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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_636_Библиотеки_им_академика_М_И_Перельмана.pdf
138
K. Umanskiy and N. Hyman
Treatment
• Factors to be considered when deciding on the
appropriate management for a patient with an
anastomotic leak include patient-specic factors (hemodynamic derangement, physiologic
reserve, nutritional status, comorbid complications, initial surgical indications/goals) and
features of the leak (location, size of the
defect, presence of concomitant tissue
ischemia).
• Perhaps the most useful classication in outlining the principles of management is early
versus late presentation.
• Patients with an early leak classically present
in the rst week after surgery with signs and
symptoms of peritonitis, organ dysfunction
associated with sepsis, and hemodynamic
instability.
• In this clinical setting, prompt return to the
operating room is required (Fig.10.2).
• Patients with an anastomotic leak often present with signs and symptoms that lead the surgeon astray and suggest other serious
postoperative complications (e.g., pulmonary
embolism, myocardial ischemia).
• If the diagnosis is established in the rst few
days after the initial surgery, most patients
will require operative exploration.
• Intravenous antibiotics and close observation
may be appropriate in a few highly selected
patients with small, contained leaks that other-
Fig. 10.2 Diffuse peritonitis after major anastomotic
disruption
wise appear reasonably well (low colorectal
anastomosis, especially if they have a proximal diversion).
• At re-operative surgery, the peritoneal cavity
is thoroughly irrigated and appropriate cultures obtained.
• In general, patients with a small bowel to small
bowel or ileocolic anastomosis are best treated
with resection and repeat anastomosis.
• Patients who are hemodynamically unstable
may be treated with an ileostomy and endloop stoma, where the distal end is brought out
through the same aperture as the ileostomy
(Fig.10.3a–c).
• Anastomosis with proximal loop ileostomy is
another alternative to address this situation
where primary anastomosis alone is deemed
unwise.
• When a colocolic anastomosis breaks down,
dividing the anastomosis and creating an end
colostomy is usually the most appropriate
option.
• Resection with anastomosis and proximal
loop ileostomy is an option for hemodynamically stable patients.
• Leak after low anterior resection creates
challenging management decisions. If the
anastomosis is divided and a colostomy created, then subsequent attempts for another
low pelvic anastomosis may be a formidable
endeavor.
• When there is no ischemia and the leak is relatively small and contained, loop ileostomy and
drainage of the anastomosis are usually most
appropriate.
• In stable patients with major disruptions,
resection with anastomosis and proximal
diversion may also be an option.
• The management of anastomotic leaks diagnosed beyond the rst week to 10days postoperatively usually differs in many important
regards from its earlier counterpart.
• Careful imaging including a CT scan of the
abdomen and pelvis with intravenous and
enteric (including rectal) contrast is typically
the key to diagnosis and treatment planning.
• Re-operative surgery is usually unnecessary
and will quite often make things worse.
10 Anastomotic Complications
139
a
b
c
Fig. 10.3 End-loop stoma. (a) The bowel is divided, and
each end is brought up through the opening. (b) The proximal portion is completely matured, while the distal end
• Most patients with late presentations are most
often best managed by patience, antibiotics,
and percutaneous drainage.
• Both covered stents and vacuum-assisted
devices have been used with anecdotal success.
• Nutritional support, using the enteral route
whenever possible, should not be neglected.
has only a corner matured. (c) Side and top view of the
matured stoma
Anastomotic Stricture
• Anastomotic stricture is a relatively common
complication of colorectal or pouch-anal
anastomosis, occurring in 3% to 30% of cases.
• The exact pathophysiology underlying anastomotic strictures remains unknown, but
140
K. Umanskiy and N. Hyman
ba
Fig. 10.4 (a) Colorectal anastomotic stricture, before dilation. (b) Anastomosis after through the scope balloon
dilation
ischemia, incomplete “doughnuts” from stapled anastomotic reconstruction, anastomotic
leakage, hemorrhage, and radiotherapy are
probably contributing factors.
• Symptoms most commonly associated with
rectal strictures are increasing constipation
and partial large bowel obstruction.
• Asymptomatic patients with a stricture and
diverting stoma can be identied based on
digital rectal examination or upon radiographic or endoscopic evaluation prior to
stoma reversal.
