MANAGEMENT OF LEAK AFTER GASTROINTESTINAL SURGERIES MANAGEMENT OF LEAK AFTER GASTROINTESTINAL SURGERIES

Background : A rate of 4 e 8% of gastrointestinal surgical complications include ﬁ stula and anastomotic leakage (AL) of the upper gastrointestinal tract. When done for cancer, postoperative leaks following esophagectomy and gastroplasty occur in around 7 e 8% of patients. Aim : The main aim of this study is to reach the ideal management for each leak according to site of the anastomosis. The goal of this update is to present the general principles of diagnosis, and treatment of AL in gastrointestinal surgery, with a speci ﬁ c focus on esophagogastric, bariatric, small bowel and colorectal surgery. Patient and method : This research was carried out on 100 patients suffering from postoperative anastomotic leak. Patients were managed in Al-Azhar University Hospitals. Results : A total of 53 (53 %) patients in the study group had drainage amounts more than 500 c. There were 18 (18 %) research participants with postoperative renal failure. 35 (35 %) of the study population ' s patients had postoperative oliguria. There were 82 (82 %) study participants with postoperative leukocytosis. 18 individuals, or 18 % of the study group, passed away. In the study population, hospital stays varied from 18 to 33 days, with a mean ± SD of 24.7 ± 2.96. Conclusion : Males had higher risk of developing AL. Postoperative leukocytosis and fever are of concern in AL. The occurrence of postoperative anastomotic leak, which is connected to poor patient outcomes and higher mortality, is in ﬂ uenced by both patient and surgical variables.


Introduction
A rate of 4e8% of gastrointestinal surgical complications include fistula and anastomotic leakage (AL) of the upper gastrointestinal tract. 1 When done for cancer, postoperative leaks following esophagectomy and gastroplasty occur in around 7%e8% of patients [Hern andez J, Boza C. 2016].
Despite the ongoing advancements in diagnostic techniques and surgical therapies, they may be a significant cause of mortality and morbidity. 2ith the development of interventional endoscopy over the last 10 years, a number of minimally invasive techniques, including the injection of fibrin glue, the use of endoclips, endoscopic vacuum sponge treatment, and stent implantation, have been suggested to get a nonsurgical repair of anastomotic leaks. 3L often develops early and may have both immediate and long-term effects.Due to septic or hemorrhagic consequences, AL, especially proximal AL with high enzymatic activity, may be fatal in the near term.After gastrointestinal resections, AL is the leading cause of death, with a mortality rate that varies from 18 to 60 %. 4 Anastomostic stricture is the main long-term effect of AL, and it has functional effects on patient quality of life.Last but not least, the beginning of AL is a predictor of worse long-term overall survival. 5he clinical manifestations of AL might range from total symptom absence to life-threatening septic shock.The greatest chance to lessen the clinical severity and effects is to diagnose an illness as soon as possible, even if the symptoms are mild.The patient is often asymptomatic when AL is treated well, and the diagnosis is diagnosed mostly as a result of the unusual problem of digestive fluid clogging the drains.According to the location of the anastomosis, the patient often exhibits systemic symptoms and concomitant thoracic or abdominal symptoms if the AL is poorly drained. 6edical, interventional radiological, endoscopic, or surgical forms of treatment are all possible.The patient's septic condition is the primary factor in the treatment decision.When a patient is asymptomatic, only medical care is provided.In the event that AL is symptomatic but not life-threatening, interventional treatment is considered.Emergency surgery is necessary when AL poses a life-threatening condition, along with intensive care.Although prevention is crucial, AL effects are reduced more quickly and with higher-quality care. 7

Patient and method
The study was carried out on 100 patients suffering from postoperative anastomotic leak.Patients were managed in Al-Azhar University Hospitals for the period from October 2017 to June 2023.The study was controlled prospectively.All patients were consented to participate in the study.A thorough informed consent form and the most recent patient information booklet should be signed by prospectively recruited patients, who should also be able to comprehend the planned tests and treatments.

Inclusion criteria
Patients with postoperative anastomotic leak at different gastrointestinal sites in any stage and age above 18 years old were included with variable general condition.

