1 / 22

GI Anastomosis

GI Anastomosis. Dr Siu Wing Tai Department of Surgery PWH. Anastomosis. Connection between 2 tubular structures Surgical anastomosis Pathological anastomosis / fistula. Pathphysiology. Lag phase (Day 0-4) Acute inflammatory response Fibroplasia phase (Day 3-14)

flavia-newman
Télécharger la présentation

GI Anastomosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. GI Anastomosis Dr Siu Wing Tai Department of Surgery PWH

  2. Anastomosis • Connection between 2 tubular structures • Surgical anastomosis • Pathological anastomosis / fistula

  3. Pathphysiology • Lag phase (Day 0-4) • Acute inflammatory response • Fibroplasia phase (Day 3-14) • Fibroplasts proliferation • Immature collage is laid down • Maturation phase (> Day 10) • Collage is remodeled • Strength of anastomosis is increased

  4. Principles • Appropriate indications • Bowel preparation / prophylatic antibiotics • Extent of resection • Anastomosis / defunctioning stoma • Adequate exposure / assessment • Preparation of bowel for anastomosis • Vascularity, healthy tissue, tension, alignment • Technique of Anastomosis • Protection against contamination • Drainage • Proximal defunctioning stoma

  5. Techniques • Sutured • Interrupted, continuous • single- / double-layer • Bowel edges are approximated & inverted • Watertight anastomosis with adequate lumen

  6. Techniques • Stapled GIA TA EEA

  7. Techniques • Sutured • Interrupted, continuous • single- / double-layer • Bowel edges are approximated & inverted • Watertight anastomosis with adequate lumen • Stapled • Unconventional • Compression rings • Tissue glue • Laser welding

  8. Configurations • End-to-end • End-to-side • Side-to-side

  9. Configurations • End-to-end • End-to-side • Side-to-side

  10. Configurations • End-to-end • End-to-side • Side-to-side

  11. Configurations • End-to-end • End-to-side • Side-to-side

  12. Factors affecting Anastomotic Healing • Intrinsic factors • Hypotension, hypoxia • Jaundice, uraemia • Malnutrition, immunocompromise • Steroid, cytotoxic drugs • Previous irradiation • Peri-anastomosis sepsis, haematoma • Distal obstruction • Surgical techniques • Blood supply • Appropriate alignment • No tension • Maintenance of apposition

  13. Post-operative Care • Vigilant for signs of anastomotic leakage • +/- water soluble contrast study / imaging • Obvious signs • Abnormal content in drainage bag, peritonitis, high fever • Obscure signs • Unexplained pyrexia, leucocytosis, prolonged ileus, chest infection, effusion

  14. Group A • A 75-y-o retired cook post-operative day 5right hemicolectomy for carcinoma of caecum. • Known IHD, DM, COPD FU medics. Noted “faculent” discharge in the abdominal drain. • How would you assess/manage the situation?

  15. Group B • 60 y.o. male post-operative day 4Ivor-Lewis oesophagectomy for carcinoma of distal oesophagus. • Past health: HT, chronic smoker, drinke • Running low grade fever, CXR diffuse hazziness in right side • How would you manage the patient?

  16. Group C • A 65-y-o woman admitted because of large bowel obstruction. Diagnosed to have obstructing recto-sigmoid tumor by contrast enema. • She underwent emergency anterior resection with primary anastomosis by mechanical stapler. • Post-operative D6, running a temp of 38.5oC, c/o left- sided abdominal pain. Then noted large amount of turbid fluid discharging from the midline wound. • How wound you treat the lady?

  17. GI Fistulas Dr Siu Wing Tai Department of Surgery PWH

  18. Intestinal Fistulas • An abnormal communication between two epithelialized surfaces. • GI fistulas • Congential / acquired • Primary (underlying gut disease) / Secondary (injury to normal gut) • Enterocutaneous / enteroenteral • Simple (short & direct tract) / complex (long & multiple tracks via an abscess cavity) • Low / high output (>500ml /day)

  19. Primary Fistulas • Malignancy • Crohn’s disease • Colonic diverticular disease • Necrotizing pancreatitis • Radiation enteritis

  20. Secondary Fistulas • Risk factors for anastomotic failure • Unrecognized enteric injury • Breakdown of repaired serosal tear • Laparostomy for severe widespread abdominal sepsis • Mesh application

  21. Management • Manage according to the degree of associated sepsis • Resuscitation • Airway, breathing, circulation • Peritonitis for operation • Drain abscess, exteriorized bowel ends, resect ischemic gut • Stable patient • Correct fluid / electrolyte imbalance • Eliminate sepsis- antibiotic, drain abscess • Wound / skin care • Nutrition • Imaging delineation of fistula anatomy • Plan for surgical correction / wait for spontaneous closure • Rehabilitation

  22. Factors affecting Fistulas Closure • Discontinuity of bowel ends • Distal obstruction • Damaged / diseased residual intestine • Intervening abscess / ongoing sepsis • Mucocutaneous continuity of the fistula with skin • Malnutrition • Foreign bodies / mesh • Malignancy

More Related