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71 Case on Leakage After LAR and Coloanal Anastomosis
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Fig. 71.2 CT scan showing
leakage of the end-to-side
anastomosis
Fig. 71.3 MRI showing
a mid rectal T3 rectal tumor
379
Five months later the loop ileostomy was closed, which happened uneventfully.
Second Patient
Diagnosis and Indication for Surgery
A 60-year-old female patient was diagnosed having distal rectal cancer. She had
symptoms of tenesmus and rectal blood loss since 2 months, and the tumor was palpated by rectal examination on the posterior aspect of the rectum, being found as not
fi xed. Colonoscopy showed no pathology in the rest of colon, and biopsies showed a
well-differentiated carcinoma. The tumor was staged as T3N0M0 by CT scan and
MRI (Fig.
71.3 ). Importantly, there was no ingrowth of tumor in the external
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sphincter or pelvic fl oor muscles. Vagina wall was also free. As a consequence, the
patient was told the chance of performing a sphincter-sparing operation was considered higher than 50 %. She was treated by neoadjuvant radiotherapy and 5 days of 5
Grays; the operation was scheduled 6 weeks later. In meantime, a new MRI and
rectal examination showed an important response of the tumor to radiotherapy.
H.W. Nijhof and M.A. Cuesta
Operation
Mechanical preparation was not given, but prior to operation, two enemas were
given: the fi rst the evening before operation and the second early the next morning.
At anesthesia, rectal examination confi rmed the possibility of a coloanal anasto-
mosis. A laparoscopic TME dissection was performed with mobilization of the
splenic fl exure. Distal dissection was performed distal of the pelvic fl oor, followed
by a transanal division of the rectum at 2 cm proximal of the dentate line. Specimen
was retrieved transanally, followed by side-to-end anastomosis, manually performed. The presacral space was drained.
Postoperative Course: Identifi cation and Treatment
of the Complication
Five days after operation, the patient developed lower abdominal pain and fever. CRP
was high and on the CT scan fl uid was seen in the peritoneal cavity with huge amounts
of free air (Fig. 71.4 ). With the diagnosis of leakage of anastomosis, her reoperation
was performed through an enlarged Pfannenstiel incision. Small leakage was seen by
injection of methylene blue through rectum at the left aspect of the anastomosis.
Abdomen was rinsed and drained, then followed by creation of a loop ileostomy.
Fig. 71.4 CT scan showing
leakage anastomosis after
LAR
71 Case on Leakage After LAR and Coloanal Anastomosis
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Fig. 71.5 Colon enema,
good patent, and no leakage
or sinus
Patient recovered and could go home after 10 days. After 3 months, anastomosis
was patent with no leakage (Fig. 71.5 ) and the ileostomy was closed. Patient retained
a good continence and cancer controls still show good results.
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Third Patient
Diagnosis and Indication for Surgery
A 57-year-old entrepreneur was operated on after a short-scheme radiotherapy, 5 × 5
Grays by an open TME, followed by a coloanal anastomosis, manually transanally
performed and a deviating loop ileostomy. Tumor was staged as pT2N0 by pathological study.
Postoperative Course and Identifi cation of Complication
At the sixth postoperative day, patient was diagnosed as having a dehiscence of
anastomosis with signs of general peritonitis confi rmed by CT scan.
At relaparotomy purulent peritonitis was found, as caused by leakage of one-
third of the anastomosis. Patient was hemodynamically stable and wished to preserve the sphincter-saving anastomosis. At laparotomy, after mobilization of splenic
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fl exure, a transanally pull-through was performed after rinsing of the abdomen and
drainage. Patient recovered after 2 days on the Intensive Care department. At the
eighth postoperative day while under anesthesia, the prolapsed colon was resected
leaving a small stump of 2 cm at the dentate line. This has healed without stenosis
and acceptable defecation was possible after closure of ileostomy. At 4 years after
operation, patient is still happy with this solution.
H.W. Nijhof and M.A. Cuesta
Discussion
Unfortunately, anastomotic leakages are inevitable in colorectal surgery, even
though they are performed by experienced surgeons. The incidence rises when the
anastomosis is performed more distally, with the highest rates of 10–20 % after
operations in the mid and distal rectum, followed by distal anastomosis [ 1 ].
An extraperitoneal anastomosis, as performed in the above-mentioned cases, is
therefore at risk for anastomotic dehiscence and leakage. Risk factors are the perfusion and tension of the anastomosis, male gender, and neoadjuvant radiotherapy. It
has not been clearly established when to mobilize “a priory” the splenic fl exure. It
is our experience to commence with this in the case of planned anterior resection
with small sigmoid loop and always in the case of LAR and coloanal anastomosis.
