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
390
https://t.me/med1917
A.A.F.A. Veenhof
References
1. Heald RJ, Karanjia ND. Results of radical surgery for rectal cancer. World J Surg. 1992;
16:848–57.
2. Peeters KCMJ, Marijnen CAM, Nagtegaal ID, et al. The TME trial after a median follow-up of
6 years. Increased local control but no survival benefi t in irradiated patients with resectable
rectal carcinoma. Ann Surg. 2007;246:693–701.
3. van der Vaart MG, van der Zwet WC, Arends JW, et al. Rectal carcinoma treated with shortterm preoperative radiotherapy followed by abdominoperineal resection. Signifi cantly more
presacral abscesses with absence of local recurrence. Dig Surg. 2006;23:173–7.
4. Veenhof AA, Brosens R, Engel AF, et al. Risk factors and management of presacral abscess
following total mesorectal excision for rectal cancer. Dig Surg. 2009;26:317–21.
5. Verlaan T, Bartels SAL, van Berge Henegouwen MI, et al. Early, minimally invasive closure of
anastomotic leaks: a new concept. Colorectal Dis. 2011;13:18–22.
Chapter 73
https://t.me/med1917
Case on Stenosis After Low Anterior Resection
Miguel A. Cuesta and Hugo W. Nijhof
Keywords Low anterior resection • Stenosis anastomosis • Endoscopic dilatation
First Patient
Diagnosis and Indication for Surgery
A 74-year-old female patient presented to our surgical outpatient clinic. Her prior
history stated an abdominal hysterectomy because of benign disease. Several times
previously she had been admitted with abdominal pain, situated in the left lower
quadrant. Earlier assessment had already revealed diverticular disease of the sigmoid for which conservative management had always been successful. Nonetheless,
due to repeated complaints and repetitive hospital admittance, a defi nite therapy by
means of sigmoid resection was agreed upon.
Operation
A laparoscopic sigmoid resection was initially intended; however, due to massive
adhesions a conversion to a classic sigmoidectomy by laparotomy was performed.
M. A. Cuesta , M.D. (*)
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
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_73,
© Springer International Publishing Switzerland 2014
391
392
https://t.me/med1917
M.A. Cuesta and H.W. Nijhof
The affected segment could be removed and enough length was obtained for creating a tension-free side-to-end anastomosis.
Postoperative Course: Identifi cation and Treatment
of Complication
The postoperative recovery was in the beginning uneventful. However, after 7
days the patient developed a fever and increased infection parameters, as revealed
in her laboratory results. A CT scan of the abdomen was performed that showed
fl uid and gas collection, suggestive of anastomotic leakage. A relaparotomy was
performed that revealed an anastomotic leakage. Because of the large anastomotic defect as well as abdominal fecal contamination, anastomosis was dismantled and defi nite colostomy was performed. Further clinical admission
occurred without complications, and the patient could be discharged 2 weeks
later. Six months after her last surgery, restoration of bowel continuity was
decided on, especially so since she expressed complaints, which were caused by
a large parastomal hernia. Surgery was performed in a standard fashion in which
the bowel continuity was restored by means of a circular stapling device. Further
hospital admittance was uneventful and during initial follow-ups the patient’s
condition steadily improved.
Four months later, she presented to our emergency ward with an acute onset
of abdominal pain, preceded by cramps for some time. She was admitted and on
CT scan of the abdomen with rectal contrast, a stenosis at the anastomotic site
with fecal impaction was observed (Fig. 73.1 ). She was treated with laxatives
Fig. 73.1 Enema showing
stenosis of anastomosis after
anterior resection
73 Case on Stenosis After Low Anterior Resection
https://t.me/med1917
Fig. 73.2 ( a ) Stenosis of
the anastomosis by
colonoscopy. ( b ) At
reoperation, stenotic segment
will be resected
a
b
393
after which normal defecation was restored. At colonoscopy, the stenosis was
treated by sequential endoscopic dilations (Fig. 73.2a ). During follow-up the
stenosis remained and complaints persisted. Finally, it was decided to perform a
re-anastomosis.
Surgery took place in a standard fashion, and the earlier performed anasto-
mosis was resected (Fig. 73.2b ). A side-to-end circular stapled anastomosis was
performed combined with a protective loop ileostomy. Her recovery was quick
and further hospital stay uneventful. The pathology report showed no signs of
394
https://t.me/med1917
Fig. 73.3 Enema showing
re-stenosis anastomosis
M.A. Cuesta and H.W. Nijhof
Fig. 73.4 CT scan showing
leakage at the place of
stenosed anastomosis
malignancy. Unfortunately, after a few months the original complaints returned.
A colonic X-ray with rectal contrast was performed. This showed a stenotic
anastomosis, necessitating repetitive endoscopic dilations again (Fig. 73.3 ). The
last endoscopic dilation had caused a small perforation, for which she was readmitted. A CT abdomen revealed a covered perforation, which could be managed
conservatively (Fig. 73.4 ).We then fi nally decided to perform a defi nite colos-
tomy and closure of the loop ileostomy, after which the patient was without
complaints.