Exclusion criteria
Represented by patients with bile leak, patients with pancreatic fistula and patients below 18 years old.

Preoperative work up
All patients underwent a history-taking process and a general and local clinical assessment.Laboratory investigation include complete, blood count (CBC), complete liver function, coagulation profile (bleeding Time, prothrombin time and concentration), electrolytes Na and K, kidney function tests, fasting and postprandial blood sugar.

Radiological investigation
All patients underwent enhanced computed tomography (CT), contrast study, endoscopy, which needs to be performed with minimal insufflation and can help assess the viability of the tissues, abdominal-pelvic ultrasound, and finally a chest radiography to look for any potential risk factors and comorbidities.Others tests were also done represented by Electrocardiography (ECG) for cardiac assessment and consultations as indicated (e.g., respiratory function tests).

Postoperative workup
All patients were followed-up after 1 week, 1 month, 3 months and 1 year to evaluate the outcome as regard response to specific therapy and recurrence of fistula.

Statistical analysis
SPSS 26.0 for Windows was utilized to gather, tabulate, and statistically analyze all of the data (SPSS Inc., Chicago, IL, USA).Number and percentage were utilized to describe qualitative data.The range (minimum and maximum), mean, standard deviation, and median were utilized to characterize quantitative data.

Results
Table 1 presented the research population's demographic features.64 (64 %) of the study  Table 3 showed drain amount/day and onset of Leak among the research population.Number of patients with high output more than 500 ml drain amount/day in the research participants was 63 (63 %).Number of patients with low output less than 500 ml Onset of Leak in the study population was 24 (24 %) (Figs. 7 and 8).Table 5 showed intrathoracic anastomosis population therapeutic strategy and outcome.Number of patients who had conservative management as the therapeutic strategy in the research participants was 0 (0 %). Number of patients with Clinical success in the research participants was 1 (50 %).
Table 6 showed Intraperitoneal anastomosis population clinical presentation.Number of patients with Pain in the research participants was 77    Finally, the main results of this study regarding demographic characteristics among the study population were that the majority of the studied patients were males 64 (64 %) with ages ranged from 21 to 66 with mean ± SD ¼ 42.45 ± 10.16.

Discussion
Both elective and emergency general operations often include bowel anastomoses.Anastomotic leaking was described as the presence of leakage indicators, which were then validated by radiographic inspection, notwithstanding various variances in the term.Leukocytosis, peritonitis, stomach discomfort, soreness, fever, fecal discharge from the pelvic drain, and pelvic abscess were some of the leakage symptoms. 8hree grades of AL exist: Grade A requires no active therapy intervention, Grade B requires active therapeutic intervention but is manageable without re-laparotomy, and Grade C, also known as clinical anastomotic leakage, is a severe form of AL that necessitates re-laparotomy. 9ne of the worst problems for surgeons and nurses is the emergence of clinical anastomotic leakage (CAL) after intestinal surgery.This is due to the increased morbidity and mortality, as well as its detrimental impact on the length of hospital stay, functional results, and oncologic outcomes, as well as higher mortality and morbidity rates. 10ntestinal surgery is often linked to a lengthy hospital stay (5 days for laparoscopic surgery and 8 days for open surgery), a 20 % increase in the likelihood of surgical site infection, and a hefty price tag.In individuals who have specific risk factors, the probability of perioperative nausea and vomiting (PONV) during the hospital stay following optional colorectal surgery may be as high as 80 %.Readmission rates after colorectal surgery have been reported to be as elevated as 35.4 %. 11 Even if surgical techniques and experiences have improved, this is still one of the most serious side effects.In addition to the acute clinical effects such sepsis, peritonitis, intra-abdominal abscess, and elevated morbidity and mortality in hospitals.Additionally, it contains long-term complications that might lead to permanent stomas, decreased pelvic organ function, higher local cancer recurrence, and cancer-specific mortality.It also has a poor prognosis risk factor. 12he large intestine (50.9 %) had the most intestinal anastomosis, and the rates of anastomotic leak depend on the type of anastomosis, with enteroenteric having the lowest rate (1e2%) and colorectal/coloanal having the greatest rate (4e26 %), Ileocolic (1e4%), ileorectal (3e7%), colo-colic (2e3%), and ileoanal pouch (4e7%). 13eak risk has been demonstrated to be directly correlated with surgical risk variables such the location of the anastomosis, laparoscopic vs open methods, and handsewn versus stapled anastomoses.Patient risk factors include male gender, older age, diabetes (increased hemoglobin A1c and perioperative hyperglycemia), smoking, weight loss, serum albumin less than 4, anemia, chemo-radiation, blood transfusion, mechanical bowel preparation, perianastomotic drain placement, tumor size, preoperative chemotherapy, longer operative time, emergency surgery, and intraoperative transfusion.These factors were all strongly connected with a higher probability of adverse outcomes. 14arly detection and modification of modifiable risk factors, especially in elective settings, cumulative and clinical judgment by the surgeon, ideal preoperative care, enhanced operative approaches, and early detection of leaks using clinical signs and biochemical markers are key to decreasing anastomosis leaks.Each patient's risk for the leak must be assessed at the time of surgery, and decisions about anastomosis and the application of proximal diversion should be made in light of those results. 15n line with the current study 16 stated that intra peritoneal anastomosis presentation includes abdominal signs that may be non-specific, but pain was usually intense, associated with peritoneal irritation, rebound tenderness or guarding.
Comparable with the current study 17 revealed that Overall mortality was 5.9 % (17/287) among patients with anastomotic leak.
Higher than the current study 18 reported that the Mortality rate was (29.41 %) 5/17 among patients with gastrointestinal anastomotic leak.
In agreement with the current study 19 stated that some leaks are present in a subtle fashion, often late in the postoperative period.
In agreement with the current study 18 revealed that the type of surgery was elective in 73 (66.36 %) patients and emergency in 37 (33.64 %) patients.Surgical technique: was open in 90 (81.82 %) patients, laparoscopic in 15 (13.64 %) patients and converted in 5 (4.54 %) patients.The study revealed type of surgery elective versus emergency (P < 0.05) was found to be significantly affecting the outcome of anastomosis.

