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_1143_Библиотеки_им_академика_М_И_Перельмана
.pdf
368
https://t.me/med1917
M.A. Cuesta
Second Patient
Diagnosis and Indication for Surgery
A 17-year-old high school girl underwent a panproctocoletomy and ileoanal pouch
anastomosis with protective loop ileostomy because of ulcerative colitis and not
reacting on conservative therapy. She was known with UC since her 13th year.
Operation was performed laparoscopically and hand assisted, that means that the
colon was resected by hand assistance followed by the resection of the rectum
through a Pfannenstiel incision. Through it the J-pouch was created followed by a
stapled ileoanal pouch anastomosis with a protective ileostomy.
Postoperative Course: Identifi cation of Complication
Postoperatively from the fi rst day on she felt sick and had fever, while the ileostomy
was vital and had started production. A possible respiratory infection was treated by
iv antibiotics. The next day she was vomiting and condition was deteriorating with
fever and increased abdominal pain. A CT scan confi rmed leakage of the pouch and
a laparotomy was proposed (Fig. 69.3 ). At laparotomy, necrosis of the pouch was
found and part of the ileal loop to the pouch necrosis was not caused by torsion, but
there was no pulse in the mesentery. Moreover, the ileostomy was not the cause of
the necrosis; it was vital. The only possibility was a defect in the vessels of the mesentery of the pouch dissected at the level of the duodenum. Pouch was resected and
a defi nitive ileostomy was created at the right lower abdomen. She lost in this way
75 cm of terminal ileum. She recovered from this reoperation but as she maintained
nutritional problems, she was considered to be a short bowel patient. Nutrition is
enteral, but she was followed by the special outpatient clinic in which not only feeding and elements are controlled but also production of ileostomy by imodium and
cholestyramine. One year later she was again admitted because of abdominal pain.
On the plain X-ray, intestinal obstruction was diagnosed. She reacted very quickly
to conservative therapy and has until now recovered without pain. During this time
she fi nished high school and began her university study in the faculty of Law.
Discussion
Diverting ileostomy has been considered mandatory for minimizing the effects of
septic complications in pelvic pouch surgery. Nowadays, it is a trend to do the
operation without diverting ileostomy, apparently with no increase of sepsis or
pouch complications on the short and long term. Two questions arise in a discussion
of these two patients. First, what is the frequency of septic complications after the
69 Case on Leakage After Ileoanal Pouch Anastomosis
https://t.me/med1917
Fig. 69.3 CT scan showing
leakage of the IAPA
369
IAPP procedure? Second, what is the need for a diverting ileostomy? Kiely et al.
studied the frequency and consequences of pelvic sepsis after IPAA [ 1 ]. Two hun-
dred (6.2 %) of 3,234 patients developed pelvic septic complications within 3
months of IPAA. They compared the complications in two groups of patients with
and without septic complications after IPAA. Patients with pelvic sepsis had higher
rates of postoperative hemorrhage (13.5 % versus 3.7 %), anastomotic leakage
(35 % versus 3.7 %), and fi stula formation (37 % versus 7.1 %). The overall median
follow-up was 7 years. Moreover, pelvic sepsis was associated with greater pouch
failure (19.5 % versus 4 %), incontinence, and worse quality-of-life score.
Gunnarsson et al. studied the complications of a diverting loop ileostomy in the
context of an IAPP intervention [ 2 ]. They studied complications following diverting
loop ileostomies in 143 patients subjected to restorative pelvic pouch surgery. In the
period between discharge after pelvic pouch surgery and closure of the loop ileostomy, 20 (14 %) patients were hospitalized because of excessive stoma fl ow and 19
(13 %) patients were treated for other surgical complications, of whom 10 (7 %)
required surgical intervention. In the early postoperative period (within 30 days)
after closure of the loop ileostomy, 18 (13 %) patients suffered complications necessitating surgery. Another 12 (8 %) patients were hospitalized because of intestinal
370
https://t.me/med1917
M.A. Cuesta
obstruction that could be treated conservatively. They concluded that the proportion
of complications associated with diverting loop ileostomies in pelvic pouch surgery
was considerable. A randomized controlled multicentre study was considered ethically defensible and recommended. Yet, this randomized study never appeared.
References
1. Kiely JM, Fazio VW, Remzi FH, et al. Pelvic sepsis after IPAA adversely affects function of
the pouch and quality of life. Dis Colon Rectum. 2012;55:387–92.
