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394
A. Macleod and S. Galandiuk
1996, with a recent case series published in
2022 of 10 patients following resection for rectal or gynecological cancer. The distal ileal mesentery is used to close peritoneal defect in a
“fan-like” method suturing the mesentery to the
peritoneum at the pelvic brim. In the most recent
publication of this technique, success was noted
by follow-up imaging reporting the absence of a
small bowel within the pelvis. At follow-up
ranging from 3–28 months, no postoperative
perineal hernia or intestinal obstruction had
occurred; however, 9/10 patients had no neoadjuvant radiotherapy. Due to the degree of brosis and tissue friability following chemoradiation
in anal SCC, suturing to residual peritoneum
may be difcult, so this technique may not be as
successful [24, 25].
Recognition
Patients typically present with abdominal pain,
distention, emesis, and inability to pass stool or
atus. In the immediate postoperative period, this
is commonly secondary to ileus and can usually
be managed conservatively. CT imaging can conrm obstruction and may aid in diagnosing the
site and etiology of obstruction, while excluding
any additional complications.
Management
Initial trial of conservative management with
nasogastrictube (NGT)for decompression, uid
and electrolyte replacement, and a gastrografn
small bowel follow-through is rst-line treatment provided no concern of bowel viability or
perforation. In a stable patient, with suspected
adhesional obstruction, a repeat small bowel
follow-through following initial failure is reasonable and may resolve obstruction while
avoiding surgery. Failure of conservative management warrants surgical intervention, the
extent of which varies depending on the site,
extent, and etiology of obstruction. Division of
adhesions may be sufcient to resolve obstruction, but in the case of signicant radiationinduced enteritis, small bowel resection or
bypass (if there are prohibitive adhesions) may
be required.
Complications ofPrimary Disease
Complications requiring surgery due to the primary disease itself include large bowel obstruction, fecal incontinence, and the development of
rectovaginal or anorectal stula. Fecal incontinence and development of stula can also be a
result of, or complicated by, chemoradiation therapy, which will be discussed later.
Large Bowel Obstruction
Background
Anal cancer may present as an acute or subacute
large bowel obstruction (LBO), with progressive
distention, pain, absolute constipation, and feculent vomiting. Large bowel obstruction may also
develop in patients with known anal cancer, with
poor response and tumor progression whilst
undergoing chemoradiation.
Prevention
Patients undergoing chemoradiation therapy
should be closely monitored and should be aware
of symptoms suggestive of impending obstruction
secondary to anal cancer. Patients with nearobstructing cancers either clinically or radiologically may benet from placement of a diverting
ostomy prior to chemoradiation to prevent complete obstruction and its associated complications.
Recognition
Patients with anal cancer with progressive
obstructive symptoms should undergo abdominal
and digital rectal examination, and CT imaging
to evaluate for obstruction.
Management
Obstructing anal cancer should be managed with
proximal diverting colostomy, ideally prior to initiation of chemoradiation. Patients presenting with
large bowel obstruction as an emergency or during
chemoradiation therapy have increased risk of
infectious, cardiopulmonary and stoma complications. In the situation of a competent ileocecal
valve, thereis an added risk of cecal compromise,
35 Anal Cancer
395
andthepatient may require colectomy. In addition
to immediate complications, there is an increased
risk of recurrence or primary disease progression due to a treatment break during therapy or
being unable to complete chemoradiation.
Fecal Incontinence
Background
Fecal urgency or incontinence is common in
patients following radiation treatment for pelvic
malignancies. A Danish study of 380 patients
found that 95% of patients had fecal urgency;
59% were incontinent to liquid and 33% to solid
stool following treatment with pelvic radiation[34]. Fecal incontinence due to anal cancer
may develop secondary to tumor invasion into
sphincter complex; the residual defect following
destruction of tumor with chemoradiation, as
well as due to radiation-induced injury and brosis. Incontinence can be further exacerbated by
radiation-induced proctitis/enteritis causing
loose bowel movements and urgency.
Prevention
There are no effective methods to prevent fecal
incontinence (FI) in anal cancer treatment, but
close monitoring and early recognition allows
earlier initiation of treatment.
proctitis can be considered, including steroid or
anti-inammatory enemas. For all causes of FI,
conservative measures have been found to improve
symptoms in 22–54% of patients [36, 37].
