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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
404
Fig. 36.3 Contrast enema showing contrast extravasation
from a colorectal anastomosis. *Arrow indicates contrast
extravasation
Management
AL Requiring Operative Intervention
Patients with clinical instability require immediate reoperative intervention. At that time the
management depends on intraoperative ndings.
The anastomosis should be resected if ischemic
and/or the anastomotic defect is large and/or
there is extensive contamination and an end
colostomy created. When a smaller defect is
encountered with limited contamination, a primary repair of the defect with placement of drains
and proximal stoma diversion is an appropriate
approach. However, if the tissues do not hold the
stitches, the anastomosis cannot be salvaged and
should be treated as in the case of larger defects.
The difference between a small and large defect
remains subjective. When polling the opinions of
several experts using a Delphi technique to standardize both denitions and management of AL,
the 2 preferred denitions of minor defect were
size less than 1cm or less than a third of the anas-
M. DeLeon and L. Stocchi
tomotic circumference [41]. If an end colostomy
is needed, a transanal rectal tube to allow rectal
decompression should be considered to help prevent rectal stump dehiscence.
In those cases in which the anastomosis is initially preserved, the AL can ultimately heal with
supportive management, including surgical and/
or percutaneous drainage and proximal diversion.
For those that do not resolve, several techniques
have been described to address chronic leaks,
sinuses and presacral abscess cavities including
endosponge, local repair, and marsupialization of
the sinus tract.
Endosponge
The use of an endosponge connected to the suction device was described by Weidenhagen in
2008 [57]. It consists of a sponge placed into the
extraperitoneal anastomotic defect connected to
a suction device based on the principle of
vacuum- assisted closure (VAC) widely used for
other wounds. Since then, a number of studies
have conrmed its applicability and efcacy [5],
with clinical success rates approaching 85%
[17]. The Endo-SPONGE® (B.Braun Medical,
Melsungen, Germany) is widely available in
Europe and elsewhere but is not readily available in the United States despite FDA approval
in 2012.
Local Repairs
A number of techniques have been described to
treat the anastomotic defect including endorectal
advancement ap, dermal ap, or simple debridement [4]. Endoscopic approaches include brin
glue injection, endosponge insertion or over-thescope-clip system (OTSC). A recent review suggests that at times a combination of different
techniques is necessary to achieve secondary closure of the anastomotic defect leading to stoma
closure and return to anorectal function [15].
With a variety of available options, it is difcult
to formulate an organized algorithm prescribing
clear indications and sequences of the individual
techniques. The reported cases remain isolated,
therefore clinical decisions should be made on an
individual basis.
36 Rectal andRectosigmoid Carcinoma
Marsupialization oftheSinus Tract
A number of short reports have described marsupialization of the sinus tract, also referred to as
septotomy or sinusotomy. This consists of division of the colonic wall which constitutes the
roof of a posterior anastomotic sinus. This can be
carried out under direct vision with electrocautery, endoscopically using the ERCP blade, vessel sealant, or application of a mechanical stapler
[1, 9, 60]. The numbers are too small to draw
denitive conclusions but anecdotal success justies this technique as one of the possible options
in the treatment of chronic sinus.
Despite these maneuvers and prolonged
diversion, the patient remains at risk of permanent stoma. In a study evaluating outcomes after
AL, 48% had not healed in 12 months [6].
Ultimately the patient may require either a colostomy after anastomosis takedown and completion proctectomy, or retain an indenite diverting
loop ileostomy created at the time of the index
surgery.
Nonoperative Management ofAL
If the patient is hemodynamically stable and
presents with a contained AL, this may be
treated nonoperatively. Abscesses less than
3 cm in diameter can be initially treated with
broad- spectrum antibiotics alone, while larger
abscesses are generally approached with percutaneous drainage [3]. In cases of inadequate
drainage, the catheter can be manipulated or
exchanged, which is also associated with a high
success rate [21].
Alternatively, transanal trans-anastomotic
drainage has been proposed for low colorectal/
coloanal anastomoses [49]. The rationale of
transanal drainage is to avoid percutaneous
drainage, particularly transgluteal drainage
which based on data from management of ileal
pouch leak [34] can predispose to the iatrogenic
creation of an extrasphincteric stula. Other
reported complications include gluteal abscess
[53], pain, and bleeding from injury to the gluteal artery [11, 23] A possible approach is to utilize Malecot catheters (Fig. 36.4) tailored to
have their head placed through the anastomotic
405
Fig. 36.4 Malecot catheters used for transanal transanastomotic drainage of pelvic abscess
defect and into the extraluminal cavity, often
located posteriorly. The straight portion of the
catheter is transected so that only a few centimeters are left into the bowel lumen and then
secured with transxing sutures to the bowel
wall near the anastomotic defect. The patient is
reexamined every 2–3 weeks for a catheter
exchange and evaluation of the defect and the
associated cavity. As the patient’s condition
improves, the cavity should reduce in size allowing for replacement with progressively smaller
Malecot catheters until ultimate removal.
