[Perioperative standards for prevention of anastomotic insufficiency]

Anastomotic leakage is a major cause of morbidity and mortality in gastrointestinal surgery. Its incidence varies in the different segments of the GI tract being highest in the distal rectum. The rate of anastomotic leakages was reduced considerably within the last 20 years. Perioperative measures have contributed to this reduction in addition to improvements and standardization in operative technique. Perioperative nutrition, perioperative antibiotic prophylaxis and mechanical bowel preparation are widely used in colorectal surgery. Therefore they can be considered as standards. High-caloric parenteral feeding is used commonly perioperative. Its efficiency to reduce postoperative septic complications has been proven until now only for malnourished patients. The aim of perioperative antibiotic prophylaxis is to reduce the bacterial count after intraoperative contamination. Therefore tissue levels must be in the therapeutic range to cover for the expected bacteria. The efficiency to reduce postoperative wound infection has been proven, however the influence on the rate of anastomotic leakages is still controversial. Mechanical bowel preparation can reduce the bowel load but not bacterial concentration inside the bowel. Orthograde lavage with polyethylenglycol solution is feasible unless bowel obstruction is present, but its influence on anastomotic healing is still under discussion. Although all of these procedures are widely used, their influence on anastomotic healing has still to be proven by prospective, controlled trials.