Subject of debate concerns the creation of protective ileostomy after these operations, but an indication to do so is quite liberal and it is left up to the surgeon. The
majority of surgeons are creating a protective ileostomy in those cases. Moreover,
the defi nition and grade of anastomotic leakage following anterior resection of the
rectum has been defi ned by the International Study Group of Rectal Cancer [ 2 , 4 ].
Anastomosis leakage has been defi ned as a defect of the intestinal wall at the level
of anastomosis leading to a communication between the intra- and extraluminal
compartments. A pelvic abscess close to anastomosis is also considered anastomotic
leakage. There are three categories (a to c) including the treatment adopted: (a)
requiring no active therapeutic intervention; (b) requiring intervention, but manageable without relaparotomy; and (c) requiring relaparotomy. Clinically, if patient is
getting worse, a CT scan with transanal and iv contrast will show fl uid (or gas) collections as signs of leakage, even with or without contrast extravasation, as was the
case in the fi rst patient [ 3 , 4 ]. Management strategies of leakage are diverse [ 3 , 4 ].
If the leakage is subclinical, or if small abscesses are present (type a), conservative
management with antibiotics and bowel rest can be performed. Contained leakage
with large abscess mostly located in the presacral area must be drained transanally
through anastomosis or percutaneously. The best is through anastomosis with creation of an ileostomy, if not done during the fi rst operation. If drainage is done
percutaneously, this can lead to a fi stula to the perineum, with diffi cult treatment.
Drainage through laparotomy is the last option. In case of general peritonitis, relaparotomy should be done. Management of a dehiscent anastomosis depends on the
size of the defect and the contamination of the abdominal cavity. Small defects usually can be salvaged by an additional suture and/or protective loop ileostomy and
71 Case on Leakage After LAR and Coloanal Anastomosis
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383
adequate local drainage. Larger defects, or extensive fecal contamination, in a
hemodynamically unstable patient mostly require dismantling of the anastomosis
and creation of a permanent colostomy. The solution for the third case remains
exciting [ 5 , 6 ] .
References
1. Komen N, Slieker J, de Kort P, et al. High tie versus low tie in rectal surgery: comparison of
anastomotic perfusion. Int J Colorectal Dis. 2011;26:1075–8.
2. Rahbari NN, Weitz J, Hohenberger W, et al. Defi nition and grading of anastomotic leakage
following anterior resection of the rectum: A proposal by the International Study Group of
Rectal Cancer. Surgery. 2010;147:339–51.
3. Breukink SO, Pierie JPEN, Grond AJK, et al. Laparoscopic versus open total mesorectal excision: a case control study. Int J Colorectal Dis. 2005;20:428–33.
4. 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.
5. Veenhof AAFA, van der Peet DL, Sietses C, Cuesta MA. Pull-through procedure as treatment
for coloanal anastomotic dehiscence following TME. Dis Colon Rectum. 2007;50:1271–4.
6. 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.
Chapter 72
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Case on Presacral Abscess and Sinuses
After LAR
Alexander A.F.A. Veenhof
Keywords Sarcoma pelvis • Rectal cancer • Leakage anastomosis • Low anterior
resection • Presacral abscess
First Patient
Diagnosis and Indication for Surgery
Presacral abscess following LAR because of sarcoma in the lower pelvis.
A 60-year-old female patient presented with anemia and lower abdominal pain.
Colonoscopy and gastroscopy were normal. Double balloon endoscopy (DBE)
showed an ulcerating tumor 120 cm past the ligament of Treitz. Biopsies could not
prove malignancy or infection. An additional CT scan of the abdomen showed a
large tumor in the lower pelvis (Fig. 72.1 ). Differential diagnosis was established
between GIST tumor, gynecological tumor, and sarcoma.
Operation
In January 2011, an en bloc resection of the tumor, both ovaries, a loop of 20 cm
jejunum, and low anterior resection (LAR) were performed. Continuity was restored
by a jejunojejunostomy and an end-to-side colorectal stapled anastomosis. This last
anastomosis was protected by a loop ileostomy.
A.A.F.A. Veenhof , M.D.
Department of Surgery , VU University Medical Centre , Amsterdam , The Netherlands
e-mail: a.veenhof@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_72,
© Springer International Publishing Switzerland 2014
385
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Fig. 72.1 CT scan showing
a rectosigmoid sarcoma in the
pelvis
Fig. 72.2 CT scan, presacral
abscess
A.A.F.A. Veenhof
Postoperative Course: Identifi cation and Treatment
of Complication
One week postoperatively, the patient developed fever and abdominal pain. A CT
scan of the abdomen showed a presacral abscess of 6 cm without clear signs of
anastomotic leakage (Fig. 72.2 ). Under anesthesia the abscess was transrectal
drained through the anastomosis. Following the latter intervention, no complications were observed.
