigmoid diverticulitis. Am J Surg 121:536-540, 1971 9. Yamakawa T, Patin CS, Sobel 5, et al: Healing of colonic anastomoses following resection for experimental diverticu litis. Arch Surg 103:17-20, 1971
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 1, 1978
To evaluate the mechanisms, diagnosis, treatment, and prevention of the anastomotic complex, 151 anastomotic disruptions (representing a 20-year-study) were analyzed from records of St. Frances General Hospital, Pittsburgh. These leaks are serious postoperative problems which require individualized treatment. Prevention should be the main approach to controlling the syndrome.
An anastomotic dehiscence is a postoperative complication which portrays increased surgical morbidity and mortality.1-9 In order to evaluate the mechanisms, diagnosis, treatment, and prevention of the anastomotic leak complex, 151 anastomotic disruptions were analyzed. The latter occurred during a 20-year period from July 1, 1957 to June 30, 1977 at St. Francis General Hospital, a 745-bed University-affiliated community facility. The main purposes of this paper are to: (1) review the clinical material; (2) analyze the animal research data; and (3) discuss
Dr. Smith is Chairman, Department of Surgery, St. Francis General Hospital, Pittsburgh, Pennsylvania. Requests for reprints should be addressed to Dr. Earl Belle Smith, Department of Surgery, St. Francis General Hospital, 408 45th Street, Pittsburgh, PA 15201.
the clinical aspects of anastomotic leaks.
nique resulted in an effective and strong anastomosis.
Clinical Material
Experimental Data In 1967, 12 mongrel dogs, ranging in weight from 20 to 26 kg, were anesthesized with pentobarbital (Nembutal). Numerous anastomotic techniques were utilized upon the esophagus, stomach, and small and large intestines. The suture techniques performed upon these animals included: (1) Standard-double inverting; (2) Halsted-single inverting; (3) Navysingle everting; and (4) Gambeesingle-through and through inverting. There was an inversion cuff, avascular necrosis, and abscess formation in the Standard and Halsted techniques. There was evidence of leakage in all anastomoses, particularly in the Standard and Halsted techniques. The Standard technique required the longest operating time. Experimentally, it was our opinion that a single-layer anastomosis was more effective than the conventional double-layer technique. In addition, the Gambee tech-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 1, 1978
During the aforementioned study period, there were 151 anastomotic leaks with an organ distribution noted in Table 1. Anastomoses which involved the colon and rectum numbered 87 cases or 71 percent. In contrast, there were 662 anastomoses involving the gastrointestinal tract with a 22.8 percent leak incidence. The anastomotic sites are listed in Table 2. There were five deaths in our series of anastomotic disruptions resulting in a mortality of 3.3 percent. Clinically, anastomotic leaks may be divided into major, moderate, and minor breakdowns. A major leak is more than 5 cm in diameter which results in peritonitis and subsequent septicemia. A moderate leak is less than 5 cm in diameter with localized peritonitis. A minor leak is one in which there is fecal or gastrointestinal material in the drainage tube with no evidence of local or generalized peritonitis. Approximately 20 percent 49
of the anastomotic leaks in this series were of the major type.
Table 1. Anastomotic Leaks
Organ
Discussion
Number of Leaks
Esophagus
9
Stomach
21
Small intestine
32
Colon
62
Rectum
25
Anus
The prime etiological reasons for anastomotic dehiscences are as follows: age, anatomic sites, bowel distension, intraluminal and extraluminal infections, inadequate blood supply, inadequate preoperative bowel preparation, techniques of anastomoses, multiple anastomoses, tension, and malignancy. The clinical features of anatomic leaks are signs and symptoms of localized and/or generalized
2
Table 2. Anastomotic Sites
Esophagojejunostomy
19
Esophagogastrostomy
8
Gastrojejunostomy Pancreaticocystogastrostomy
Gastroduodenostomy
50
118 5
102
Jejunojejunostomy
22
lleoileostomy
14
Jejunoileostomy
10
Duodenojejunostomy
6
Pancreaticojejunostomy
9
Cholecystojejunostomy
23
Choledochojejunostomy
18
Choledochoduodenostomy
11
Colocolostomy
155
Ileocolostomy
22
Jejunocolostomy
6
Coloproctostomy
44
I leoproctostomy
4
Coloanastomy
4
peritonitis, intraperitoneal abscesses, intestinal fistulas, and wound infections. In the latter, bacteriologic and chemical analyses of the exudate may be the clues to an anastomotic leak. The resultant effects of anastomotic breakdowns are systemic and local sepsis, partial and complete intestinal obstruction, secondary anemia, hypoproteinemia, electrolyte imbalance, avitaminosis, deficiency of trace metals and fatty acids, and increased collagenolytic activity. The aforementioned sequellae result in increased mortality and morbidity, prolongation of hospital stays, increased hospital costs, prolonged convalescence, and lost manpower hours and wages. The diagnosis of an anastomotic leak can be substantiated by an evaluation of the clinical symptoms and signs, analysis of sump drainage materials, digital anorectal examinations, proctosigmoidoscopy, colonoscopy, barium enema, and other radiological techniques. The management of anastomotic leaks may vary with each individual case; however, proximal intestinal defunctionalization, intestinal bypass, intestinal resection, turn-in procedures, patch graft procedures, intraperitoneal sump drainage, metabolic corrections and support, and parenteral and enteral hyperalimentation are contemplated approaches. It is our opinion that prevention is the effective approach to solve or minimize these surgical problems. Effective measures are as follows: 1. Preoperative intestinal decompression 2. Careful and thorough intraabdominal exploration 3. Antibiotics 4. Positive nitrogen balance 5. Adequate circulatory blood volume
6. Intraoperative aseptic intestinal decompression 7. Intraperitoneal irrigation and instillation with antibiotic solutions 8. Meticulous operative technique 9. Effective sump drainage 10. Complementary proximal colostomy 11. Postoperative intestinal decompression 12. Single layer anastomoses 13. Types of suture materials
Conclusions Anastomotic dehiscences or leaks are serious postoperative complications which are dependent upon numerous factors. Specific treatment has to be individualized; however, the main approach should be preventive.
Literature Cited 1. Adams YG, Volk H, State D: Low colorectal anastomosis after resection for cancer. Surg Gynec Obstet 125:1259-1268, 1967 2. Cole W, Petit R, Bernard H: Factors affecting incidence of anastomotic leak following esophagogastrectomy. Ann Thoracic Surg 6:396-399, 1968 3. Cronin K, Jackson DS, Dunphy JE: Specific activity of hydroxyprolive-tritium in the healing colon. Surg Gynec Obstet 126:10611065, 1968 4. Inberg MV, Linva Ml, Schernin TM, et al: Anastomotic leakage after excision of esophageal and high gastric carcinoma. Am J Surg 122:540-544, 1971 5. Garnjobst W, Hardwick C: Further criteria for anastomosis in diverticulitis of the sigmoid colon. Am J Surg 120:264-270, 1970 6. Goligher JC, Graham NG, DeDombal FT: Anastomotic dehiscence. Br J Surg 57:109-119, 1970 7. Oberless D, Seymour TK, Lenaghan R, et al: Effect of zinc deficiency on wound healing in rats. Am J Surg 121:566-568, 1971 8. Miller D, Wechein WA: Perforated sigmoid diverticulitis. Am J Surg 121:536-540, 1971 9. Yamakawa T, Patin CS, Sobel 5, et al: Healing of colonic anastomoses following resection for experimental diverticu litis. Arch Surg 103:17-20, 1971
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 1, 1978