73 Case on Stenosis After Low Anterior Resection
https://t.me/med1917
Second Patient
Diagnosis and Indication for Surgery
A 32-year-old secretary could not work for long periods because of endometriosis
complaints. Eventually, she was diagnosed having stenosis of the proximal rectum
with the endometriosis at the level of the recto-vaginal septum (Fig. 73.5 ). Hormonal
activity was blocked by Lukrin ® but patient had defecation complaints and a desire
to have children.
395
Fig. 73.5 MRI, recto-vaginal
endometriosis
396
https://t.me/med1917
M.A. Cuesta and H.W. Nijhof
Operation
Therefore, a laparoscopic operation was performed elsewhere, in which a partial
rectal resection had been performed along with a small resection of vaginal wall.
The vaginal wall was closed and rectal continuity was done by circular stapled
anastomosis.
Postoperative Course: Identifi cation and Treatment
of Complication
Patient developed a recto-vaginal fi stula and had to be treated by a loop ileostomy. After referral, 6 months later a relaparotomy was performed, dissection of
rectum distal of the fi stula was done, the vaginal wall closed, and an end-to-side
anastomosis with omentum interposition performed. After 3 months following a
control by rectal and vaginal examination, the loop ileostomy was closed.
During the postoperative period, the patient complained of thin defecation with
constipation. Referred to gastroenterologist for proctoscopy, he scheduled a
dilatation program after fi nding stenosis of anastomosis (Figs. 73.6 and 73.7 ).
After three dilatations to 1.5 cm patient was again referred to us because
Fig. 73.6 Stenosis by
colonoscopy of the
anastomosis after LAR
73 Case on Stenosis After Low Anterior Resection
https://t.me/med1917
Fig. 73.7 Enema showing
the distal stenosis
dilatation was not possible due to fi brotic ring. At rectal examination, stenosed
anastomosis was palpated at 4 cm from the anus and we proposed to perform
digital or by Hegar’s dilatation under anesthesia. Under anesthesia, the stenosis
could be dilated until an optimal size was gained without problems. Control of
anastomosis at 3 months remains patent.
397
Discussion
Anastomotic stenosis after colorectal resection occurs in up to 30 % of patients;
however, only 4–10 % of these are symptomatic [ 1 , 2 ]. Risk factors are male gender
and the use of a stapling device, which is nowadays used for most patients [ 3 ].
However, the majority of them do not need any intervention, and for those who do,
such can usually be managed by means of endoscopic dilatation. Success rates vary,
but are usually in the range of 88–100 % for benign strictures [ 2 , 4 , 5 ]. Complications
after endoscopic dilatation can be re-stenosis (11 %) and local perforation (5 %),
which both occurred in the fi rst case. If the patient is refractory to repeated endoscopic dilatation, resection of the affected anastomosis is usually the next step
(Illustration
73.1 ). A permanent colostomy, as was the case of the fi rst patient, is
rarely necessary, though. Moreover, if stenosis is palpable by digital examination,
doing digital dilatations under anesthesia qualifi es as a good and effective
treatment.
398
https://t.me/med1917
M.A. Cuesta and H.W. Nijhof
Stenosis
Illustration 73.1 Symptomatic stenosis of an anastomosis after LAR should be treated by endoscopic dilatations. If not successful, resection of the anastomosis should be done. If stenosis is
palpable by digital examination, digital dilatation under anesthesia is a good and effective
treatment
References
1. Schlegel RD, Dehni N, Parc R, et al. Results of reoperations in colorectal anastomotic stric-
tures. Dis Colon Rectum. 2001;44:1464.
2. Bannura GC, Cumsille MA, Barrera AE, et al. Predictive factors of stenosis after stapled colorec-
tal anastomosis: prospective analysis of 179 consecutive patients. World J Surg. 2004;28:921.
3. Matos D, Atallah ÁN, Castro AA, Silva Lustosa SA. Stapled versus handsewn methods for
colorectal anastomosis surgery. Cochrane Database Syst Rev. 2008;2:CD003144.
Dilatation
or
New
anastomosis
73 Case on Stenosis After Low Anterior Resection
https://t.me/med1917
4. Suchan KL, Muldner A, Manegold BC. Endoscopic treatment of postoperative colorectal anas-
tomotic strictures. Surg Endosc. 2003;17:1110–7.
5. Ambrosetti P, Francis K, De Peyer R, Frossard JL. Colorectal anastomotic stenosis after
elective laparoscopic sigmoidectomy for diverticular disease: a prospective evaluation of 68
patients. Dis Colon Rectum. 2008;51:1345–9.
399
Соседние файлы в папке Библиотека им академика М.И. Перельмана