2. Gunnarsson U, Karlbom U, Docker M, et al. Proctocolectomy and pelvic pouch-is a diverting
stoma dangerous for the patient? Colorectal Dis. 2004;6:23–9.
Chapter 70
https://t.me/med1917
Case on Leakage After Sigmoid Resection
Hugo W. Nijhof
Keywords Laparoscopic sigmoid resection • Leakage anastomosis • Colostomy •
Diverticulitis
First Patient
Diagnosis and Indication for Surgery
At issue is a 46-year-old window cleaner, who after a persistent period of acute
diverticulitis including recovery and recurrence, now underwent an elective laparoscopic sigmoid resection.
Operation
This operation went well; no technical problems appeared, although the splenic
fl exure was not mobilized. Anastomosis was performed end to end on the level of
the promontory.
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_70,
© Springer International Publishing Switzerland 2014
371
372
https://t.me/med1917
Fig. 70.1 CT scan, leakage
of anastomosis with
pneumoperitoneum
H.W. Nijhof
Postoperative Course: Identifi cation and Treatment
of Complication
On the 4th postoperative day, the condition of the patient worsened, with abdominal
pain, fever, and abdominal distension.
A CT scan with contrast was performed and a leakage of the anastomosis was found
with an abscess in the lower abdomen and with free air under the diaphragm (Fig. 70.1 ).
Patient underwent a median laparotomy; the leakage was located and the anasto-
mosis was dismantled with creation of a colostomy and closure of the rectal stump.
Basis of the decision was that the leakage included fecal peritonitis and because the
patient showed signs of hemodynamic instability.
After operation, patient developed a deep wound infection and after its drainage,
he recovered. As a consequence of this, he developed an important incisional her-
months later, a new operation was proposed; an anastomosis was performed after
mobilization of the splenic fl exure and the incisional hernia repaired by means of an
onlay Marlex ® mesh. The patient recovered and returned to work after a period of 3
months after operation.
70 Case on Leakage After Sigmoid Resection
https://t.me/med1917
Fig. 70.2 CT scan, leakage
with intraabdominal
abscesses
Second Patient
A 41-year-old male patient with two recurrences of acute diverticulitis was operated
on elsewhere by means of laparoscopic sigmoid resection. Patient was sent to home
the 4th postoperative day in good general condition, yet having a temperature of
38 °C. Two days after discharge, he was readmitted because of abdominal pain,
fever, and sepsis. On the CT scan, free air was observed with fl uid collections in the
four abdominal quadrants (Fig. 70.2 ) Under a diagnosis of general peritonitis, he
was reoperated by median upper and lower laparotomy. One-third of anastomosis
was found leaking with fecal peritonitis, and the anastomosis was dismantled with
creation of a colostomy in the left lower abdomen. Patient was treated by mechanical
ventilation for 2 days in the intensive care ward. There he developed a dehiscence
of the abdominal wound that led to an open abdomen approach. He developed two
intraabdominal abscesses, being drained percutaneously (Fig. 70.3a, b ). These
abscesses became two intestinal fi stulas at the edge of the huge incisional hernia
(Fig. 70.4 ). Referred to our unit, the rectal stump and the rest of colon were assessed
by colonoscopy, showing a stump of 15 cm with good patency. The two fi stulas
were found connected to the terminal ileum and rectal stump (Fig. 70.5 ). Six months
after the discharge from the other hospital patient was again operated. After excision of the split skin used to close the granulation wound and adhesiolysis, the two
fi stulas were found and treated by a small terminal ileum resection and partial resection of recto-sigmoid stump. After mobilization of splenic fl exure an end-to-side
anastomosis was performed without tension and good donuts. Thereafter, we used a
double Vycril ® mesh to repair the huge defect of abdominal wall, in an onlay
position.
Surprisingly, the patient recovered very quickly and could go home 10 days after
the operation with a supporting corset. Because of the very weak abdominal wall,
he requested its repair. He is currently on the waiting list to undergo an components
separation technique of the abdominal wall.
