Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
Div
34 Composite Pelvic Resection forOvarian Cancer
Fig. 34.2 Fecal
diversion for postoperative anastomotic
leak
erting loop
Ileostomy
383
contrast should be performed prior to ostomy
reversal to ensure no persistent leaks or strictures. Reversal is usually performed about
12weeks after the initial injury if adequate nutrition and performance status have been
re-established.
In some cases, intra-abdominal adhesions or a
“frozen abdomen” render the usual diversion
and/or repair impossible. Damage control methods including temporary abdominal closure, open
abdomen negative pressure therapy, or delayed
abdominal closure may be necessary.
Collaboration with a colorectal or trauma surgeon is often helpful in these cases.
Bowel Injury
Background
Bowel injury can occur during composite pelvic
resection when the colon or small bowel is adher-
Anastomotic leak
ent to or invaded by a bulky pelvic mass or when
the serosa or mesentery is involved by miliary
disease.
Prevention
Prevention of bowel injury begins with careful
tissue handling and sharp rather than cautery
or blunt dissection in proximity to the bowel
wall. Thermal injuries are especially dangerous since the initial injury may be unrecognized, or its extent minimized, and thus present
several days to a week post-operatively. A rectal probe or proctoscopy with insufflation to
distend the colon during dissection can better
delineate the bowel wall. Inspection of the
entire large and small bowel should be performed in order to identify and repair any injuries prior to closure. A systematic approach to
examining the bowel can avoid unrecognized
injuries.
384
B. Long and W. A. Cliby
Recognition
Careful inspection of both the small and large
bowel should be performed to rule out inadvertent serosal injuries, colotomies or enterotomies,
or thermal injuries. While anastomotic leaks are
most feared, it is important to remember that
enteric leaks in the absence of bowel resection
are a common source of major post-operative
morbidity. Proctoscopy to distend the pelvic
colon with air can also be useful to recognize
occult injuries.
A delayed or unrecognized bowel injury will
present similarly to an anastomotic leak, as
described above (“Anastomotic leak:
recognition”).
Management
When bowel injury is noted intra-operatively, primary repair can be performed for small defects.
The bowel is typically repaired in two layers,
using a running, delayed absorbable suture to
reapproximate the mucosa and permanent (silk)
Lambert sutures to reapproximate the serosa. The
defect should be repaired in a transverse fashion
in order to prevent the narrowing of the bowel
lumen. Larger defects, thermal injuries or those
involving the mesentery of the small or large
bowel typically require resection of the damaged
segment. Primary anastomosis can be performed
in most cases.
Delayed bowel injuries are managed similarly
to anastomotic leaks, as described above
(‘Anastomotic leak: Recognition’).
Prevention
There are no well-established methods for the
prevention of anastomotic bleeding. Intraoperative proctoscopy can be used to ensure
hemostasis at the anastomosis, but most bleeding
is delayed. There is no high-quality evidence to
suggest a lower risk of bleeding with hand-sewn
or stapled anastomoses.
Recognition
Anastomotic bleeding presents as hematochezia
or passage of blood and clots per rectum. This
usually occurs within 24–48 hours postoperatively. Given the distal location of the rectosigmoid anastomosis, the bleeding is typically
immediately apparent.
Management
Bleeding from the rectosigmoid anastomosis following composite pelvic resection for ovarian
cancer can typically be managed expectantly.
Some patients may require transfusion, and anticoagulation should be held until hemostasis is
ensured. If bleeding continues despite conservative measures, colonoscopic clipping or fulguration should be attempted. Re-operation and
revision of the anastomosis is rarely required but
can be necessary if endoscopic methods are not
successful.
Anastomotic Stricture
Anastomotic Bleeding
Background
Anastomotic bleeding (often mucosal) after low
anterior resection is rare but can result in signicant blood loss and/or contribute to failure of the
anastomosis.
Background
Anastomotic stricture is typically attributed to
tissue ischemia, though the rate of stricture after
composite pelvic resection for ovarian cancer is
not well-dened. Risk factors for anastomotic
stricture include obesity, anastomotic leak, smoking, and low or ultra-low anastomosis.
34 Composite Pelvic Resection forOvarian Cancer
385
Prevention
Anastomotic stricture can result from ischemia, tension, or subclinical leaks/tissue
remodeling. In addition to the maneuvers
described above (see: “Anastomotic leak: prevention”), surgeons should avoid using circular
staplers less than 25mm in diameter: in cases
of narrow diameter proximal colon stump an
end-to-side anastomosis should be used to
avoid this.
