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Chapter 74
https://t.me/med1917
Case on Problems After Coloanal
Anastomosis (Stenosis Coloanal Anastomosis
and Frequent Stools and Soiling)
Miguel A. Cuesta
Keywords Rectal cancer • Coloanal anastomosis • Stenosis anastomosis • Diffi cult
defecation • Incontinence
First Patient
Diagnosis and Indication for Surgery
A 62-year-old man was diagnosed of distal rectum cancer because of complaints of
tenesmus and blood in feces. A tumor was located very low, at 4 cm of the anal canal
and staged as T3-T4, N1 M0 by CT scan and MRI. The MRI revealed that the tumor
was not growing into the pelvic fl oor or in the external sphincter (Fig. 74.1 ).
Chemoradiation was proposed as neoadjuvant therapy followed by surgery 6 weeks
later. After chemoradiation, clinically and on MRI, it became clear that the tumor
showed a good regression grade.
Operation
An open TME resection was performed, the splenic fl exure mobilized, and an endto- side anastomosis transanally performed (Fig. 74.2 ). A deviation ileostomy was
created during the same operation.
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_74,
© Springer International Publishing Switzerland 2014
401
402
https://t.me/med1917
Fig. 74.1 MRI, distal rectal
cancer T3
M.A. Cuesta
Fig. 74.2 At operation,
coloanal anastomosis
74 Case on Problems After Coloanal Anastomosis
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403
Postoperative Course: Identifi cation and Treatment
of the Complication
Patient did well and went home after 10 days. At the outpatient policlinic, it became
clear from the beginning that the anastomosis was importantly stenosed (Fig. 74.3 );
consequently, attempts were made to dilate it under anesthesia. Because of the diffi culties to dilate it with Hegar’s dilators, a decision was taken to introduce a guide
wire and use the Savary’s dilatators, followed by manual dilations by means of the
fi nger (Illustration 74.1 ). The dilatation program took several weeks during which
biopsies were taken to rule out a recurrence of cancer. Finally, anastomosis was
considered open by rectal examination and proposed to close the ileostomy. After 5
months we could take down the ileostomy. Currently, the patient is doing fi ne,
despite some soiling, but still very happy that a defi nitive colostomy was not necessary. He also is visiting the urologist regularly for treatment of a mild impotency.
Second Patient
Diagnosis and Indication for Surgery
A 63-year-old female patient was diagnosed with having a distal adenocarcinoma of
the rectum. She suffered from claustrophobia and so it was very diffi cult to convince
Fig. 74.3 Proctoscopy
showing the stenosis of a
coloanal anastomosis
404
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Illustration 74.1 Stenosis of
a coloanal anastomosis
should be dilated by means of
digital dilatations or Hegar’s
dilators. If digital dilatations
are not possible, Savary’s
should be used. In a patient
with soiling and frequent
defecation after coloanal
anastomosis, lavage
procedure should be advised
Digital
dilatation
M.A. Cuesta
Hegar’s
her to undergo all studies and posteriorly to administer the neoadjuvant therapy in
the form of 5 × 5 Grays followed by intervention 6 weeks later. She had a younger
partner and wished to undergo an operation without defi nitive stoma.
Operation
The tumor was low, 3.5 cm from the anal canal, but she had good sphincters after
two previous deliveries. A new MRI after radiotherapy showed again that there was
no involvement of a tumor in the external sphincter or pelvic fl oor. Patient was told
that she had 50 % chance for getting a very distal anastomosis. A laparoscopic TME
was performed, after mobilization of splenic fl exure followed by a coloanal anastomosis. An ileostomy for deviation was created.
Postoperative Course: Identifi cation and Treatment
of the Complication
The patient did well, recovered, and she was put on a physiotherapy program for the
pelvic fl oor. Pathology showed a good distal margin of 1.5 cm and a CRM of 4 mm.
Three months later, the anastomosis was patent and the ileostomy was closed.
74 Case on Problems After Coloanal Anastomosis
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Thereafter, a diffi cult period for the patient took place, not due to incontinence but
caused by diffi cult defecation in spite of laxatives. Defecation was either interrupted
or diarrhea and we discussed with her the possibility of creating a colostomy. A
lavage of the neorectum was proposed and contrary to what we expected, the patient
is very happy with this therapy. All controls of cancer are good.
405
Discussion
These two cases illustrate certain diffi culties surrounding a coloanal anastomosis.
