Intraabdominal anastomotic leak after upper gastro-intestinal surgery: Definition, diagnosis, management and prevention

Resumen

ABSTRACT The augmenting number of upper gastrointestinal (UGI) procedures, especially due to bariatric surgery, entails an expected increase in the absolute number of surgical complications. Among the most devastating complications is that of a postsurgical leak, increasing morbidity and mortality thus affecting long-term survival rate and treatment¿s cost. Consequently nowadays we think it should be considered like a real public health problem. Incidence and risk factors are well described in literature. Surprisingly, a definition for this entity nor a management algorithm has not been described yet. Between 2003 and 2013, 1.856 patients underwent an UGI operation in our center: 121 gastrectomies (total: 58 subtotal: 63); 1.654 gastric bypass; and 81 sleeve gastectomies. 15 (0,08%) patients with confirmed intraabdominal post-surgical leak were reported (10 acute; 5 chronic). Diagnosis methods, management and complications were analyzed. Intraabdominal anastomotic leak (IAAL) has been defined in our study as a disruption of esophago-jejunal, gastro-jejunal or jejuno-jejunal anastomosis, as well as on the staple line and paraanastomotic abscesses seen on radiological images. Early diagnosis was possible due to high index suspicion. Identification of patients with severe sepsis or septic shock was provided by SIRS classification. CT scan with oral and/or intravenous contrast, established evidence of leak in 13 patients. Endoscopy verified radiological findings and assessed severity in 9 patients. In 5 cases it was performed before surgery. No differences in rates in reoperation, leakage and postsurgical complications were described in this group. Imminent exploratory laparoscopy was performed in 2 hemodynamic unstable patients. Treatment was established promptly combining endoscopic, surgical and/or radiological techniques. Management options were determined by hemodynamic conditions of the patient and the characteristics of leakage to assure enteral nutrition as soon as possible. Conservative management was carried out in 4 patients, healing 3 of them. 11 patients submitted surgical treatment (8 laparoscopies; 1 urgent laparotomy; 2 elective surgeries). Stent was deployed in 8 patients (sealing rate: 62,5%). Life-threatening complications requiring ICU management (Clavien-Dindo IV) (33.3%) were more frequent in patients with surgical management. One (6,6%) patient died. Patients with conservative management had short intensive care course (10 versus 13 days) and hospital stay (15 versus 26 days). Early diagnosis of IAAL is paramount and it should not be based on clinical suspicion alone. Therefore endoscopic exploration should be performed when possible, allowing early diagnosis, providing information of anastomosis¿ morphologic characteristics that will help accurate the best management. Eventually treatment can be done at the same time. Management by a multidisciplinary team, combining endoscopic, surgical and radiological techniques is the best strategy to reduce time until leak healing. It is important to considerate severity and location of the leak as well as the day of appearance. In hemodynamic stable patients, conservative management is effective and can obviate a reintervention, thereby avoiding postoperative complications. Goals are effective drainage, covering dehiscence by an endoscopic stent and renutrition. Endoscopic treatment can heal or may help to make a chronic leak until a definitive surgery can be performed in a patient¿s optimal clinical and nutritional status. Hemodynamic unstable patients need a prompt surgical repair. Laparoscopic approach allows evaluation of anastomosis¿ characteristics, consents peritoneal lavage and positioning effective drains. Laparotomy remains anecdotal for hemodynamic unstable non-responding patients excluded of mini-invasive treatment, in order to diminish disadvantages and complications of operative treatment. We suggest applying IAAL definition in forthcoming studies on UGI surgery to homogenize reporting of outcomes thus facilitating comparison of the results from different studies so in the future this concept can be standardize. To conclude, a management algorithm is proposed.