373
374
https://t.me/med1917
Fig. 70.3 ( a ) CT scanguided drainage abscess
median lower abdomen. ( b )
CT scan-guided drainage
abscess left paracolic gutter
H.W. Nijhof
a
b
Fig. 70.4 CT scan showing
open abdomen and colostomy
(Hartmann procedure)
70 Case on Leakage After Sigmoid Resection
https://t.me/med1917
Fig. 70.5 Fistulogram, two
tracks terminal ileum and
rectal stump
Discussion
375
The main lesson of these two cases is to be careful using the indication for sigmoid
resection in case of diverticulitis. A clear policy warns being more conservative
using this indication and also not selecting patients for operation on the basis of the
number of episodes of acute diverticulitis. The second lesson is that a proper operative technique should be used, meaning that sigmoid should be divided at the level
of promontory distally and at the level of a healthy descending colon-sigmoid proximally. Anastomosis should be performed without any tension; otherwise, splenic
fl exure should be mobilized. And third, a leakage developing in 5 % of the anastomosis at this level should be treated by dismantling the anastomosis with the temporary creation of a colostomy [
1 , 2 ] .
References
1. Snijders HS, Wouters MW, van Leersum NJ, et al. Meta-analysis of the risk for anastomotic
leakage, the postoperative mortality caused by leakage in relation to the overall postoperative
mortality. Eur J Surg Oncol. 2012;38:1013–9.
2. van Leersum NJ, Snijders HS, henneman D, et al. The Dutch Surgical Colorectal Audit. Eur J
Surg Oncol. 2013;18. Available online.
Chapter 71
https://t.me/med1917
Case on Leakage After LAR
and Coloanal Anastomosis
Hugo W. Nijhof and Miguel A. Cuesta
Keywords Rectal cancer • Low anterior resection • Laparoscopy • Leakage
anastomosis • Ileostomy
First Patient
Diagnosis and Indication for Surgery
A 68-year-old male with no previous medical history was referred to our outpatient
surgical clinic by the gastroenterologist. He had suffered from abdominal pain and
change in stools since a few months. Physical examination showed no abnormalities; however, rectal examination revealed a tumor that was palpable at the tip of the
fi nger. A colonoscopy was performed, which revealed a tumor located at the posterior wall of the rectum approximately 8 cm from the anus. The biopsy report showed
adenocarcinoma. Further radiological investigation, by means of CT thorax and
abdomen, showed no distant metastases and the MRI showed a 5-cm-long tumor, at
9 cm from the anus, being classifi ed as a T2-3N0M0 rectum carcinoma. According
with the location of the tumor, he was treated by short radiotherapy scheme of
5 × 5 Gys with a long interval to operation of 6 weeks. Preoperative colon preparation was done using two enemas and prophylactic antibiotics.
H. W. Nijhof , M.D. ()
Department of Surgery , Kennemer Gasthuis , Haarlem , The Netherlands
e-mail: hw.nijhof@kg.nl
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_71,
© Springer International Publishing Switzerland 2014
377
378
https://t.me/med1917
H.W. Nijhof and M.A. Cuesta
Operation
A laparoscopic low-anterior resection was performed, according to the TME principles after a low tie of the IMA. After mobilization of the sigmoid and descending
colon, it was evident that not enough length was available for an adequate distal
anastomosis. Therefore, splenic fl exure was mobilized before completion of a sideto- end double-stapled anastomosis. There were no tensions at the anastomosis; the
donuts were intact and methylene blue test showed no leakage at all. No deviating
ileostomy was performed.
Postoperative Course: Identifi cation and Treatment
of Complication
The initial postoperative period was uncomplicated. However, 3 days after surgery,
the patient complained of abdominal pain. At physical examination there was tenderness in the lower abdominal region. Diuresis was minimal and he had developed
a fever of 40 °C. Laboratory tests showed elevated CRP of 280 and Leukocytosis of
18,000 and an additional performed chest X-ray revealed a large amount of abdominal free air (Fig. 71.1 ). A CT abdomen was performed that showed anastomosis
leakage with fl uid collections in the whole abdomen and free air (Fig. 71.2 ).The
patient was reoperated, thereby enlarging the earlier performed small Pfannenstiel
incision. Free air was present, with initial signs of purulent peritonitis. The anastomosis was identifi ed, which revealed a ventral perforation of 1.5 cm. Policy became
to secure the perforation with additional sutures. The abdominal cavity was rinsed
and drained using two large-caliber silicon drains. Moreover, a protective loop ileostomy was performed. The further postoperative course was uncomplicated.
Fig. 71.1 Pneumoperitoneum
Соседние файлы в папке Библиотека им академика М.И. Перельмана