Sacral nerve stimulation (SNS) is an effective
treatment option and should be considered as a rstline surgical option in those patients in whom conservative measures fail [36, 38]. A systematic
reviewwhich measured thesuccess rateof SNS, as
at least a 50% improvement in incontinence episodes, reported a median of 89% of patients had
successful outcomes after a 36-month follow-up
[39]. Success of SNS is best predicted by temporary
trial stimulation. Clinical parameters such as the
presence of a sphincter defect, pudendal neuropathy, or previous repairs shincter were not associated
with SNS outcome [36, 40]. Patients in which sacral
neuromodulation fails or FI recurs may require
colostomy diversion to manage symptoms.
Rectovaginal Fistula
Background
Rectovaginal stulas (RVFs) can develop as a
result of primary disease or secondary to chemoradiation [41]. Due to the location of anal cancer,
these are usually low, but can occur in the midrectum in the case of higher cancers (Fig.35.6).
Recognition
Bowel function and continence should be
assessed at all follow-upofce visits for patients
who have undergone, or are undergoing, treatment for anal cancer. Objective measures of
severity, such as the IMPACT score should be
used to determine baseline score for patients, and
response to therapies [35, 36]. Due to nature of
radiation-induced damage, symptoms may continue to evolve and progress several years after
completion of treatment.
Management
Theprimary managementof FI includes the use of
stool-bulking agents, anti-diarrheals, dietary modication, pelvic oor physical therapy, and biofeedback. Topical treatment for radiation- induced
Fig. 35.6 Pelvic MRI, sagittal view showing a rectovaginal stula (white arrow) resulting from a high anal squamous cell carcinoma within the mid-rectum. This stula
required colostomy diversion prior to beginning
chemoradiation
396
A. Macleod and S. Galandiuk
Data on risk of RVF development following
denitive CRT for anal cancer specically is
sparse; however, the incidence is reported to be
5–7% in patients following radiation therapy for
cervical cancer [41, 42].
Prevention
Avoidance of stula development is difcult;
inammatory response and brosis of irradiated
tissue increases the risk of RVF.Fecal diversion
with a proximal colostomy, while not preventing
RVF development allows for early control of
symptoms while treatment is ongoing it permits
continuation of chemoradiationtherapy and minimizes stula complications [42].
Recognition
RVF development should be suspected based on
patient symptoms of atus, foul smelling discharge, or stool per vagina. Evaluation by way of
examination under anesthesia and radiologic
assessment is used to dene the anatomy of the
tract and the structures involved. Assessment of
quality and function of anal sphincter is crucial
in decision-making regarding optimal repair
technique. This is of particular importance in
anal SCC patients who likely have sphincter
involvement from their primary disease along
with exposure to high dose perineal targeted
radiation [41].
Denitive management options include
endorectal advancement ap, interposition ap or
completion proctectomy; overall success ranges
from 41% up to 80% with repeated procedures
[41, 43–46]. Pelvic radiation greatly increases
the risk of failure of endorectal advancement ap
although it is a less invasive, local procedure.
Procedures using gracilis or bulbocavernosusap
(Martius ap) are more likely to succeed. More
advanced stulas, particularly in the setting of
radiation-induced proctitis and RVF, may require
completion proctectomy with or without a coloanal anastomosis (see Chap. 36, Rectal and
Rectosigmoid Carcinoma).
Complications ofTherapy
(Chemoradiation)
High dose pelvic radiation contributes to and worsens many of the surgical and disease-related complications as discussed above. Several complications
occur as a direct result of radiationtherapy including radiation enteritis andthe developmentof late
sigmoid and ureteral strictures. Ureteral strictures
and their management are discussed in Chap. 17
“Injury/Repair of Pelvic Ureter”.
Radiation Enteritis
Management
Any consideration of repair cannot be undertaken
until all cancer treatment has been completed and
the patient has no evidence of residual disease.
Acute inammation or infection can be managed
with a loose tting seton, along with appropriate
anti-microbial therapy. This may also benet
patients who still require ongoing chemoradiation, prior to consideration of a more denitive
repair [41]. Symptomatic relief is achieved with
proximal fecal diversion alone. Due to the high
dose of radiation given and signicant radiation
injury typically seen, patients should undergo
fecal diversion prior to repair. In addition, they
should be counseled regarding preoperative
smoking cessation.
