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67 Anastomotic Rotation After Laparoscopic Right Hemicolectomy for Colonic Cancer
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Illustration 67.1 Twist of the anastomosis after right hemicolectomy is an infrequent complication. During laparoscopy perhaps it is more frequent. It is very important during extracorporeal
resection not to twist the small bowel! Before anastomosis check that the small bowel is in good
position and not twisted
357
During operation, a complete rotation of the anastomosis was found without vas-
cular compromise or ischemia, but with an important proximal distension. Resection
of the anastomosis was performed, followed by the creation of a new hand-sewn
end-to-side anastomosis (Illustration 67.1 ). Care was being taken that no rotation or
vascular compromise was present.
Outcome
Unfortunately, the patient developed progressive signs of abdominal sepsis with multiple organ failure. Another abdominal CT scan with oral contrast showed evidence of air
and contrast leakage, supporting the suspicion of an anastomotic leakage (Fig. 67.3 ). A
relaparotomy was performed to take down the anastomosis and create an ileostomy and
mucous fi stula at the transverse colon. The same day, another laparotomy was performed because of postoperative hypovolemic shock due to a laceration of the spleen,
and a splenectomy was performed. After long recovery at the intensive care unit, the
patient could be discharged from the hospital 6 weeks postoperative. After 6 months,
continuity of the bowel was restored together with reconstruction of the abdominal
wall, by means of sub-lay mesh. A long period of postoperative intestinal paralysis followed (Fig. 67.4 ). At the most recent visit of the outpatient clinic, the patient had an
acceptable bowel function, and routine follow- up for colon cancer will be carried out.
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Fig. 67.3 Postoperative CT
scan showing leakage of
anastomosis
Fig. 67.4 Intestinal paralysis
after reconstruction
B.R. Klarenbeek
Discussion
Anastomotic misalignment is a very rare complication in colorectal surgery.
Laparoscopic surgery might have increased this risk of rotation, because the bowel
is exteriorized through a small incision. The creation of an extracorporeal anastomosis through the same small incision might facilitate misalignment. However, current literature shows only four reports of this complication after laparoscopic
colectomy. Two retrospective cohort studies report one case each (0.5–0.8 %) [ 1 , 2 ].
Also, two case reports describe cases of anastomotic rotation: one after right hemicolectomy [ 3 ] and another after anterior resection [ 4 ]. Presumably, these fi gures are
an underestimation of anastomotic misalignment, because probably if rotation is
less than 180° that is clinically not signifi cant. It seems that only a more than 180°
rotation or more will most certainly give obstructive complaints and vascular
67 Anastomotic Rotation After Laparoscopic Right Hemicolectomy for Colonic Cancer
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359
compromise to some extent. In our case, there was no recovery of bowel function
after initial surgery and reoperation took place during the same hospital admission.
Two other cases in literature report initial intestinal passage and posterior discharge,
with readmission after several weeks up to 2 years because of bowel obstruction.
This partial recovery might refl ect a subtotal obstruction, with peristaltic compromise causing recurrent symptoms. Identifi cation of anastomotic misalignment
seems diffi cult; CT scans and colonoscopy will not always reveal the origin of the
bowel obstruction. Surgical re-intervention appears to be the only way to correct
this complication. Whether a new anastomosis or an ileostomy should be created
depends on individual factors, such as the extent of vascular compromise and the
general condition of the patient.
References
1. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Postoperative complications of laparoscopicassisted colectomy. Surg Endosc. 1997;11:119–22.
2. Croce E, Olmi S, Azzola M, et al. Laparoscopic colectomy: indications, standardized technique
and results after 6 years experience. Hepatogastroenterology. 2000;47:683–91.
3. Bonjer HJ, Lange JF. Rotation of the terminal ileum in laparoscopic right hemicolectomy. Surg
Endosc. 1993;7:534–9.
4. Lynes K, Takacs K, Paice AG, Trotter G. Delayed presentation of a 360-degree rotational anastomotic misalignment following laparoscopic anterior resection. Colorectal Dis. 2010;12:
1268–71.