Conclusion
Postoperative gastrointestinal anastomotic leak is a very serious complication that has great clinical impact on patients, putting surgeons in dilemmas of detection and management.The presentation of AL varying from severe peritonitis and leakage of bowel content through the wound or from the drain to asymptomatic (small pelvic abscess).
Early diagnosis is a crucial and challenging clinical target to decrease leakage-associated complications and mortality.However, the shift from on-demand assessment toward the adoption of a routine imaging approach appears not justified, particularly considering its limited clinical value in asymptomatic patients and the required resource allocation.
Diagnosis timing still remains a bottleneck for an efficient management.The diversity of presentation and severity of leakage, in combination with a number of available diagnostic and therapeutic techniques, make optimal management challenging.
Recent trends in AL treatment notice a shift toward a more conservative management compared with the past, along with an increasing adoption of endoscopic intervention Mostly for esophagogastric leak (mainly EVAC technique, stenting) while surgery reserved for the most severe cases.
population's patients were men.The research population's age varied from 21 to 66, with a mean ± SD of 42.45 ± 10.16, respectively (Figs.1 and 2).Table2showed type of surgery among the study population.Number of patients who had Intraperitoneal anastomosis surgery in the study population was 98 (98 %).Number of patients who had Esophageal Procedure in the study population was 2 (2 %).Number of patients who had elective operation in the study population was 72 (72 %).Number of patients who had CT as a diagnostic tool in the study population was 82 (82 %) (Figs.3e6).

Fig. 1 .
Fig. 1.A bar chart displaying Sex-related research population data.

Fig. 2 .
Fig. 2. Box-plot depicting Age data for the study population.

Fig. 5 .
Fig. 5. Pie chart showing research population data as regard type of operation.

Fig. 6 .
Fig. 6.Pie chart showing research population data as regard diagnostic tools.

Table 1 .
Characteristics of the studied population's demographics.

Table 2 .
Surgery type in the research population.

Table 3 .
Drain amount/day and onset of leak among the research population.

Table 5 .
Intrathoracic anastomosis population therapeutic strategy and outcome.

Table 7 .
Intraperitoneal anastomosis population therapeutic strategy and outcome.