The components of the ESCP Safe-anastomosis checklist
Objective 3: The components of the ESCP Safe-anastomosis checklist
The ESCP Safe-anastomosis checklist has three key steps which should be discussed sequentially in the operating theatre.
The aims of these are to identify intra-operative events which might limit the safety of the anastomosis, to support the surgeon as the decision-maker, and to ensure all equipment required for a handsewn or stapled anastomosis is readily available.
To download the checklist click on the image below:
Read more about the evidence base for the factors highlighted in the ESCP Safe-anastomosis checklist:
The anaesthetist and theatre staff should be asked whether they have again concerns about the safety of anastomosis, or the patient’s physiological reserve.
This should include:
- Haemodynamic instability (including the need for vasopressors or ionotropes)
- Blood loss or transfusion
- Unexpected prolonged operation (>4 hours)
The anaesthetist may also wish to highlight any concerns from their pre-operative risk assessment.
Related paper (Hemodynamic instability): Perioperative Vasopressors Are Associated with an Increased Risk of Gastrointestinal Anastomotic Leakage
Related paper (Blood loss and transfusion): Risk Factors for Anastomotic Leakage After Colectomy
Related paper (Operative time): Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study
The surgeons (including trainees and assistants) should be asked:
- What was the calculated preoperative risk of anastomotic leak? http://anastomoticleak.com
- Have there been unforeseen surgical events (operative field contamination or technical difficulties during the operation) that will influence this risk? This should include contamination of the operative field and any technical challenges.
The surgical team should also consider whether the patient has the physiological reserve to withstand the adverse effects of anastomotic leak as part of this step.
Related paper (Field contamination): Risk Factors for Anastomotic Leakage after Surgery for Colorectal Cancer: Results of Prospective Surveillance
Related paper (Intra-operative complications): Risk Factors for Anastomotic Leak After Colon Resection for Cancer
Related paper (Mortality after anastomotic leak): Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer
At the end of Step 2, the surgeon should decide whether or not there is a decision to proceed to anastomosis, and communicate it clearly to the rest of the operating theatre team
If there is a decision to proceed to anastomosis, the team should move onto Step 3.
If not the checklist will end at Step 2.
In this step, the surgeon should consider whether there are any factors that might limit the safety of stapled anastomosis, for example:
- Bowel oedema or inflammation
- Bowel end ischaemia
- Mesenteric torsion
The surgeon should then clearly state whether the planned anastomosis will be stapled or handsewn
If a stapled anastomosis is planned, the team should discuss:
- What configuration is planned?
- What instruments are required?
- What stapler size is required?
- How will the surgeon test the anastomosis?
If a handsewn anastomosis is planned, the team should discuss:
- What configuration is planned?
- What type of sutures are required?
- Will it be single or double layer?
- Interrupted or continuous?
- How will the surgeon test the anastomosis?
The checklist is now complete.
The member of theatre staff completing the checklist should check that the appropriate patient identification label or details are attached to the checklist, should sign the checklist, and then file this in the patient’s medical notes.