Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

EP.WE.205Impact of the Covid-19 Pandemic on Loop Ileostomy Formation

Aim Uncertainty during the early phases of the Covid-19 pandemic regarding availability of critical care beds and peri-operative impact of SARS-CoV-2 led to changing intercollegiate guidance in favour of increased stoma formation. This study assessed the impact the Covid-19 pandemic had on loop ileostomy formation. Methods Data were reviewed from a prospectively collected database on the number of loop ileostomies formed over a 10-month period from 1st March to 31st December 2020. Comparison was made with the same period in 2019. Details were confirmed using clinical letters. Results 114 loop ileostomies were formed in the 20-month period. There was a 10.0% reduction in loop ileostomy formation in 2020 compared with 2019. The median number of loop ileostomies formed per month over the two 10-month periods was 6. This peaked at 11 in April 2020 coinciding with the first wave of Covid-19, falling in subsequent months. All 11 of these loop ileostomies were formed in colorectal cancer patients undergoing anterior resection, after appropriate counselling. Conclusions There was a reduction in the number of ileostomies formed in 2020 compared with 2019 reflecting the impact of the Covid-19 pandemic on both elective and emergency case load and presentations. These results show reactive change in surgical practice corresponding to guidance at a time of maximum uncertainty. Primary anastomosis still occurred but with an increased likelihood of a defunctioning stoma to minimise the consequences of an anastomotic leak. A subsequent reduction in stoma formation in the following months indicates that practice rapidly returned to normal.

Revising Our Concepts about Stoma Covering a Low Rectal Anastomosis

Introduction There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However, whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis.

Literature review on hydrostatic vaginal and anorectal injuries caused by personal watercraft

Introduction The use of personal watercrafts (PWCs) has increased in popularity, size and engine power over time. Hydrostatic injuries when the passenger falls into water and the pelvic floor is directly hurt by the water jet remain rarely reported in literature but potentially lethal. Perineal, gynaecological and rectosigmoid regions present significant points of anatomical weakness to the force vector of the water. Biomechanical aspects on water-associated injuries on PWC may include disruption of the perineal soft tissues, inefficient anal sphincter and hydrodynamic insufflation. Methods This is a study involving a literature review from 1972 to 2020 using suitable search terms to identify all hydrostatic PWC injuries following PRISMA guidelines. Data were extracted from suitable articles on mechanism of injury, injuries sustained, treatment and outcomes. Results Thirty-two patients with major perineal, gynaecological and/or digestive injuries due to hydrostatic PWC traumas were identified. Major risk factors were female gender (84.4%), young age (25.5 years), being a rear passenger and wearing a standard swimsuit (100%). The injuries were digestive tract only (81.3%), gynaecological only (46.9%) or combined (28.1%). The interdisciplinary surgical management must include a vaginal and anal exploration under general anaesthesia and an exploratory surgery. Vaginal repair (41.9%) may be associated with a transanal anorectal suturing for lacerations of the intraperitoneal rectum (40.6%). A defunctioning stoma was performed in 62.5% and consisted of a loop sigmoidostomy (43.5%) or Hartmann’s procedure (34.8%) depending on laceration complexity. Conclusions PWC-related hydrostatic injuries are still rare but associated with a mortality rate of 6.3% which rises to 25% if initial haemodynamic instability was present. Expert guidelines such as adding an automated engine shut-off switch for the rear passenger and wearing a protective and safety clothing should be more widely respected.

80 Defunctioning Stomas the Answer to Avoid Anastomotic Leaks – Mere Precaution or A Necessity?

Introduction Anastomotic leaks account for one of the major complications following Colorectal Surgery. One of the surgical procedures to help avoid this complication include providing a defunctioning stoma. Evidence surrounding the provision of a defunctioning stoma has been supported extensively in the field of Colorectal Surgery. Method A retrospective study was performed using a cohort of patients from a single teaching hospital between 2014 and 2019. 559 who had undergone elective bowel resection with primary anastomosis were identified and followed up. Data was captured using the hospital’s electronic medical records; Quadramed and Evolve. Results From the 559 patients 167 received a defunctioning stoma, out of which 114 were successfully reversed. 2 patients out of the 114 were deceased at 6 months following the reversal (p = 0.332). Furthermore, 15 patients of the 167 went on to develop complications at the anastomotic site (chi-square 25.37, p = <0.00001). 8 patients had anastomotic leaks and 9 patients developed strictures of which 2 patients developed both strictures and leaks. Conclusions Although written literature points in favour of providing a defunctioning stoma; it is important to consider such a decision in a case-by-case manner, due to the complications involved instead of routinely providing a stoma as a prophylactic measure.

P85 Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

Aim This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic. Method This was an international cohort study of patients undergoing elective colon or rectal cancer resection, without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2, and a comparison with a pre-pandemic European Society of Coloproctology cohort data. Results From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. 30-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073), and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV2 (14/1601, 0.9%), and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with an anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20), and advanced cancer stage (3.43, 1.16-10.21). Compared to pre-pandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%), an overall shorter length of stay (6 versus 7 days), but higher mortality (1.7% versus 1.1%). Conclusion Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative, and organisational risks.