Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer...
Transcript of Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer...
![Page 1: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/1.jpg)
Anastomotic Leakage Following Laparoscopic TME
ByDr. Mostafa Shalaby, M.B.B.Ch, MSc, MD
Lecturer of Surgery, Department of General Surgery “8”, Mansoura University
Consultant of Colorectal Surgery, Mansoura University Hospitals
![Page 2: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/2.jpg)
Introduction
• Anastomotic leakage (AL) is considered the most feared andlife-threatening complication after rectal cancer surgery.
• It is associated with an increased morbidity, mortality, thelength of hospital stay, the rate of re-intervention, and pooroncological outcomes.
• Furthermore, the quality of life is usually affected with poorfunctional outcomes and a higher rate of a permeant stoma in56% of patients.
![Page 3: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/3.jpg)
Methodology
![Page 4: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/4.jpg)
Methods
• The study was approved from the local ethical committee inboth University of Mansoura and University of Rome TorVergata.
• Patients underwent curative laparoscopic LAR or ULAR withcolorectal or coloanal anastomoses for biopsy proven primaryrectal cancer were recruited for the study.
• The patient’s recruitment process was started from January2015 until January 2017.
![Page 5: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/5.jpg)
Methods (continued)
Preoperative workup and preparation
• All patients were discussed on colorectal multidisciplinarymeeting.
![Page 6: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/6.jpg)
Methods (continued)
Figure 1. Trocars position;
C) A 10-mm for the scope;
L1) 12-mm in the right lower quadrant;
L2) 5-mm port in the right upper quadrant;
L3) 5-mm port in the. left lower quadrantAdditionally, a 5-mm trocar may be placedsuprapubic which later could be extended andused for specimen extraction.
The line shows a planned 5-7 cm Pfannenstielincision which is deployed for the specimenextraction
![Page 7: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/7.jpg)
Methods (continued)
Figure 2. Identification of the IMA.
![Page 8: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/8.jpg)
Methods (continued)
Figure 3. Identification of the left ureter
![Page 9: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/9.jpg)
Methods (continued)
Figure 4. IMV ligation at the Treitz ligament“duodenojejunal flexure”.
![Page 10: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/10.jpg)
Methods (continued)
Figure 5. High ligation of the IMA 1-1.5 cmdistally to the origin. The artery is divided by avascular stapler Endo GIATM loaded with whitecartilage 45 mm.
![Page 11: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/11.jpg)
Methods (continued)
Figure 6. Mobilization of the splenic flexure.
![Page 12: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/12.jpg)
Methods (continued)
Figure 7. TME as described by Heald.
![Page 13: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/13.jpg)
Methods (continued)
Figure 8. Transection of the rectum with anEndo GIATM introduced through the 12-mmport.
![Page 14: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/14.jpg)
Methods (continued)
Figure 8. Creation of the anastomosis.
![Page 15: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/15.jpg)
Methods (continued)
• Competence of doughnuts combined with air leak test (ALT)was employed routinely to check anastomotic integrity.
• At the end of the procedure, a routine pelvic drain was placedin the presacral space.
• A defunctioning ileostomy was constructed if there were anytechnical difficulties during performing the anastomosis.
![Page 16: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/16.jpg)
Methods (continued)
Definition and diagnosis of anastomotic leakage
• We defined AL when; there was a feculent material obtainedfrom the drain or the wound, extravasation of dye on CT withrectal contrast, anastomotic defect directly visualized duringcolonoscopy, and finally the presence of peri-anastomotic airor fluid visualized on CT scan.
![Page 17: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/17.jpg)
results
![Page 18: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/18.jpg)
RESULTS
Patients’ and tumors' characteristics
Patients No (%)
Total 59
Male 27 (46%)
Female 32 (54%)
Age (Mean ± SD) 63.49 ± 11.16 years
BMI (Mean ± SD) 24.95 ± 3.56 kg/m2
ASA
I 2 (3%)
II 11 (19%)
III 46 (78%)
![Page 19: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/19.jpg)
RESULTS (continued)
Patients’ and tumors' characteristics.
Patients No (%)
Median distance tumor from anal verge (range) 7 cm (range; 4-12 cm)
Patients received neoadjuvant CRT* 26 (44%)
![Page 20: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/20.jpg)
RESULTS (continued)
Operative details
Patients No (%)
Rectal resection
LAR* 53 (90%)
ULAR** 6 (10%)
Median duration of operation (range) 195 min (range; 120-315 min)
Conversion 5 (8%)
Two firing 48 (81%)
Diversion 24 (41%)
![Page 21: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/21.jpg)
RESULTS (continued)
Post-operative morbidity, treatment, and Clavien-Dindo classification
Complication Patients No Treatment Clavien-Dindo
classification
Total no 10
Anastomotic leakage 4 3; Transanal anastomotic drainage/antibiotics
1; Hartmann’s colostomy
IIIA
IIIB
Postoperative bleeding 3 Blood transfusion (total transfusion 5 unit of blood) II
Wound infection 2 Antibiotics treatment II
Paralytic ileus 1 Conservative treatment I
![Page 22: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/22.jpg)
RESULTS (continued)
Post-operative course; time to resume eating and length of hospital stay
Median in days (range)
Length of hospital stay 10 (6- 28)
Time to resume eating 3 (2- 10)
![Page 23: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/23.jpg)
RESULTS (continued)
• Overall, there was no recorded mortality during the studyperiod.
• Only one patient developed anastomotic stricture which wastreated with regular dilation in outpatients’ department, thispatient did not show any manifestations of AL.
![Page 24: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/24.jpg)
Conclusions
![Page 25: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/25.jpg)
Conclusions
• On expert hands, it is feasible to perform a laparoscopicsphincter-saving TME for rectal cancer patients.
• Justification and selection criteria should be identified forconstruction of defunctioning ileostomy.
• Individualization of the treatment is important.
![Page 26: Anastomotic Leakage Following Laparoscopic TME 03...Dr. Mostafa Shalaby, M.B.B.Ch, MSc, MD Lecturer of Surgery, Department of General Surgery “8”, Mansoura University ... Post-operative](https://reader034.fdocuments.us/reader034/viewer/2022052016/602f534dcb707a542b46f20a/html5/thumbnails/26.jpg)
THANKS