Subclinical AL For patients with fecal diversion who are found to have an AL on contrast
enema, delay of ileostomy closure for 3–6months
often results in spontaneous resolution of small
leaks without further intervention. For patients
with a persistent leak/sinus beyond 6months, the
aforementioned treatment strategies should be
employed. Reoperative intervention with takedown and reconstruction of the anastomosis or
permanent colostomy is ultimately the last resort.
406
Anastomotic Stricture
Background
The incidence of anastomotic strictures varies
widely in the literature, ranging from 5–20%.
The most commonly described denition is a
narrowing unable to allow passage of a standard
colonoscope (12 mm in width). Risk factors
include AL, pelvic sepsis, radiotherapy, low
anastomosis and diverting stomas [42]. The
pathophysiology is multifactorial and thought to
be due to ischemia that ultimately leads to brosis and narrowing of the intestinal lumen.
Prevention
Prevention focuses on avoiding ischemia to the
colonic conduit and taking measures to prevent
AL as discussed previously. It is imperative that
appropriate multidisciplinary discussions are
held preoperatively to plan radiation in the neoadjuvant setting if indicated and limit the need
for adjuvant radiation therapy.
Recognition
Patients may present with constipation, abdominal cramping, distention, difculty passing
stools, and a change in the stool caliber. They
may also experience frequency and overow
incontinence due to an inability to pass formed
stools. Radiographic imaging may show a dilated
colon in cases of severe colonic obstruction. A
denitive diagnosis is made with a colonoscopy.
Management
Patients with an anastomotic stricture should
have biopsies and radiographic imaging with pelvic MRI to rule out recurrent disease. In the
absence of malignancy, the management of anastomotic strictures depends on their location. Low
coloanal anastomoses can be dilated digitally or
using Hegar dilators (Fig.36.5). This may require
M. DeLeon and L. Stocchi
Fig. 36.5 Hegar Dilators
repeated dilations, and many patients can be
taught to do this safely at home. The majority of
higher anastomotic strictures can be managed
successfully with endoscopic balloon dilation
(EBD) (Fig. 36.6). Other techniques like endoscopic electrocautery incision [29] and endoscopic stricturotomy can be used as adjuncts to
EBD for severe strictures, or strictures refractory
to EBD (Figs. 36.7 and 36.8). Metallic stent
insertion is described in the literature (Fig.36.9);
however, stent migration limits its long-term
efcacy [35]. TAMIS has emerged as a minimally invasive option that may allow for more
aggressive stricturotomy compared to an endoscopic approach. Small series in the literature
have shown the safety and efcacy of this technique [63].
For those patients who fail endoscopic treatment, reoperative intervention is required. As the
majority of strictures are secondary to ischemia
and pelvic sepsis in a reoperative and often irradiated eld, these operations are technically challenging and associated with signicant morbidity.
The anastomosis and adjacent rectum will be
brotic, and surgical planes obscured. There is a
high risk for signicant pelvic bleeding and iatrogenic injury to surrounding structures. We recommend the routine use of ureteral stents to help
with ureteral identication. The anesthesia team
should be prepared for the possibility of signicant hemorrhage due to presacral venous bleed-
36 Rectal andRectosigmoid Carcinoma
407
Fig. 36.6 Endoscopic Balloon Dilation. Top panel—A
wire is rst passed across the anastomotic stricture. Bottom
panel—Balloon dilatation at anastomotic stricture. Photo
courtesy of: Vivek Kumbhari, MD and Mahmoud
Mahfouz, MD
Fig. 36.7 Needle knife used for endoscopic
stricturotomy
Fig. 36.8 Endoscopic stricturotomy. Top panel before
stricturotomy. Bottom panel—after stricturotomy. Photo
courtesy of Vivek Kumbhari, MD and Mahmoud
Mahfouz, MD
Fig. 36.9 Colonic stent across anastomotic stricture.