Chapter 68
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Case on Leakage After Ileocecal
Resection for Crohn’s Disease
Hugo W. Nijhof
Keywords Crohn’s disease • Laparoscopic ileocecal resection • Anastomosis
leakage • Abdominal abscess
Diagnosis and Indication for Surgery
A 20-year-old healthy female patient presented to the surgical outpatient clinic elsewhere.
For the last 3 years, she had been conservatively treated for ileocecal Crohn’s disease.
However, since her disease with developing of symptomatic stenosis did not successfully
respond to medical treatment, a laparoscopic ileocecal resection was proposed.
Operation
The procedure was performed in a standard fashion with antibiotic prophylaxis. By
laparoscopy, a disease was localized in the ileocecal area. By using four trocars,
ascending colon and ileum were mobilized, exteriorized through a transumbilical
incision, resected, and anastomosed in side-to-side isoperistaltic stapled anastomosis, which was overseen with PDS 3-0.
Postoperative Course: Identifi cation and Treatment
of Complication
The initial postoperative period was without complications. However, the
patient suffered from a continuing paralytic ileus, which was at fi rst
H. W. Nijhof , M.D.
Department of Surgery , Kennemer Gasthuis , Haarlem , The Netherlands
e-mail: hw.nijhof@kg.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_68,
© Springer International Publishing Switzerland 2014
361
362
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H.W. Nijhof
conservatively managed with fl uid resuscitation and gastric tube drainage.
Nonetheless, at the l7th postoperative day, she developed fever with increased
infection parameters. A contrast- enhanced CT scan of the abdomen was performed that showed a fl uid collection at the anastomotic site without signs of
contrast extravasation (Fig. 68.1 ). A CT-scan-guided drainage was performed,
after which the drain remained in place for 10 days (Fig. 68.2 ). The drain had
become accidentally dislocated, after which the patient’s condition deteriorated
with continuous episodes of spiked fever. On her request, she was fi nally transferred to our hospital.
Presentation in our department, at the 12th postoperative day, revealed a
patient in poor nutritional condition, septic with a fever of 38.5 °C, respiratory
rate of 30, pulse of 124, and abdominal tenderness in the right abdomen. A CT
scan of the abdomen was performed, which showed a large pelvic and right paracolic abscess. Because of her septic condition, we did not opt for a CT scanguided drainage, but for an explorative laparotomy, which revealed the large
Fig. 68.1 CT scan showing
a large pelvic and right
paracolic fl uid collection
68 Case on Leakage After Ileocecal Resection for Crohn’s Disease
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Fig. 68.2 CT abdomen
showing the percutaneous
placed drain in the right
paracolic fl uid collection
363
abscesses. Already depicted with CT scan, these were an almost complete anastomotic dehiscence, the rest being converted in an infl ammatory plastron.
Dissection was diffi cult, yet an ileostomy without eversion and colostomy could
be performed. After extensive rinsing of the abdominal cavity two large drains
were left, after which the abdominal wall was closed. Antibiotic treatment was
continued for 7 days.
Postoperatively the patient’s condition improved steadily. Oral intake improved
and the drains were removed. Two weeks after the last laparotomy she was discharged. Nasogastric tube feeding was continued at home because of her poor nutritional condition.
Five months later, her ileostomy could be closed as well as the resection of a
small enterocutaneous fi stula that she had developed. Further recovery was without complications. Progressively, she has gained weight and recently she has
married.
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H.W. Nijhof
Discussion
Although much care is always given to an bowel anastomosis, leakage still may
occur. The lowest rates are found after ileocolic anastomosis; however, these nonetheless occur in 1–3 %. Although patients with Crohn’s disease may be at risk for
leakage because of the immunosuppressive medication used, yet leakage while performing a side-to-side stapled or manual anastomosis remains low [ 1 ]. Usually
leakage presents itself between postoperative days 5–7; however, later manifestation can occur [ 2 , 3 ]. There is no clear defi nition of radiological or clinical anasto-
motic leakage. As in the present case, the CT scan of abdomen initially revealed no
clear anastomotic leakage of contrast, but fl uid (or gas) collections were presented
early as signs of anastomotic leakage. Together with clinical signs as pain, fever,
tachycardia, and peritonitis, we regard anastomotic leakage as more likely [ 4 ].
