Mx of Anastomotic Leak + wound healing +SSI👮🏻‍♂️

Question 1

Definition of anastomotic leak

Answer 1

Definition
- No universally accepted definition
- A leak of luminal contents from a surgical joint between two hollow viscera (UK Surgical Infection Study Group 1991)
- A defect of the intestinal wall at the anastomotic site, including suture and staple lines, leading to a communication between the intra and extraluminal compartments (International Study Group of Rectal Cancer 2010)

Question 2

General Leak rates

Answer 2

General leak rates
Lowest leak rates are found with ileocolic anastomoses (1 to 3 percent)
Highest leak rates occur with coloanal anastomosis (10 to 20 percent)

Question 3

Risk Factors for anastomotic Leak

Answer 3

Risk factors
Pre operative:
- Male gender (narrower pelvis)
- Smoker
- Immunosuppression
- Malnutrition ( Albumin low, Anaemic)
- IBD (if you’re anastomosing inflamed bowel segments)

Intraoperative:
- Low anastomosis (within 5cm FAV)
- Emergency surgery (unprepped bowel risking contamination, higher chance of bowel diameter discrepancy during anastomosis)
- **Poor surgical technique **leading to anastomosis under tension, or poorly vascularized anastomosis
- Anastomosis involving Left colon due to
1) Higher intraluminal pressures compared to Right colon
2) Areas of precarious vascular supply due to incomplete vascular arcades such as Griffith’s Point at splenic flexure (Between SMA and IMA supply) and Sudeck’s Point at rectosigmoid junction (between last sigmoid arterial branch of IMA, and superior rectal artery supply)

Question 4

Clinical Features of Anastomotic leak

Answer 4

Clinical Features
- Most anastomotic leaks usually become apparent between five and seven days postoperatively
- Pain
- Fever
- Tachycardia
- Peritonitis
- Purulent or Feculent drainage

Ix
- Raised inflammatory markers including CRP
- Contrast enhanced CT abdo/pelvis (fluid and/or gas containing collections)

Question 5

Classification of anastomotic leak

Answer 5

Grade A: No change in management/detected incidentally on radiological imaging (rarely seen in clinical practice)
Grade B (No peritonism, sepsis controlled): Requires intervention but not laparotomy, e.g. percutaneous drain
Grade C (Peritonism, severe sepsis): Requires re-laparotomy
Alternative classification: Intraperitoneal/extraperitoneal leak

Question 6

Management of Grade B anastomotic leak

Answer 6

General fluid resus, broad spectrum IV Abx
Para anastomotic collections < 3cm in size: Bowel rest, Abx alone
Para anastomotic collections > 3cm: Generally require percutaneous drainage (e.g. CT guided)
If feculent drainage noted or sepsis unresolved, for proximal fecal diversion (Grade C)

Question 7

Management of Grade C anastomotic leak

Answer 7

Laparotomy, repair/redo anastomosis, defunction patient OR
Laparotomy with Hartmanns procedure (resect anastomosis)- likely safer exam answer

Question 8

If you don’t resect anastomosis and do Hartmanns, how else could you defunction the patient?
- Loop ileostomy (preferred if minimal stool in colon)

Answer 8

Advantages:
Reduced rates of stomal prolapse and post-reversal complications
Easier to perform than colostomy

Disadvantages:
Risk of dehydration and electrolyte disturbances esp in elderly

Question 9

If you don’t resect anastomosis and do Hartmanns, how else could you defunction the patient?
- Loop Colostomy

Answer 9

Loop colostomy just proximal to the anastomosis, or loop transverse colostomy (If high colonic stool burden or patient too frail to tolerate ileostomy)

Disadvantages:
Prone to prolapse
Can interfere with future reconstructive options should anastomosis require revision later on
Transverse colostomy creation can damage marginal artery if high IMA ligation performed at index operation (can devascularize distal colon)

Question 10

Overview of wound healing

Answer 10

Question 11

Overview of Wound Dishiscience

Answer 11

Question 12

Overview of SSI

Answer 12

Question 13

SSI prevention by J&J

Answer 13

Question 14

SSI prevention summary - Preoperative

Answer 14

Question 15

SSI prevention summary - Intraoperative

Answer 15

Question 16

SSI Prevention summary - Post operative

Answer 16

Question 17

Pathogenesis of Tuberculous (TB) Lymphadenitis 🦠🧫

Answer 17

➔ Step 1: Primary Infection
• Infection usually starts via inhalation of aerosolized droplets containing M. tuberculosis.
• The lungs (especially alveolar macrophages) are the first site affected.
• The bacilli multiply inside macrophages.

➔ Step 2: Dissemination
• From the lungs, bacilli spread through lymphatics or blood (hematogenous spread) to regional lymph nodes — particularly the hilar or mediastinal nodes first.
• In some cases, the organism seeds peripheral lymph nodes directly.

➔ Step 3: Host Immune Response (Granuloma Formation)
• The immune system reacts by activating T-helper 1 (Th1) cells, releasing cytokines (like IFN-γ).
• This recruits macrophages to the site, transforming into epithelioid cells and multinucleated Langhans giant cells.
• These form granulomas — the hallmark of TB.

➔ Step 4: Caseous Necrosis
• Central part of granulomas undergo caseous necrosis (“cheese-like” necrotic tissue) due to immune-mediated tissue destruction.
• This is characteristic of TB lymphadenitis.

➔ Step 5: Clinical Manifestation
• Affected lymph nodes become enlarged, firm, sometimes matted together, and can break down to form cold abscesses or sinus tracts if untreated.
• Most common sites: Cervical lymph nodes (especially posterior triangle — called scrofula).