Recognition
Anastomotic strictures typically present weeks to
months after surgery and should be recognized
on imaging when patients present with obstructive symptoms, pain, and/or incontinence.
Management
Anastomotic stricture after rectosigmoid resection typically presents weeks to months after
surgery with symptoms of complete or partial
obstruction. Low anastomotic strictures can be
dilated digitally or with exible dilators. More
proximal strictures can be dilated with endoscopic balloon dilation or stenting. Re-operation
for revision of an anastomosis is required in rare
cases, and permanent diversion can be performed if symptoms persist and revision is not
possible.
References
1. Hammond IG, et al. The control of severe intraoperative bleeding using an overlay autogenous tissue (OAT) patch: case reports. Gynecol Oncol.
2004;94(2):564–6.
2. American College of Obstetricians and Gynecologists’
Committee on Gynecologic Practice. Topical hemostatic agents at time of obstetric and gynecologic surgery: ACOG committee opinion, number 812. Obstet
Gynecol. 2020;136(4):e81–9.
3. White LA, Joseph JP, Yang DY, Kelley SR, Mathis
KL, Behm K, Viers BR. Intraureteral indocyanine
green augments ureteral identication and avoidance
during complex robotic-assisted colorectal surgery.
Color Dis. 2021;23(3):718–23.
4. Boyan WP Jr, Lavy D, Dinallo A, Otero J, Roding A,
Hanos D, Dressner R, Arvanitis M.Lighted ureteral
stents in laparoscopic colorectal surgery; a ve-year
experience. Ann Transl Med. 2017;5(3):44.
5. Abu-Zaid A, Abou Al-Shaar H, Azzam A, Alomar
O, Al-Otaibi MF, Amin T, Al-Badawi IA. Routine
ureteric stenting before cytoreductive surgery plus
hyperthermic intraperitoneal chemotherapy in managing peritoneal carcinomatosis from gynecologic
malignancies: a single-center experience. Ir J Med
Sci. 2017;186(2):269–73.
6. Teeluckdharry B, etal. Urinary tract injury at benign
gynecologic surgery and the role of cystoscopy: a systematic review and meta-analysis. Obstet Gynecol.
2015;126(6):1161.
7. Narasimhulu DM, Bews KA, Hanson KT, Chang
YH, Dowdy SC, Cliby WA. Using evidence to
direct quality improvement efforts: dening the
highest impact complications after complex cytoreductive surgery for ovarian cancer. Gynecol Oncol.
2020;156(2):278–83.
8. Richardson DL, Mariani A, Cliby WA.Risk factors
for anastomotic leak after recto-sigmoid resection for
ovarian cancer. Gynecol Oncol. 2006;103(2):667–72.
9. Kalogera E, Nitschmann CC, Dowdy SC, Cliby
WA, Langstraat CL. A prospective algorithm to
reduce anastomotic leaks after rectosigmoid resection for gynecologic malignancies. Gynecol Oncol.
2017;144(2):343–7.
10. Liu D, Liang L, Liu L, Zhu Z. Does intraoperative
indocyanine green uorescence angiography decrease
the incidence of anastomotic leakage in colorectal
surgery? A systematic review and meta-analysis. Int
J Color Dis. 2021;36(1):57–66.
11. Pang HY, Chen XL, Song XH, Galiullin D, Zhao
LY, Liu K, Zhang WH, Yang K, Chen XZ, Hu
JK.Indocyanine green uorescence angiography prevents anastomotic leakage in rectal cancer surgery: a
systematic review and meta-analysis. Langenbeck’s
Arch Surg. 2021;406(2):261–71.
12. De Nardi P, Elmore U, Maggi G, Maggiore R, Boni
L, Cassinotti E, Fumagalli U, Gardani M, De Pascale
S, Parise P, Vignali A, Rosati R.Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic
colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc. 2020;34(1):53–60.
13. Phitayakorn R, Delaney CP, Reynolds HL, et al.
Standardized algorithms for management of
anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J Surg.
2008;32:1147–56.
Anal Cancer
AnneMacleod andSusanGalandiuk
35
Introduction
First described in 1974, the Nigro protocol using
denitive chemoradiotherapy (CRT) is the primary treatment for most cases of anal squamous
cell carcinoma (SCC), which encompasses >90%
of anal cancers [1, 2]. Surgery is indicated for the
treatment of (i) perianal cancers without sphincter involvement (local excision), (ii) patients with
persistent or recurrent disease following initial
chemoradiation therapy (salvage surgery), (iii)
complications of primary disease, and (iv) complications resulting from chemoradiation therapy
(CRT).