Management of the leakage, however, is diverse and is dependant on many
factors.
With non-septic patients, their small abscesses (<3 cm) can merely be treated by
antibiotics. With larger intra-abdominal abscesses, an attempt is usually made to
perform a radiologically guided drainage of the collection [ 5 ]. However, if the con-
dition of the patient fails to improve, deteriorates—or as in this case—develops into
general sepsis, time must not be wasted for drainage to be completed. In such a case,
explorative surgery for drainage and a new anastomosis or deviation stomas are
necessary.
References
1. Resegotti A, Astegiano M, Farina EC, et al. Side-to-side stapled anastomosis strongly reduces
anastomotic leak rates in Crohn’s disease surgery. Dis Colon Rectum. 2005;48:464–8.
2. Dietz DW, Bailey HR. Postoperative complications. In: Church JM, Beck DE, Wolff BG,
Fleshman JW, Pemberton JH, editors. The ASCRS textbook of colon and rectal surgery. New
York: Springer; 2007. p. 143.
3. Hyman N, Manchester TL, Osler T, et al. Anastomotic leaks after intestinal anastomosis: it’s
later than you think. Ann Surg. 2007;245:254–63.
4. Law WI, Chu KW, Ho JW, Chan CW. Risk factors for anastomotic leakage after low anterior
resection with total mesorectal excision. Am J Surg. 2000;179:92–8.
5. Phitayakorn R, Delaney CP, Reynolds HL, International Anastomotic Leak Study Group, et al.
Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J Surg. 2008;32:1147–52.
Chapter 69
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Case on Leakage After Ileoanal
Pouch Anastomosis
Miguel A. Cuesta
Keywords Ulcerative colitis • Proctocolectomy • Ileoanal pouch • Leakage IAPA
pouch
First Patient
Diagnosis and Indication for Surgery
A 25-year-old male student underwent a total proctocolectomy and ileoanal pouch
anastomosis (IAPA) because of an intractable ulcerative colitis by conservative means.
Operation
The operation was performed totally laparoscopically, that means that the
Panproctocolectomy was followed by the extracorporeal formation of a J-pouch
through a well-protected incision in the right lower abdomen. The pouch was anastomosed to the anal canal by a circular stapler, without protective ileostomy.
Postoperative Course: Identifi cation of Complication
Patient had a long postoperative ileus period without fever or increased infl ammatory
parameters (Fig. 69.1a, b ). In this period he received TPN. After 2 weeks a CT scan
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_69,
© Springer International Publishing Switzerland 2014
365
366
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Fig. 69.1 ( a ) Abdominal
X-ray showing a
postoperative intestinal
obstruction. ( b ) Lateral X ray
showing intestinal
obstruction
M.A. Cuesta
a
b
was performed showing a progressive imaging of a leakage of the ileoanal anastomosis with an ischiorectal abscess around the pouch and the anastomosis (Fig. 69.2 ).
Patient developed fever, lower abdominal pain, and a high CRP of 325. We decided
to drain the abscess transanally under anesthesia. Inspection revealed a defect on the
posterior side of the anastomosis, and through it the abscess could be drained whereby
a Penrose-like drain was left in the collection (Illustration 69.1 ). Thereafter, a laparo-
scopic loop ileostomy was created. Postoperatively, the abscess had to be drained two
more times and rinsed under anesthesia. During this period, the patient was fed by
69 Case on Leakage After Ileoanal Pouch Anastomosis
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Fig. 69.2 CT scan, leakage,
and ischiorectal abscess left
side
367
Illustration 69.1 Septic complications after IPAA should be treated by local drainage and diverting ileostomy. It is not clear what will be the ideal operation with or without diverting ileostomy.
The ileostomy can protect the pouch and anastomosis during the immediate postoperative course,
but it is also cause of high morbidity
enteral feeding by duodenal tube, and fi nally after a period of 6 weeks he recovered.
Once the CT scan had demonstrated that there was no more abscess or leakage, the
anastomosis was dilated before taking down of the ileostomy 3 months later.
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