Background
Radiation to the small bowel causes proliferating
cell apoptosis, denuding of themucosa, and loss
of the intestinal barrier function. The loss of
intestinal barrier function leads to disruption in
gut microbiota and inammation causing acute
enteritis. Acute enteritis presents with abdominal
pain, emesis, diarrhea, and dehydration, and
while symptoms may be signicant, these usually resolve with supportive treatment. However,
around 5–15% of patients with irradiated small
bowel will go on to develop severe chronic enteritis [47]. Chronic enteritis results in signicant
intestinal brosis ,which can lead to obstruction
or perforation, along with dysregulation of the
intestinal microbiome [48, 49].
35 Anal Cancer
397
Prevention
The radiation dose and protocol are the most signicant risk factors for developing enteritis.
Image-guided or intensity-modulated radiotherapy (IMRT) protocols can better localize tumor
with reduced reduce risk to surrounding structures, such as thesmall bowel, compared to conventional protocols [49–51].
Recognition
Acute radiation-induced enteritis should be
suspected in all patients with nausea, emesis,
diarrhea, or abdominal pain during, or immediately following, abdominal/pelvic radiation.
Chronic enteritis should be considered in
patients with chronic diarrhea or malabsorption. This can develop 3months to 6years after
radiation exposure and should be considered in
patients presenting with small bowel obstruction following treatment for anal SCC.Patients
may also present with, or develop, short bowel
syndrome, or develop anemia secondary to telangiectasia [52].
Management
Acute enteritis is usually managed with supportive therapy. Surgery is indicated for complications of chronic enteritis such as bowel obstruction
(discussed previously) and perforation. Fibrosing
enteritis causing complete small bowel obstruction requires small bowel resection and primary
anastomosis or bypass. In the case of perforation,
resection is indicated with the decision to perform an anastomosis dependent on degree of contamination, bowel viability and the patients’
general condition and nutritional status. Patients
with chronic radiation enteritis often present with
malnutrition or anemia. In such cases, or in the
case of an a unstable, or immunocompromised
patient in which further chemoradiation is
planned, a proximal diverting loop, ileostomy
may be required.
Novel therapies for radiation-induced enteritis
include stem cell therapy, probiotic microbial
therapy, and fecal microbiota transplantation.
Experimental studies have been reported to show
restoration of intestinal microbiota and epithelial
repair and regeneration [48, 49].
Sigmoid Stricture Formation
Background
Tissue damage and brotic reaction secondary to
radiation are progressive, so sigmoid stricture may
develop several years following initial chemoradiation treatment [53]. The rectosigmoid junction is
particularly susceptible to radiation- induced injury
due to its relatively xed nature [54].
Prevention
Modication of radiotherapy protocols as above
may reduce the inadvertent irradiation of surrounding bowel; however, there are no surgical or
medical preventative measures to reduce the
occurrence of strictures. Early recognition may
allow intervention with more favorable treatment
options and reduce risk of resection and stoma.
To prevent complications of known strictures,
ensuring soft stools with a bowel regimen and
avoidance of constipation is important.
Recognition
Symptomatic strictures may present as an acute
or slowly progressive large bowel obstruction as
described above or be found incidentally on follow up imaging or sigmoidoscopy. Radiological
severity does not always correlate to clinical or
endoscopic severity; therefore, imaging should
be interpreted in context of symptoms and endoscopy ndings.
Management
All strictures should be biopsied to exclude alternative causes such as malignancy or inammatory bowel disease. Once benign disease is
conrmed treatment is guided based on acuity of
symptoms and patients’ overall function and
goals. Acute complete obstruction management
is as per LBO above, which includes gastric
decompression, uid and electrolyte resuscitation and emergent surgery. Surgical options
include loop colostomy, resection, and end colostomy or resection and primary anastomosis +/−
diverting loop ileostomy.
Patients presenting with partially obstructing
strictures may undergo trial of nonoperative
interventions such as endoscopic balloon dilata-
398
A. Macleod and S. Galandiuk
tion. In radiation-induced strictures, the degree of
brosis means strictures commonly recur and
repeated interventions, often resulting in colonic
resection are required. Fibrotic and inammatory
effects of radiation increase the risks of surgery,
with scarring making dissection more difcult,
and anatomy of surrounding structures less welldelineated. Following resection, the distal colon
or rectum for anastomosis may be free of signicant stricture, but it has also been exposed to signicant radiation and therefore at increased risk
of anastomotic leak. Diverting loop ileostomy is
commonly performed in this situation, with
reversal once water-soluble enema has conrmed
healing and patency of anastomosis [54].