This chapter will focus primarily on the management of complications of radical surgery performed for progressive disease including, (i)
perineal wound complications; (ii) pelvic uid
collections/abscess/organ space infection; (iii)
perineal hernia, and (iv) small bowel obstruction
as well as those secondary to primary disease and
chemoradiation therapy. Complications of primary disease and nonoperative therapy discussed
include large bowel obstruction; fecal incontinence; rectovaginal and anorectal stulae; sigmoid and ureteral stricture formation and
radiation enteritis.
Complications ofLocal Excision
Local excision for anal squamous cell cancer is
indicated in T1N0, well-differentiated peri-anal
cancer [3, 4] as well as supercial anal cancer
that has been completely excised (T1NX <3mm
deep and <7mm horizontal spread) (Fig.35.1).
These are often completely excised at biopsy, and
local resection with negative margins may be sufcient [3, 5] (Fig.35.2). Complications of local
excision are uncommon; if healing problems
occur, most wounds will heal by secondary
intention.
A. Macleod
Price Institute of Surgical Research, University of
Louisville, Louisville, KY, USA
S. Galandiuk (*)
Division of Colon & Rectal Surgery, Hiram C Polk
Jr., MD Department of Surgery, University of
Louisville, Louisville, KY, USA
e-mail: s0gala01@louisville.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_35
387
388
Palliative
Palliative
A. Macleod and S. Galandiuk
CRT*
CRT*
Groin
Groin
Dissection
Dissection
+/- Further
Chemotherapy
Chemotherapy
+/– Radiotherapy*
+/– Radiotherapy*
+/– Immunotherapy
+/– Immunotherapy
Disease
Disease
Metastatic
Metastatic
Salvage Surgery
Salvage Surgery
• APR
• APR
Local
Local
Recurrence/
Recurrence/
• ELAPE
• Exenteration
• ELAPE
• Exenteration
Progression
Progression
+/– Further
Node
Node
Inguinal
Inguinal
Recurrence
Recurrence
Surveillance
Surveillance
Disease
Disease
Metastatic
Metastatic
Chemo-radiotherapy (CRT)
Chemo-radiotherapy (CRT)
• 5-FU/Mitomycin or
• 5-FU/Mitomycin or
Loco-regional
Loco-regional
+
+
Anal Canal
Anal Canal
Cell Cancer
Cell Cancer
Squamous
Squamous
• Mitomycin/Capecitabine or
• 5-FU/Cisplatin
• Mitomycin/Capecitabine or
• 5-FU/Cisplatin
Disease
Disease
(any T,N stage)
(any T,N stage)
+
+
Radiotherapy
Radiotherapy
perineum and inguinal nodes)
perineum and inguinal nodes)
(Minimum 45Gy to pelvis, anus,
(Minimum 45Gy to pelvis, anus,
N+
N+
T0 poorly
T0 poorly
T2-4, or any
T2-4, or any
differentiated
differentiated
+
+
Peri-Anal
Peri-Anal
Squamous
Squamous
Consider re-excision first
Consider re-excision first
Cell Cancer
Cell Cancer
Inadequate Margins
Inadequate Margins
Local
Local
Excisionˆ
Excisionˆ
T1, NO Well
T1, NO Well
differentiated
differentiated
T1Nx supercial cancer completely excised at biopsy; *Additional CRT/radiotherapy
depending on prior dose/eld included. APR Abdominal-erineal resection, ELAPE
extra-levator abdominal-perineal resection
Adequate Margins
Adequate Margins
Suspected
Suspected
Anal Cancer
Anal Cancer
Anal adenocarcinoma and melanoma histology- use alternative treatment algorithm.
Fig. 35.1 Treatment algorithm following anal SCC diagnosis: Adapted from (3).
+
^Local excision: 1 cm margin recommended. Local excision also recommended in
35 Anal Cancer
Fig. 35.2 Perianal cancer without sphincter involvement
Complications ofRadical Surgery
Performed forPersistentor
Recurrent Disease
Major pelvic surgery is reserved for locally progressive or recurrent disease, occurring in
10–30% of anal SCCcases [6, 7]. Patients who
are HIV positive, those with advanced T or N
stage, and incomplete CRT therapy have an
increased risk of recurrence and requiring subsequent radical surgery [8, 9]. A conventional APR
or ELAPE (if there is an extension beyond the
sphincters to the levators) are the most common
salvage surgeries performed for anal SCC.The
aims of salvage surgery are local disease control
and prevention of distant recurrence. Positive
resection margins are a reliable predictor of
recurrence and poor survival; therefore, en-bloc
resection of involved adjacent organs to achieve
negative surgical margins may be required [10].