Photo courtesy of Victoria Gomez, MD
408
M. DeLeon and L. Stocchi
ing. The goal is to resect all areas of brosis to
normal healthy tissue, which often requires coloanal anastomosis. In cases of severe pelvic sepsis
and brosis, delayed anastomotic reconstruction
with a Turnbull-Cutait technique should be considered [36]. Due to the complexity of these operations, most patients will require temporary
diversion. Prior to embarking on surgery, realistic
functional expectations should be discussed with
the patient, and the option of permanent colostomy should be offered as this may ultimately
afford the best quality of life. A signicant proportion of patients may suffer from incontinence
and low anterior resection syndrome [59]. Elderly
individuals with signicant comorbidities and
suboptimal sphincter function are not good candidates for reconstructive surgery. For patients
with signicant symptoms who are too frail to
undergo a major pelvic operation, proximal
diversion alone is recommended. Very obese
individuals should lose weight to render this
option technically feasible. In the largest series to
date including 200 patients, the 1-year success
rate was 80%. The authors elaborated a scoring
system to estimate success rate based on recognized risk factors including male gender, age
greater than 60years, obesity and history of pelvic radiotherapy. The success rate ranged from
92% if none of these factors were present to 62%
if all 4 factors were present [13].
Anastomotic Bleeding
Background
It is very common for patients to experience
minor anal bleeding with bowel movements
immediately after surgery. The majority of these
cases are self-limited and clinically insignicant.
The incidence of anastomotic bleeds that require
some form of intervention has been reported to
be less than 1% [37].
Prevention
Preoperatively, any coagulopathies should be
addressed and corrected. Blood thinning medica-
tions should be held if possible. Intraoperatively, it is
important to ensure that either mesocolon or mesorectum (if applicable) are not incorporated into the
staple line. We recommend routine endoscopy to
evaluate all anastomoses so that any bleeding
encountered can be corrected at the time of surgery
either by endoscopic clipping, or extraluminal oversewing of the vessel under endoscopic guidance.
Recognition
Patients with colorectal anastomotic bleeding
generally present with bright red blood per rectum and are usually otherwise asymptomatic.
Those with clinically signicant bleeding may
have associated hemodynamic instability, clinical
symptoms and a drop in hematocrit.
Management
Minor bleeding episodes can resolve spontaneously without the need for transfusion or intervention. For patients with clinically signicant
bleeding, management begins with correction of
underlying coagulopathies, cessation of medications affecting coagulation and transfusion of
packed red blood cells. For persistent bleeding in
patients with mid to high anastomoses, endoscopic
intervention with clipping is the preferred modality of choice. Electrocautery and epinephrine
injection can also be effective but carry a small
risk of ischemia and compromise to the anastomosis. Coloanal anastomotic bleeding can be suture
ligated with anoscopy and exam under anesthesia.
Reoperative surgery and angiography are
reserved for patients that fail endoscopic maneuvers. Interventional radiology (IR) embolization
can be successful but also carries the risk of ischemia and subsequent anastomotic leak. On the
other hand, reoperative surgery can lead to inadvertent injury of nearby structures or inadequate
length for revision and re-anastomosis. Therefore,
the decision to proceed with angiography versus
surgery should be made on a case-by-case basis,
taking into account the predicted hostility of the
abdomen, comorbidities and risk factors for reoperation and ability to refashion an anastomosis.
S
venous plexus
36 Rectal andRectosigmoid Carcinoma
409
Presacral Venous Bleeding
Background
Presacral venous bleeding is not uncommon,
occurring in 0.25–8.6% of rectal cancer operations [14]. It can cause massive hemorrhage,
quickly leading to hemodynamic instability and
even death if not controlled rapidly. Risk factors
for bleeding include history of radiotherapy, previous rectal surgery, distal tumor and locally
advanced tumors.
Recognition
Massive hemorrhage during pelvic dissection is
indicative of presacral venous plexus bleeding.
Prevention
The presacral venous plexus resides posterior to
the presacral fascia (Figs.36.10 and 36.11). Proper
total mesorectal excision (TME) requires the rectal dissection to occur in the avascular plane
between the fascia propria and presacral fascia.
Dissection outside of the presacral fascia can lead
to venous plexus injury and severe hemorrhage.
Blunt dissection may also cause inadvertent tearing of the presacral fascia and the underlying
venous plexus. Sharp dissection in the proper
plane and avoidance of excessive retraction are
key to avoiding this devastating complication.
