Anastomoseninsuffizienz - Anastomoseninsuffizienz

Classification according to ICD-10
K91.81 Insufficiency of anastomoses and sutures after operations on the gallbladder and biliary tract
K91.82 Insufficiency of anastomoses and sutures after operations on the pancreas
K91.83 Insufficiency of anastomoses and sutures after operations on the rest of the digestive tract
T81.0 Bleeding and hematoma as complications of a procedure, not elsewhere classified
ICD-10 online (WHO-Version 2019)

In surgery, the term anastomotic leakage stands for the rupture or leakage of a connection between two anatomical structures ( anastomosis ).

causes

In the case of insufficiency of anastomoses in the gastrointestinal tract , the causes in most cases are inadequate blood flow and the resulting wall necrosis as well as inflammatory processes in the environment. Far less common causes are operational inadequacies such as incorrect suturing technique or lack of tension in the bowel ends.

In vascular surgery , anastomotic leakage is often due to the inadequate strength of the arteriosclerotic vessels or an excessively high dose of anticoagulants ( heparin ), which results in puncture duct bleeding. Here too, of course, technical defects in the creation of the anastomosis are possible.

consequences

If the contents of the gastrointestinal tract enter the free abdominal cavity, this can lead to life-threatening peritonitis if not recognized and rectified immediately . In less dramatic cases, an abscess (“covered” anastomotic leakage) or an enterocutaneous fistula develops locally in the course of a previously existing drainage.

Anastomotic leakage in vascular surgery sometimes leads to life-threatening secondary bleeding, and occasionally (in the case of late insufficiencies) to the formation of a suture aneurysm .

treatment

Operative: In most cases, a rapid operative revision is required.

Conservative: In exceptional cases, a wait-and-see approach can be used in the event of an anastomotic leak, but this depends on the patient's clinical condition. In the case of anastomotic leakage in the abdomen, if there is fever, peritonism or a sharp increase in inflammatory parameters in the blood, surgery must be carried out.

prevention

It has been proven that the anastomotic leakage after operations on the gastrointestinal tract is bacterial in addition to technical causes. Due to the disease, the bacterial flora in the gastrointestinal tract changes to more aggressive germs that can destroy the tissue in the area of ​​the seams. Antimicrobial prophylaxis with substances that specifically eliminate these aggressive types (decontamination), started before the operation, can ensure that the rows of sutures heal. [1] [2] [3] [4]

Individual evidence

  1. H. M. Schardey, T. Kamps, H. G. Rau, S. Gatermann, G. Baretton, F. W. Schildberg: Bacteria: a major pathogenic factor for anastomotic insufficiency. In: Antimicrob Agents Chemother. 1994 Nov; 38(11), S. 2564–2567.
  2. H. M. Schardey, U. Joosten, U. Finke, K. H. Staubach, R. Schauer, A. Heiss, A. Koistra, H. G. Rau, R. Nibler, S. Lüdeling, Klaus Unertl, G. Ruckdeschel, H. Exner, F. W. Schildberg: The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multi center trial. In: Ann Surg. 1997 Feb; 225(2), S. 172–180.
  3. A. D. Olivas, B. D. Shogan, V. Valuckaite, A. Zaborin, N. Belogortseva, M. Musch, F. Meyer, W. L. Trimble, G. An, J. Gilbert, O. Zaborina, J. C. Alvery: Intestinal tissues induce an SNP mutation in Pseudomonas aeruginosa that enhances its virulence: possible role in anastomotic leak. In: PLOS ONE. 2012; 7(8), S. e44326. doi:10.1371/journal.pone.0044326
  4. Daniel Schneider: The prevention of suture insufficiency after deep anterior rectal resection by means of local antimicrobial prophylaxis - a cost-benefit analysis. Dissertation . 2005.