The reader is referred to Chap. 38 “Exenteration”
for details specic to pelvic exenteration, which
may be required with disease extending to involve
389
the bladder or in cases of severe radiation damage/radiation necrosis.
Due to the high dose of radiation utilized for
the primary treatment of anal SCC, healing problems are not uncommon in the postoperative
period (see also Chap. 37, Pelvic Radiation
Therapy). Added risk factors include malnutrition and the presence of cigarette smoking, which
can also lead to impaired wound healing. The latter has been linked to higher HPV16 viral levels
[11]. Common complications include perineal
wound infection/dehiscence, pelvic uid collections/abscesses/organ space infections, perineal
hernia, and small bowel obstruction. These will
be discussed below.
Perineal Wound Infection/Dehiscence
Background
Impaired perineal wound healing is a major
source of morbidity following pelvic surgery.
APR for anal cancer generally follows the same
technique principles as for rectal cancer (see
Chap. 36); however, wider perineal margins or an
extra-levator (ELAPE) approach may be required.
A larger perineal wound in combination with
higher doses of perineal radiation may result in
an increased risk of wound infection and poor
healing [12, 13]. The incidence ofwound dehiscence or infection following primary closure varies but has been reported in 15–70% of cases
following APR or ELAPE [7, 12, 14].
Prevention
The use of reconstructive muscle or myocutaneous aps for perineal closure has led to reduced
rates and severity of perineal wound complications [15] (see also Chap. 41, Pelvic
Reconstructive Procedures). A myocutaneous
ap using rectus abdominis (VRAM), gluteal, or
gracilis muscle are the most widely reported
techniques (Fig. 35.3). Reconstructive aps aid
with wound closure and contribute to reduced
wound infections by lling the dead space within
the pelvis. A 2016 meta-analysis of primary versus ap closure included 10 studies and 566
patients. Eight studies used rectus abdominis
390
a b
A. Macleod and S. Galandiuk
Fig. 35.3 (a) Rectus muscle ap harvested to help ll a pelvis and (b) following abdominoperineal resection
aps and twoused gracilis aps. Overall major
wound complications were higher in the primary
closure groups [16]. In 98 patients undergoing
salvage surgery for anal cancer, Baloch et al.
reported signicantly higher perineal wound
healing at 3 months following perineal reconstruction using a vertical rectus abdominis
(VRAM) ap, versus primary closure or gluteal
ap [17]. A small RCT comparing biologic mesh
versus primary closure following ELAPE for
rectal cancer found no difference in wound healing at all time intervals measured [18]. Despite
many retrospective studies and systematic
Recognition
Perineal wound dehiscence or poor healing presents similarly to wound complications elsewhere,
however, due to the location of the wound, it is at
risk of being missed in the early postoperative
period. Careful monitoring is crucial to identify
early signs of complications such as inammation, discharge, necrosis, or swelling, which may
indicate a nonhealing wound or ap failure.
Identication of the depth and extent of dehiscence guides the appropriate management and
will be dependent on the perineal reconstruction
technique at primary surgery.
reviews, the heterogeneity of indication for surgery along with selection bias and confounding
Management
patient factors, has resulted in a lack of consensus regarding optimal perineal closure technique
[13, 19].
Modiable risk factors associated with poor
wound healing preoperatively should be
addressed where possible, including preoperative
smoking cessation, optimizing nutrition, and diabetic control [13].
Acute
Full-thickness dehiscence with evisceration or ap
loss are surgical emergencies and require an immediate return to the operating room for debridement
and re-closure. Careful inspection of small bowel
and mesentery for evidence of trauma should be
performed prior to washout and re-closure [13].
35 Anal Cancer
Incomplete dehiscence with evidence of perineal infection should be managed with intravenous antibiotics, local exploration, and
debridement of any nonviable tissue. CT scan
evaluation for deeper pelvic collections or tracts
should be performed and managed as per the section on pelvic uid collections below.
Chronic
A chronic nonhealing wound of >6months duration is dened as a persistent perineal sinus.