The pathology result showed a radically removed sarcoma and 17 lymph nodes
without metastases. After control of anastomosis by enema, ileostomy was reversed
6 months later. Patient is doing well.
72 Case on Presacral Abscess and Sinuses After LAR
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387
Second Patient
Diagnosis and Indication for Surgery
A 48-year-old male patient was diagnosed having a T2 N0 M0 adenocarcinoma at
12 cm of anal verge. He had blood loss in the stools since 3 months.
Operation
Patient was proposed to have a LAR after a mechanical colon preparation. The
operation was conventionally performed without protecting ileostomy. Anastomosis
was created in an end-to-side fashion at the level of the pelvic fl oor.
Postoperative Course: Identifi cation and Treatment
of Complication
On the seventh postoperative day the patient’s health became worse, and he was
reoperated on because of a suspicion of leakage. At the relaparotomy, a leakage
of anastomosis was found with a huge abscess around the anastomosis
(Fig. 72.3 ). The abdomen was rinsed, drained, and a double colostomy was done
in sigmoid colon. After stabilization patient was referred to us with the question
if a restoration of continuity was possible. At proctoscopy (Fig. 72.4a, b ) it
became clear that a presacral abscess was still present with pus discharge and
consequently treated by an VAC Endo-sponge. Pus discharge disappeared and
Fig. 72.3 MRI, T2 N0 rectal
cancer
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A.A.F.A. Veenhof
a
Fig. 72.4 ( a , b ) Proctoscopy showing leakage of the anastomosis with abscess and treatment with
Endo-sponge
b
we proposed a waiting period of 6 months, after which the sinus still persisted
but now without pus discharge. Under diagnosis of chronic presacral sinus, we
decided to restore the continuity by taking down the colostomy. Initially, the
patient had complaints of tenesmus and some fever, but fi nally he recovered. His
defecation remains irregular but continent.
Discussion
Few articles are available regarding the approach of the presacral abscesses following LAR. Total mesorectal excision after neoadjuvant radiotherapy or chemoradiotherapy remains the fi rst choice of treatment with a low local recurrence rate
(<5 %) and the high 5-year survival rate (80 %) in patients with mid- and low-rectal
cancer [
1 , 2 ]. In 2006, van der Vaart reported higher incidences of presacral
abscesses following the onset of neoadjuvant therapy [ 3 ]. The incidence following
total mesorectal excision is believed to be approximately 10 % [ 4 ]. No real evi-
dence exists on whether the presacral abscess develops following an infected presacral hematoma, or an anastomotic leakage, or following both. Higher incidences
of presacral abscesses have been found in patients receiving neoadjuvant therapy,
patients in poor condition, and patients with large tumors [ 4 ]. In our experience,
the presacral abscess is best managed by drainage through the anastomosis following LAR or through the perineal suture line following abdominoperineal resection.
The need for a concomitant diverting colo-/ileostomy is subject to debate. No evidence exists to support any decision making. If on pre-drainage CT scan with rectal
and oral contrast no anastomotic leak can be objectifi ed, then diversion stoma may
be unnecessary. In this case, an abscess is most likely based on an infected presacral hematoma. However, if anastomotic leakage is observed, then diversion stoma
should be done after drainage of the abscess. The VAC Endo-sponge has been
72 Case on Presacral Abscess and Sinuses After LAR
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Presacral
abscess
Presacral
sinus
389
Drainage
or
Sponge?
Illustration 72.1 No evidence exists to support any decision making concerning the treatment of
presacral abscess. If on CT scan with rectal and oral contrast no anastomotic leak can be objectifi ed, then diversion stoma may be unnecessary. In this case, an abscess is most likely based on an
infected presacral hematoma. However, if anastomotic leakage is observed, then diversion stoma
should be done after drainage of the abscess. The VAC Endo-sponge has been introduced in the last
years in patients with a content distal rectal anastomosis leakage in order to create an optimal suction system leading to a quick closure without presacral sinus
introduced in the last years for patients having a content distal rectal anastomosis
leakage in order to create an optimal suction system leading to a quick closure
without presacral sinus (Illustration
more evidence is necessary before further implementation [
The fi nal question concerns, What to do with a chronic presacral sinus, like in
case number 2? If we close the ileostomy/colostomy, will the abscess recur?
If the presacral sinus is huge and deep, probably the best policy will be to reconvert the LAR in a coloanal anastomosis or a pull-through procedure with omentum
or muscle plasty in the presacral space. In the case of a small chronic sinus, probably reversal of ileostomy/colostomy will be enough.
72.1 ). In spite of favorable initial rapports,
5 ].
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