Anastomotic Leak Medical Slides

Present the Dutch Leakage Score concept: CRP trajectory is the single most useful postoperative marker for anastomotic leak. Normal post-operative CRP peaks at POD 2-3 then declines. A CRP >140 mg/L on POD 3 or rising CRP on POD 4-5 (failing to decline) has 68-82% sensitivity for anastomotic leak. The Dutch Leakage Score combines CRP with clinical parameters and has 97% NPV — a normal trajectory effectively rules out leak. When CRP trajectory is abnormal → CT abdomen/pelvis with IV + oral/rectal contrast (sensitivity 89-97% for colorectal leak). Key teaching point: tachycardia, fever, or ileus after POD 4 in a patient who was previously improving should be considered a leak until proven otherwise. Early detection (POD 3-5 vs POD 7+) significantly reduces morbidity.

Present the escalating non-operative options: Grade B leaks (contained, no sepsis): (1) IV antibiotics + bowel rest ± NPO/TPN. (2) Percutaneous CT-guided drainage of collections >3 cm. (3) Endoscopic management: endoscopic stenting (esophageal leaks — covered SEMS bridge the defect, success rate 70-85%), endoscopic vacuum therapy (E-VAC/Endo-SPONGE — negative pressure sponge placed in the cavity, changed every 3-5 days, healing rate 85-90% for rectal leaks), endoscopic clips or sutures for small defects. (4) Transrectal drainage for low rectal leaks. Key patient selection: non-operative management is appropriate for contained leaks without diffuse peritonitis, in patients who are not septic and are clinically stable. Close monitoring is essential — failure to improve within 48-72 hours warrants escalation.

Present the operative decision framework: Grade C leak (generalized peritonitis, sepsis, hemodynamic instability) requires urgent reoperation. Options depend on clinical scenario: (1) Takedown and diversion — safest option: dismantle the anastomosis, create an end stoma (Hartmann procedure for colorectal), definitive but requires future reversal surgery. (2) Repair and divert — repair the defect (suture + omental patch) and create a proximal diverting stoma (ileostomy for colorectal). Appropriate for small, accessible defects with viable tissue. (3) Drainage alone with proximal diversion — if the defect is inaccessible or the patient is too unstable for extensive dissection. (4) Damage control — temporary abdominal closure with planned relook in 48 hours if physiologically deranged (acidosis, hypothermia, coagulopathy). Principles: control sepsis, divert fecal stream, drain all collections, preserve bowel length when possible.