Recurrent or residual cancer should be considered
in any persistent wound/sinus and an examination
under anesthesia performed with biopsies of suspicious areas along with exploring +/− deroong
tracts. MRI is useful in assessing for recurrence or
undrained uid collections. Denitive management is guided by the size of the wound and the
involvement of surrounding structures. This can
range from conservative local excision and
debridement with the use of negative pressure
dressings to extensive surgery involving coccygectomy or sacral body resection with muscle ap
transposition. Negative pressure or vacuumassisted closure (VAC) dressings are known to
accelerate open wound healing via reduction of
edema, mechanically drawing together wound
edges, increasing local perfusion, and promoting
the formation of granulation tissue [22, 23].
Although positionally more difcult to maintain a
vacuum seal, these can be used for open perineal
wounds with favorable outcomes. Alternative
nonsurgical adjuncts, such as topical application
of growth factors and mesenchymal stem cell
treatments, are being explored in other chronic
wounds, such as diabetic ulcers, and may in the
future offer an alternative treatment option in perineal wound management [20, 21].
Pelvic Fluid Collections/Abscesses/ Organ Space Infections
Background
Pelvic uid collections following anorectal excision often result from the accumulation of exudative uid or hematoma in the pelvic dead space.
More extensive excisions such as in ELAPE and
391
Fig. 35.4 Large infected presacral uid collection in a
woman 10days following pelvic exenteration for complications due to radiation therapy for anal squamous cell
cancer
pelvic exenteration have increased dead space
and are higher risk for organ space infection [13]
(Fig. 35.4).
Prevention
Filling or excluding the empty pelvic space has
been shown to improve perineal wound healing and reduce both pelvic uid collection/
abscess formation and perineal hernia rates along
with keeping small bowel out of the pelvis.
Several techniques for pelvic exclusion have
been described, including omentoplasty, mesh or
ap reconstruction, prosthesis placement, and the
use of terminal ileal mesentery to reconstruct the
pelvic peritoneum [24–26].
The use of an omental ap to obliterate the
pelvic dead space has been reported in several
case series and retrospective studies with contradictory results. The largest recent cohort study
examining the benet of omentoplasty after
APR/ELAPE for rectal cancer included a cohort
of 477 patients (of which 96% received neoadjuvant CRT) who were found to have no benet
from the omentoplasty + primary closure versus
primary closure alone. Thirty-day nonhealing
rates, chronic perineal wounds, and presacral
abscess formation were similar [26]. These ndings were supported by a 2021 systematic review
in which omentoplasty was not associated with
risk of pelvic abscess formation, wound healing
at 30 days, or chronic perineal sinus [27]. A
2022 systematic review of six different techniques for lling the empty pelvis following pelvic exenteration found no consensus on the best
392
A. Macleod and S. Galandiuk
method of pelvic exclusion. Mesh reconstruction and breast prosthesis placement were associated with the lowest rates of small bowel
obstruction and abscess formation. Flap reconstruction had similar outcomes, although higher
rates of perineal wound morbidity and re-operation. Omentoplasty was associated with
increased rates of wound infection and morbidity [28]. Some centers have trialed the use of
obstetric balloons and silicone expanders, and
while outcomes were promising in reported case
series, there is insufcient evidence to compare
to more traditional techniques.
Recognition
Patients develop pyrexia, leukocytosis often
accompanied by abdominal pain, ileus, and a systemic inammatory response. Perineal wound
discharge may increase or become purulent.
Imaging with a CT scan can delineate a collection and assess suitability for percutaneous drainage. Imaging <5 days postoperative is likely to
show a degree of free pelvic uid, which must be
interpreted cautiously andin clinical context.
The nding of pelvic free uid in an unwell
patient following APR/ELAPE should prompt
consideration of inadvertent injury to surrounding
structures such as small bowel, bladder, or ureters.
Renal function and urinary output should be
assessed, a discussion of recognition and management of urinary tract complications can be found
in Chap. 17 “Injury/Repair of Pelvic Ureter”.
Management
Initial resuscitation and intravenous broadspectrum antibiotics followed by percutaneous
drainage is the primary management in most
cases of pelvic abscess. CT-guided percutaneous
drainage is the rst-line treatment for most
abdominal-pelvic collections greater than 3 cm
and is successful in >90% of patients, with low
complication rates [29, 30]. Following drain
placement, regular drain ushing ensures drain
patency. Upsizing or re-positing of the drains
may be required. Patients should undergo repeat
imaging prior to drain removal to evaluate collec-
tion resolution along with microbial culture of
abscess contents to rationalize antibiotic choice.