• Diagnosis is typically made by imaging (i.e.,
contrast enema) or endoscopically—the inability to pass a 12-mm-diameter sigmoidoscope
through the anastomotic narrowing.
• Luchtefeld found that stenosis was diagnosed at 1–6months after surgery in 54% of
patients and at more than 6months after surgery in 14%.
• Recurrent cancer must be considered as a
cause of stricture prior to deciding on the
treatment approach.
• Short strictures in low colorectal, coloanal,
and ileoanal pouch anastomoses can be treated
by simple digital dilation or Hegar dilators
with a low rate of restenosis.
• Endoscopic balloon dilatation is the most
commonly used method for treatment of short
(<1 cm) colonic and colorectal anastomotic
strictures (Fig. 10.4a, b) with success rates
that range from 86% to 97%.
• A less frequently used method of bougie dilation of anastomotic stricture is accomplished
by the radial vector of an axially directed force.
• In a case study, Pietropaolo found balloon
dilation more effective than bougie dilation
with respect to the proportion of patients successfully treated in a single session (76.9% vs.
51.8%).
• Recurrent cicatricle strictures may be treated
with the combination of incision plus balloon
dilation or endoscopic stricturotomy with neodymium-yttrium aluminum garnet laser.
• Complications of electrocautery and laser
strictureplasty are very low, with only one
group reporting a 2.7% technical failure rate.
• Alternatively, transanal endoscopic microsurgical approach (TEM) strictureplasty with
electrocautery or laser can be used.
• Anastomotic strictures that are irregular,
markedly angulated, xed, or longer than
1–2 cm in length may not be amenable to
endoscopic treatment.
• Re-operative rectal dissection in the presence
of scarring from previous operations or from
ongoing local sepsis is technically demanding
and should not be underestimated.
• Shleigel reported a series of 27 patients who
underwent surgical correction of anastomotic
10 Anastomotic Complications
141
stenosis (7 colorectal anastomoses for upper
rectal anastomotic strictures and 20 coloanal
anastomoses for middle and lower rectal strictures). Intestinal continuity was restored in all
cases.
• In long segment distal rectal strictures or after
failure of local therapy, immediate or delayed
coloanal anastomosis through a combined
abdominal and perineal approach is
recommended.
• A less invasive technique using an end-to-end
anastomosis (EEA) stapler may be applied to
correct mid- to proximal rectal strictures with
or without laparotomy. Prior to stapling, the
rectal anastomotic stricture is dilated and
assessed by rigid sigmoidoscopy. Long-term
results following this technique of stricture
resection have been reported as 89–100%
return to normal bowel function with a mean
follow-up of 12–49months.
• Self-expanding metallic stents (SEMS) have
been considered for medium-term symptom
relief for recalcitrant benign colorectal strictures in patients who are otherwise unt for
surgery. They associated with a delayed complication rate of 38% of cases.
• Diverting ileostomy or colostomy may be the
only available treatment option in some cases.
Anastomotic Bleeding
• Anastomotic bleeding following stapled
colorectal, colonic, or intestinal anastomosis
is usually self-limited complication occurring
in up to 5% of anastomoses.
• The risk of postoperative bleeding can be
decreased by avoiding the inclusion of mesocolon into the staple line.
• We recommend intraoperative assessment of
colorectal anastomoses with intraoperative
exible sigmoidoscopy where an actively
bleeding vessel can be visualized and immediate hemostasis achieved by placement sutures
under direct inspection, endoscopic injection of
1:200,000 epinephrine, or careful coagulation.
• The optimal treatment choices depend on the
site of bleeding, patient factors, and skill of
the surgeon or endoscopist.
• Postoperative anastomotic bleeding usually
occurs in the rst 9days.
• Initial management includes correction of any
associated coagulopathy and transfusion of
blood and blood products if necessary.
• Between 2 and 10units of packed red blood
cells may be required in the nonoperative
treatment of anastomotic bleeding, and hypothermia should be avoided.
• For persistent bleeding, colonoscopy allows
for direct inspection of the anastomosis and
potentially for treatment.
• Submucosal peri-anastomotic injection of up
to 10ml of 1:200000 epinephrine in saline has
been shown to result in control of anastomotic
bleeding.
• Cirocco reported the successful use of electrocoagulation (anastomotic stula that developed in one of six cases may have been related
to this technique).