Conclusion
Complications associated with anal squamous
cell cancer are varied. They can occur either as a
result of the primary disease or following surgery
for persistent or recurrent disease or following
surgery for complications of treatment. Careful
patient assessment is key in achieving good
outcomes.
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Rectal andRectosigmoid
Carcinoma
MichelleDeLeon andLucaStocchi
36
Introduction
Despite advances in surgical technology, there is
still signicant morbidity associated with rectal
cancer surgery. This is in part due to the close
proximity of vital structures to the rectum, the
effects of radiotherapy and the challenges of
operating in the narrow pelvis, particularly in the
obese population. This chapter reviews the common postoperative complications of rectal cancer
surgery and key strategies for prevention and
management.
Anastomotic Leak
Background
The International Study Group of Rectal Cancer
has proposed the denition of a colorectal anastomotic leak (AL) as a “defect of the intestinal
wall integrity at the colorectal or coloanal anastomotic site (including suture and staple lines of
neorectal reservoirs) leading to a communication
between the intra- and extraluminal compartments. A pelvic abscess close to the anastomosis
M. DeLeon · L. Stocchi (*)
Division of Colon and Rectal Surgery, Mayo Clinic,
Jacksonville, FL, USA
e-mail: deleon.michelle@mayo.edu;
Stocchi.luca@mayo.edu
is also considered as anastomotic leakage.” The
denition excludes symptoms that are difcult to
uniformly report. A corresponding grading system for the management of colorectal anastomotic leaks based on their severity has also been
proposed (Table36.1) [43].
The sequelae of AL are profound and can lead
to permanent colostomy, derangements in bowel
function, urinary and sexual dysfunction, reduced
fertility and overall worsened quality of life.
Recovery from pelvic sepsis and prolonged hospitalizations may cause a delay in chemotherapy,
and AL has been arguably associated with
increased rates of local recurrence and worse
overall survival [22]. Prevention of this devastating complication is paramount.
Prevention
Prevention begins with addressing modiable
patient risk factors preoperatively. This includes
Table 36.1 Classication of anastomotic leakage following anterior resection of the rectum based on severity
[43]
Grade
A Anastomotic leakage requiring no active
therapeutic intervention
B Anastomotic leakage requiring active
therapeutic intervention but manageable
without relaparotomy
C Anastomotic leakage requiring relaparotomy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
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M. DeLeon and L. Stocchi
smoking cessation, weight loss, nutritional supplementation/counseling, diabetic control and
prehabilitation to improve frailty and functional
status. Ideal optimization can be difcult for
patients proceeding directly to surgery but is
becoming more feasible in the era of total neoadjuvant therapy (TNT) where patients undergo
radiation and chemotherapy for several months
prior to surgery.
Intraoperatively, prevention focuses on proper
assessment of perfusion, lack of tension, surgical
technique and endoscopic evaluation.
Blood Supply After high ligation of the inferior
mesenteric artery (IMA), the blood supply of the
descending colon conduit relies primarily on the
middle colic artery and marginal artery of
Drummond. A low ligation (a division of the
superior rectal artery just distal to the takeoff of
the left colic artery) is an acceptable oncologic
alternative if tension-free anastomosis can still be
achieved. Careful attention to the marginal artery
is imperative during mobilization of the descending colon and splenic exure. In 10–20% of
patients, the Arc of Riolan connecting the IMA
and SMA is present and contributes to the colonic
blood supply [52]. It can cross the IMV near the
inferior border of the pancreas (Fig. 36.1). The
artery of Moskowitz, found in 11–16% of patients
may similarly supply the colonic conduit [32]
[20]. When mobilizing the splenic exure, any
aberrant vessels encountered near the IMV
should be spared if possible.
After mobilization of the splenic exure, assessment for adequate perfusion can be done by intentional transection and then ligation of the marginal
artery seeking visible pulsatile blood ow, with
Doppler ultrasound, or the use of indocyanine
green (ICG) uorescence (Fig. 36.2). In a recent
randomized controlled trial comparing ICG to marginal artery bleeding, there was no statistically signicant difference in AL rates [16] [28]. Therefore,
any of the aforementioned adjuncts to visual bowel
inspection may be used to ensure adequate perfusion to the descending colon conduit.