Management
As with any situation with signicant hemorrhage, the rst step is to control bleeding with
direct pressure. The anesthesia team should be
Fig. 36.11 Presacral veins during robotic TME dissection. Blue arrows indicate plane between mesorectum and
presacral fascia, red arrow indicates presacral vein
Fig. 36.10 Presacral
venous plexus
acral promontory
Presacral fascia
Interval vertebral
venous plexus
Presacral
Rectum
410
ab
M. DeLeon and L. Stocchi
notied immediately to ensure adequate vascular
access and availability of blood products. The
surgeon should maintain direct pressure until
hemodynamic stability can be achieved. At this
point, if the area of bleeding can be identied,
electrocautery, preferably bipolar energy should
be applied. One should avoid the use of monopolar energy directly on the vessel, which can exacerbate bleeding as the vein retracts into the sacral
foramina. Instead, indirect monopolar electrocautery should be applied through an epiploica
appendix or piece of anterior rectus abdominis
muscle. Historically, pins or tacks have been successfully used to address presacral bleeding [56].
However, in practice, these items are not always
readily available and can be difcult to place correctly in the narrow deep pelvis. The use of a
ProTack™ device on a hemostatic agent like
Surgicel® may be more effective and overcome
the shortcomings of manual pin/tack placement.
The successful use of a free rectus abdominis
muscle fragment sutured to the presacral tissue to
tamponade the bleeding has been described [44]
(Fig. 36.12a, b). A possible alternative or complementary maneuver to suturing of a muscle
fragment is muscle fragment welding using electrocautery [24]. Bilateral ligation of the internal
iliac artery has been described but is relatively
extreme and could lead to ischemia of pelvic
muscles or bladder [48]. If bleeding cannot be
controlled directly, the surgeon should proceed
with pelvic packing. This is traditionally done
with laparotomy pads and a planned reoperation
to address bleeding after any coagulopathies and
hemodynamic instabilities are corrected. Other
options for pelvic packing include a lled intravenous saline bag [40] or breast implant sizer [7].
In most cases, pelvic packing with laparotomy
pads achieves hemodynamic stability after which
the patient can be transferred to the intensive care
unit and returned to the operative room in
24–48hours. If a restorative operation had been
originally planned the surgeon should make an
effort to remove the specimen at the time of the
initial operation and transect the distal anorectum
before pelvic packing with the plan of reestablishing intestinal continuity at the time of the
planned reoperation.
Low Anterior Resection Syndrome
Background
Low anterior resection syndrome (LARS) refers
to the constellation of symptoms and the complexity of anorectal dysfunction that may result
in patients undergoing low anterior resection
[19]. These symptoms include fecal incontinence, urgency, frequency, clustering, and painful defecation. There is no clear etiology but it is
thought to be a combination of radiation-induced
mucosal injury, loss of the rectal reservoir, autonomic denervation, decreased recto-anal sensitiv-
Fig. 36.12 Rectus abdominis muscle fragment sutured to presacral fascia to control bleeding
36 Rectal andRectosigmoid Carcinoma
411
ity and decreased anal resting pressure. The
incidence is signicant with studies showing
average rates of 44% [51].
Prevention
Unfortunately, there are no well-established strategies to prevent LARS. There is a relationship
between anastomotic leakage and the development of LARS [25, 30]. Short-term improvements
have been seen with colonic J pouch, side-to-end
anastomosis and transverse coloplasty, but these
benets do not persist beyond 12–18months [10,
27]. There is literature to suggest that a defunc-
tioning stoma may contribute to impaired functional outcomes [33, 58], and that early closure
may mitigate the severity of LARS [50]; however,
the latter has not been replicated in subsequent
studies. Trans-stomal irrigation, intraoperative
nerve monitoring, pelvic oor physical therapy
prior to stoma closure and transanal irrigation are
techniques that may be helpful preventative measures and are currently under investigation [2].
Recognition
Patients will present with symptoms including
frequency, urgency, fecal incontinence, clustering, and painful bowel movements. Their symptoms can be quantied using the LARS score
(Fig. 36.13). Other etiologies including anastomotic stricture, tumor recurrence, radiation enteritis, bile salt, or pancreatic malabsorption and
small bowel bacterial overgrowth should be ruled
out prior to conrming the diagnosis of LARS.
Management
Initial management begins by increasing dietary
ber intake and adding ber supplementation.
For persistent symptoms, anti-motility agents
including Imodium, loperamide, and tincture of
opium should be prescribed.