• Endoscopic application of clips is an excellent
alternative to coagulation and has been shown
to be safe and effective in control of anastomotic bleeding.
• Briskly bleeding anastomoses may be amenable to angiographic localization and embolization but with the risk of bowel ischemia or
infarction by interrupting the distal arterial
blood supply.
• Although extremely rare, signicant anastomotic bleeding after large bowel resection can be
severe enough to require reoperation with surgical revision or reconstruction of anastomosis.
Part II
Anorectal Disease
Approach toAnal Pain
AmirL.Bastawrous
11
Key Concepts
• A careful history should direct the diagnosis
for patients with anal pain.
• A considerate yet thorough physical exam will
usually establish the diagnosis by visualizing
pathology or by palpating abnormalities. If
not possible in the ofce, then an exam under
anesthesia should be performed.
• Imaging is rarely needed to determine the
etiology.
• An anal ssure will typically cause sharp anal
pain during and after a hard bowel movement.
• The anal pain associated with a thrombosed
external hemorrhoid is usually constant and
accompanied by a palpable swelling but without systemic signs of infection.
• Cancer should always be included in the differential diagnosis.
Introduction
• Anal and rectal pathologies can be inconvenient and are commonly debilitating.
• Anal pain is a symptom which encompasses a
broad spectrum of diagnoses from the benign
and self-limited to the neoplastic and
life-threatening.
A. L. Bastawrous (*)
Swedish Cancer Institute, Swedish Colon and Rectal
Clinic, Seattle, WA, USA
e-mail: amir.bastawrous@swedish.org
Patient History
• An experienced colorectal surgeon can often
surmise the patient’s diagnosis prior to any
examination just by listening to key descriptions by the patient.
• Pain characteristics are important [duration,
location (intra-anal, external), character (burning, sharp, dull), causative agents (bowel
movement, diarrhea, hard stool, exercise, fecal
incontinence, drainage), associated signs and
symptoms (fever, chills, weight loss, change
in bowel habits), and items that provide any
relief (warm water bath, bowel movement,
topical creams)].
• Elements of the patient history can provide
some guidance:
– Diabetes may suggest an anal abscess or
Fournier’s gangrene.
– Inammatory bowel disease may hint at an
anal ssures, stulae, or abscess.
– Iniximab or etanercept use may point to
psoriasis as a cause for pruritus.
– Family history of colorectal cancer may
lead to consideration to rule out rectal
cancer.
– Anoreceptive intercourse may raise the
concern about sexually communicable
infectious diseases, anal dysplasia, or anal
cancer.
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_11
145
146
• Finally, one should not be misled by either the
patient’s or referring physician’s working
diagnosis, which is often inaccurate.
Anal Fissure (Fig.11.1)
• Patients typically describe sharp, “knifelike,”
during and immediately after a bowel
movement.
• The pain may last for minutes or hours after
passing stool.
• Spotting of blood on the toilet paper after wiping or dripping into the bowl is common.
Acutely Thrombosed External
Hemorrhoid (Figs.11.2 and11.3)
• Patients describe sharp, constant pain following straining (either with a bowel movement
(loose or constipated) or lifting something
heavy).
• The pain will coincide with a “bulge” they feel
near the anal opening.
• The pain will last all day, usually increasing
gradually, and then decrease over the week.
A. L. Bastawrous
Fig. 11.2 Acutely thrombosed external hemorrhoid
Fig. 11.1 Anal ssure
Fig. 11.3 Hemorrhoidal crisis
11 Approach toAnal Pain
Perianal, Perirectal, or Ischiorectal
Abscess (Fig.11.4)
• Their history is one of the gradually worsening pressures and pain.
• The pain is constant but worse before and during a bowel movement.
• They will typically describe fever and chills.
• These patients often refuse to sit due to the pain.
• There can be some similarity of symptoms
with patients who have a thrombosed external
hemorrhoid, but the primary difference in presenting symptoms is the presence of systemic
symptoms of infection.
• Inability to urinate is a rarely associated complaint, seen most commonly with large abscesses.
Pruritus Ani (Fig.11.5)
• The pain can be described as pain but is often
claried to be burning or itching, with some
overlap.
• The irritation is nearly universally chronic in
nature, occurring in ares and cycles.