Tension Although splenic exure mobilization
is often necessary to attain adequate reach to the
pelvis, routine splenic exure mobilization has
not been shown to improve clinical or oncologic
outcomes [46], and has been associated with
increased operative time and intraoperative complications. We recommend selective splenic ex-
VERSE COLON
PANCREAS
Fig. 36.1 Relation of Arc of Riolan and Moskowitz
Artery to the marginal artery of Drummond
a. of DRUMMOND
RIOLAN’S arch
a. of MOSKOWIT
Fig. 36.2 Use of ICG uorescence to evaluate colonic
perfusion. Stitch marks the area of mesenteric transection
to the bowel wall. Top panel—visual inspection alone.
Bottom panel—visual inspection using ICG uorescence
36 Rectal andRectosigmoid Carcinoma
403
ure mobilization and careful evaluation of the
anastomosis. If there are any signs suggesting
anastomotic tension, full mobilization of the
splenic exure, with the division of the IMV at
the inferior border of the pancreas should be performed. In some cases, additional maneuvers
may be necessary [54]. If the anastomosis is possible but only after additional lengthening maneuvers, there should be strong consideration for
diverting loop ileostomy, if this is not already
planned.
Surgical Technique The majority of colorectal
anastomoses are completed with a double-stapled technique due to their ease and reproducibility. However, stapling the distal rectum in the
narrow pelvis remains a signicant challenge,
particularly in minimally invasive surgery (MIS).
It is important to avoid an angled staple line and
limit the number of rings required, as multiple
staple lines may increase the risk of AL [8]. For
very distal transections, perineal pressure helps
to accommodate the stapler in the pelvis and
facilitates proper stapling technique. For patients
who may require multiple rings of a laparoscopic or robotic stapler, the surgeon should not
hesitate to create an incision to insert an open
stapler. When using the circular stapler, anastomotic rings should be evaluated for completeness and uniformity. Any disruptions or thinned
areas may indicate a dehiscence or weakening of
the anastomosis. The anastomosis should be
inspected visually—if any obvious defects are
seen, the anastomosis should be redone if possible. If anastomotic reconstruction is not possible
due to inadequate length, the defect should be
repaired and a defunctioning stoma created.
Endoscopic Assessment Assessment of the
integrity of the anastomosis should be done in all
patients undergoing low anterior resection for
rectal cancer. Air leak tests have been shown to
help identify intraoperative AL and decrease the
risk of clinically signicant postoperative AL
[61]. The use of routine endoscopic assessment
is under debate, but has the advantage of visual
inspection of the anastomosis to evaluate for
mucosal integrity, viability, and bleeding [31].
We recommend routine exible endoscopy and
especially air leak tests to evaluate all colorectal
anastomoses. If an anastomotic air leak test is
positive, the anastomosis should be reconstructed or repaired with a defunctioning stoma.
Suture repair alone is associated with an
increased risk of subsequent clinical AL when
compared to either anastomotic reconstruction
or additional stoma diversion and is not recommended [45].
Fecal Diversion Risk factors for AL include previous radiotherapy, malnutrition, smoking, obesity, emergency surgery, use of immunosuppressive
medications, and a short distance of the anastomosis from the anal verge [38]. Fecal diversion should
be considered on a case-by-case basis, taking into
account the quality of the anastomosis and the
number of risk factors involved. We recommend
routine diversion for patients who have undergone
neoadjuvant radiation and those with an anastomosis within 7 cm from the anal verge [55].
Recognition
Patients with an AL may present with abdominal
pain, distention, fevers and tachycardia.
Laboratory evaluation often reveals leukocytosis
and increased C-reactive protein (CRP). There is
increasing evidence that an elevated CRP is
highly predictive of AL and is now being used in
many enhanced recovery protocols to facilitate
early discharge [12]. A meta-analysis based on
23 studies with 6647 patients identied a cut-off
CRP of 148 milligram/liter on postoperative day
3 with sensitivity and specicity of 95% [62].
Computed Tomography (CT) scan may show
intraperitoneal free air, extravasation of contrast
or abscess. Contrast enema will show extravasation at the level of the anastomosis (Fig.36.3).
Patients with a diverting stoma and radiological
AL discovered at the time of preoperative contrast enema are often asymptomatic.