Pelvic oor physical therapy and biofeedback
should be recommended in conjunction with medical therapy. Retrograde colonic irrigation (RCI)
helps to completely evacuate the neorectum and
Fig. 36.13 LARS score (Emmertsen and Laurberg [19])
412
ry
M. DeLeon and L. Stocchi
improve symptoms of fecal incontinence, frequency and clustering of bowel movements. RCI
has also been shown to improve LARS scores
[47]. Though not FDA-approved for LARS, there
are several small series showing improvement of
LARS and fecal incontinence with sacral nerve
stimulation [26]. A systematic review assessing
different interventions for LARS indicated that
posterior tibial nerve stimulation was ineffective at
improving LARS symptoms. Other interventions
such as pelvic oor training, ramosetron and probiotics were effective in the short term, but their
benets could not be sustained in the long term.
The best intervention to improve symptoms was
RCI [18] . For those who continue to have debilitating symptoms despite these treatment strategies, fecal diversion is a surgical option that can
afford these patients an improved quality of life.
Sexual andUrinary Dysfunction
Background
The cause of sexual dysfunction after rectal cancer
treatment is multifactorial, due to a combination of
autonomic pelvic nerve injury during surgery,
chemoradiation-induced ovarian failure and radiation damage causing vaginal atrophy and brosis.
Urinary incontinence is due to sympathetic nerve
injury causing increased bladder tone, reduced
bladder capacity, and urinary dysfunction.
Prevention
From a surgical perspective, an understanding of
autonomic pelvic nerve anatomy is essential to
prevent injury. The sympathetic autonomic
plexus arises from T12-L2 and forms the superior
hypogastric plexus (SHP) that emerges from the
aorta at the level of the IMA (Fig.36.14). High
ligation of the IMA should be 1–2cm from the
origin of the aorta to avoid injury of this plexus.
The SHP then splits into the right and left hypogastric nerves as they course over the sacral
promontory (Figs.36.14 and 36.15). As the operation commences into the pelvis, sharp dissection
should be carried out in the avascular retrorectal
space between the fascia propria anteriorly and
the parietal fascia posteriorly to avoid injury of
the hypogastric nerves (Fig.36.16) Injury at this
level may cause urinary urgency and incontinence [39].
The SHP then joins the pelvic splanchnic
nerves (PSN) to form the inferior hypogastric
plexus (IHP). The PSN enters at the level of
S2-S4 and makes up the parasympathetic component. They lie in the lateral ligament joining
the parietal fascia of the pelvic sidewall to the
fascia propria medially. These nerves are responsible for detrusor contractility, vaginal lubrication, and genital swelling during sexual arousal.
Damage at this level may cause decreased blood
ow leading to reduced vaginal lubrication. The
IHP continues anterolateral to the rectum, lateral
Fig. 36.14 Pelvic
autonomic nerves
Superior hypogastric plexus
Rectum
Urinary bladder
Interior
mesenteric artery
Sympathetic trunk
and ganglion
External iliac arte
Hypogastric nerve
Pelvic splanchnic
nerves
Sacral nerves
Inferior hypogastric
plexus
Levator
Neurovascular
Pe
scia
36 Rectal andRectosigmoid Carcinoma
413
to the cervix, and extends to the lateral vaginal
wall at the base of the bladder (Fig. 36.14).
Injury to the PSN and IHP may occur if the TME
dissection is taken too far laterally, or with
excessive retraction of the rectum, displacing the
IHP medially [39]. Because the IHP contains
Fig. 36.15 Robotic view of hypogastric nerves over the
sacral promontory during TME dissection. Blue arrows
indicate hypogastric nerves over sacral promontory. Red
arrows indicate plane of dissection between mesorectum
and nerves
both sympathetic and parasympathetic nerve
bers, injury can result in both urogenital and
sexual dysfunction.
The anterior dissection around Denonvilliers
fascia is less dened in women than in men. In
women, the rectovaginal septum is described to
have an anterior and posterior compartment. The
posterior compartment is a continuation of the fascia propria of the rectum, and the anterior compartment is dened as Denonvilliers fascia, though
this distinction is not always readily apparent [64].
Dissection in the plane to include Denonvilliers
fascia is at high risk for autonomic nerve injury
and is only required for anterior tumors, where a
posterior vaginectomy may also be necessary. For
posterolateral tumors, Denonvilliers fascia may be
spared to avoid nerve injury.
Recognition
It is important for the provider to initiate conversations regarding sexual and urinary function
once the patient has recovered from surgery, as
ani muscle
Levator
ani nerve
Fig. 36.16 Hypogastric nerves in relation to presacral fascia
lvic plexus
Sacral nerve
Piriformis
muscle
Pelvic
splanchnic
nerves
bundles
Denonvilliers
fascia
Rectal proper
fascia
Rectum
Mesorectum
Rectal proper
fascia
Prehypogastric
nerve fascia
Hypogastric
nerves
Parietal
presacral fa
Sacrum