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Anastomotic Leak

This is a serious post-operative complication in which the contents of a surgically-joined hollow organ leak through a defect in the join. This typically occurs 5-7 days postoperatively, but more insidious and chronic leaks can occur in which the diagnosis is much later.

“Laparoscopic operation of resection of sigma. Handanastomosis” © Anpol42 CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/) “Anastomotic leak” © Federica Viazzi CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/)

The leaked bowel contents can contaminate the peritoneal cavity, leading to complications such as peritonitis, colonic abscess formation, and abdominal sepsis.


Risk factors - Issues with the surgical join, patient-related factors e.g. DM, or systemic issues such as poor tissue perfusion.


Presentation

  • Abdominal pain (+/- peritonism)

  • Sepsis

  • Patients not progressing as expected


N.B. As a rule of thumb, any patient not progressing appropriately post-operatively with an anastomosis has an anastomotic leak until proven otherwise.


Differentials

  • Postoperative ileus - Failure of intestinal motility without any physical obstruction

  • Surgical site infection - Presents with localised swelling, erythema, and tenderness at the surgical site

  • Abdominal abscess - Presents with abdominal pain, fever, and a palpable mass


Investigations

  • Bloods - FBC, U&E, CRP, Clotting, G&S, VBG - Check PH and Lactate (indicators of tissue ischaemia)

  • CT AP w/contrast - This is the diagnostic investigation, and the contrast has to be given to see the leak. Contrast can either be given via:

    • Contrast enema - preferred way

    • IV


Management

  • Small leak - Conservative with Bowel rest (NBM), IV Fluids, Abx, abdominal monitoring

  • Larger leaks/Pertonitis - Urgent laparoscopic repair



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