147
Fig. 11.5 Pruritus ani
Levator Syndrome
• A lack of tting into a typical pain pattern
often makes the diagnosis challenging.
• The pain may be sharp, dull, burning, or achy.
Fig. 11.6 Anal squamous cell carcinoma
• It may be intermittent or constant, may
improve with warm water baths, or may
be worsened or improved with bowel
movement.
• Often the pain is chronic and worse late in the
day.
• Some will complain of difculty with evacuation of stools.
Anal or Rectal Cancer (Fig.11.6)
• The majority of patients who present with anal
pain have benign processes; however, the alert
physician will always consider cancer within
the differential diagnosis.
• Anal and rectal cancers can present with pain,
often with concurrent bleeding and/or change
in bowel habits.Fig. 11.4 Perianal abscess
148
• Anal cancer can present more subtly with
symptoms overlapping with those of anal ssure with pain during and after a bowel movement along with spotting of blood on the toilet
paper.
• There may or may not be an associated mass
felt by the patient.
Physical Examination
A. L. Bastawrous
• The regional high yield focus of the examination includes the abdomen; inguinal, perianal
skin and soft tissue; buttocks and gluteal cleft;
and anal canal and rectum.
Abdominal Examination
• Anal pathology can on occasion manifest with
abdominal ndings.
• An obstructing cancer can cause distention or
alteration of bowel sounds.
• Metastases can present with hepatomegaly.
• Crohn’s disease patients may be very thin and
cachectic if they have both anal disease and
bowel manifestations.
Inguinal Examination
• The inguinal examination may identify adenopathy in the setting of low rectal
adenocarcinoma or anal canal and anal margin
squamous cell carcinomas.
• This exam nding has implications for radiotherapy mapping and surveillance of disease
regression or recurrence.
Perianal, Gluteal, andIntergluteal
Examination
• Patients will appreciate a careful description
of the exam as it is performed and an explanation of ndings along the way.
Fig. 11.7 Anal stula
Fig. 11.8 Anal stricture
• Visual examination of the perianal skin
includes color, scaly skin, thickened folds,
masses, secondary openings of stula-in-ano
(Fig.11.7), evidence of abscess with swelling
or redness, skin tags, and external hemorrhoid
enlargement.
• Anal ssure can be diagnosed by visualizing
the anoderm with gentle retraction of the buttocks to evert the anoderm and expose the
ssure.
• In the intergluteal cleft, look for sinuses,
abscess, and pilonidal pits.
• Anal stenosis can be seen in some patients
after anal surgery (Fig.11.8).
• The rare subcutaneous mass may be benign or
malignant; an assessment of size, xation,
character, rmness, and tenderness is sometimes helpful in establishing the diagnosis
(Fig.11.9).
11 Approach toAnal Pain
Fig. 11.9 Solitary brous tumor
149
Anorectal Inspection, Anoscopy,
andSigmoidoscopy
• An anoscopic examination should be performed to identify intra-anal lesions.
• A sigmoidoscopic should be performed to
identify rectal lesions.
• Lesions including hemorrhoids, polyps,
masses, mucosal inammation, and rare anal
melanoma may be seen (Fig.11.10).
Imaging andDiagnostic Testing
• Following the history and examination, one
may need to gather additional diagnostic
imaging studies:
– CT of the pelvis (mass, pain, or abscess)
– Cine-videodefecogram or dynamic MRI of
the pelvis (proctalgia fugax or other pelvic
oor disorders)
Digital Rectal Examination
• One should feel for any abnormal anal or distal rectal masses and anal tone:
– If low resting tone, stool seepage may be a
cause for pruritus pain.
– If tone is high and there is twitching of the
anal sphincter, even if there is no visible
ssure, a diagnosis of anal ssure disease is
likely.
• The tightness of levator muscles should be
assessed bilaterally starting at the coccyx; this
will often reproduce the pain or pressure of
levator spasm.
• The sacral hollow should be examined for presacral masses or cysts.
• The coccyx should be distracted/palpated to
assess for coccydynia.
• The prostate should be palpated since prostatitis may be the cause of anal pain.
• If the pain is too intense and the patient cannot
tolerate the exam in the ofce setting, an
examination under anesthesia should be scheduled in the proper clinical circumstances.
Fig. 11.10 Anal melanoma