Patients without access to interventional radiology or signicant hemodynamic instability
require a return to theatre for either laparoscopic
or open surgical washout. Recurrent, multiloculated, or complex intra-loop abscesses may
not respond to conservative management and
mayrequire surgical washout. In the case of very
low-lying collections, these are sometimes most
easily drained transperineally.
In the case of bilious drain output, communication of abscess cavity with small bowel is
likely, and the patient should be managed as for
an entero-cutaneous stula. This is a rare complication of APR/ELAPE, although may occur due
to a missed, or failed repair of, inadvertent enterotomy, particularly in patients with friable small
bowel due to radiation enteritis. Detailed principles of stula management are beyond the scope
of this chapter; however, in brief, these include (i)
control of infection, (ii) reduction of stula output, (iii) optimization of nutrition, and (iv) imaging with oral contrast and/or stulogram to assess
anatomy prior to consideration of surgical repair.
Most low output stula will heal without surgical
intervention.
Perineal Hernia
Background
Perineal hernia is a late, and relatively underappreciated, complication following APR/
ELAPE.There are little data regarding the incidence and outcomes of treatment, with much evidence reported from expert opinions and small
case series with short follow-ups. High-dose
radiation along with an extra-levator resection
increases the risk of perineal hernia. Many small
or minimally symptomatic hernias likely go
undiagnosed; however, the overall incidence has
been reported in studies between 12–26% [31,
32]. The incidence of this complication appears
to be increasing with the increase in minimally
invasive surgical approach.
35 Anal Cancer
393
Prevention
Closure of a perineal defect with a reconstructive
ap or mesh, and pelvic exclusion as described
above for wound complication and pelvic abscess
prevention, can also be used to reduce the frequency of perineal hernia. While not the primary
aim of the study a prospective randomized controlled trial, comparing primary versus biologic
mesh closure following ELAPE for rectal cancer
found a signicantly lower 1-year perineal hernia
rate in the biologic mesh closure patients (13 vs.
27%) [18]. Conversely, a large Dutch observational study found the use of omentoplasty for
pelvic space exclusion increased the rate of perineal hernia development [26]. Patients should be
aware of modiable risk factors preoperatively to
reduce the risk of perineal hernia, including
weight loss, careful postoperative wound care,
and avoidance of strenuous daily activities
postoperatively.
Recognition
The diagnosis of a perineal hernia is primarily
clinical, with patients reporting a bulge or mass,
often positional and associated with pain or discomfort. Complications associated with perineal
hernia include skin erosion, urinary or sexual
dysfunction, and bowel obstruction. CT or MRI
imaging may be useful in supporting diagnosis,
however, hernias that present on standing or
straining may not be detected on imaging.
there was no signicant risk difference identied
between any repair techniques. Synthetic mesh
had the lowest recurrence rate but the highest
postoperative morbidity [33].
Small Bowel Obstruction
Background
There is an increased risk of small bowel obstruction (SBO) following surgery due to pre- operative
high-dose chemoradiation in anal SCC.The terminal ileum is at particular risk of radiation
enteritis (see section “Complications of Therapy
(Chemoradiation)” later in this chapter) and is
often the site of SBO (Fig. 35.5). Other causes of
obstruction include surgical adhesions or small
bowel adherent in the pelvis with associated
radiation- induced brosis.
Prevention
Pelvic exclusion techniques, as described above,
aim to keep small bowel out of the pelvis and
reduce the risk of SBO, along with the risk of
additional injury associated with further radiation. Closure of the pelvic peritoneum using the
distal ileal mesentery was rst described in
Management
Given the relative rarity of this complication,
there is a lack of consensus on the optimal surgical approach (perineal vs. abdominal) or technique (primary closure, insertion of mesh,
reconstructive ap, or combination) for repair. A
recent meta-analysis of 29 studies included 325
patients undergoing 347 perineal hernia repairs
and found an overall recurrence rate of 22% with
no signicant difference between the abdominal
versus perineal approach. A combined approach
was reported in ve studies, and results appear to
suggest a lower rate of recurrence; however, current evidence is not sufcient to conrm this.
Mesh repairs have largely replaced primary
repair in recent years; however, at meta-analysis,
Fig. 35.5 Coronal CT scan showing severely narrowed
small bowel (white arrows) due to radiation enteritis
resulting in refractory small bowel obstruction