Important is to remark, that being this operation far from ideal,it is for many patients
a better solution than a APR. But is an operation with technical problems and functional diffi culties. Starting with the radiotherapy, radiotherapists will radiate not
only the intra-abdominal rectum but also the perineum. It is a diffi cult issue, but my
conjecture is that a radiated perineum will develop fi brosis and stenosis. Second, an
optimally vascularized descending colon is the most optimal segment of colon for
an anastomosis in an end-to-side fashion, protected by an ileostomy. The development of a presacral abscess can invalidate the advantages of a coloanal anastomosis;
thus, a good drainage of the space is important. Third, it is important to avoid the
development of stenosis, by carrying out rectal examination control. Moreover, pelvic fl oor physiotherapy and fi ber intake are important for an optimal defecation.
In my opinion, the second case shows the functional diffi culties female patients
have with coloanal anastomosis. Incontinence and disturbed defecation are the most
known problems. No defi nitive study about this point is available. Lavage of the
neorectum may be a good therapy for a patient with these problems.
Chapter 75
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Case on Ureter Lesion During Laparoscopic
Low Anterior Resection
Miguel A. Cuesta
Keywords Rectal cancer • Ureter lesion • Ureter stent • Ureterography •
Nephrectomy
First Patient
Diagnosis and Indication for Surgery
A 52-year-old healthy man was diagnosed having a high rectal cancer, staged as
T3N0M0, and was proposed to undergo a laparoscopic proximal mesorectal
excision.
Operation: Identifi cation and Treatment of Complication
During this operation—while dissecting from medial to lateral—the surgeon made
a perforation of the left ureter resulting in some leakage of urine. Urologist was
called for a cystoscopy and double J-stent. While waiting for the urologist, the intervention was continued by dividing the inferior mesenteric vessels and by dividing
the rectum at the proper level by means of endostapler. The urologist went on to
perform the cystoscopy and introduced a guide wire through the left ureteral orifi ce.
Using the guide wire, a double J-stent was introduced under laparoscopic vision
(Illustration 75.1 ). The stent went proximal without problems. The colorectal
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_75,
© Springer International Publishing Switzerland 2014
407
408
https://t.me/med1917
M.A. Cuesta
Illustration 75.1 Ureter lesion discovered during the operation should be solved together with the
urologist during the operation. Lesions diagnosed in a late period should be treated together with
the urologist. Treatment includes from double J-stent and dilatation to percutaneous nephrostomy
and eventually nephrectomy
surgeon closed the small ureteral defect by means of two reabsorbable 4.0 stitches.
After anastomosis, a drain was left in the pelvis.
Postoperative Course
The postoperative period went without problems, and the patient could be discharged on the 7th postoperative day. At the 4th postoperative week, an ultrasonography of the kidneys showed no dilatation of the left system, and at the 6th week, the
J-stent was retired through cystoscopy. After a period of 2 years, neither dilatation
of the ureter nor distance metastases have been observed.
Second Patient
Diagnosis and Indication for Surgery
A 59-year-old man experienced rectal blood loss and was diagnosed having a distal
rectal cancer staged as T3N1M0.
75 Case on Ureter Lesion During Laparoscopic Low Anterior Resection
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Fig. 75.1 CT scan
showing dilatation of the
left ureter after a LAR
409
Operation
After short period radiotherapy (5 × 5 Gy), and after an interval of 6 weeks, a laparoscopic total mesorectal excision (TME) was performed with an end-to-side coloanal anastomosis.
Postoperative Course: Identifi cation and Treatment
of Complication
The patient’s postoperative period was uneventful, and the postoperative stage was
pT2N0. During the fi rst postoperative control at 4 months, no distance metastases
were seen, yet there was dilatation of the left ureter (Fig.
retrograde ureterography by the urologist showed a stenosis of the left ureter at the
level of the previous dissection. Through a cystoscopy, a guide wire could be passed
through stenosis, and a double J-stent was placed (Fig. 75.2a, b ). After a period of 2
years during which the patient went through different episodes of ureter dilatation
and a recurrence of urinary infections, the urologist decided to perform a left
nephrectomy.
75.1 ). Consultation and
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M.A. Cuesta
Fig. 75.2 ( a , b ) CT scan, dilated system treated by a double J-stent
ba
Discussion
Ureter lesion during surgical interventions is more frequent than reported. It can
happen not only on the left side during gynecological or left colon and rectal operations but also at the right ureter during LAR as shown in Fig. 75.3 and managed by
a double J-stent or a leak from the left ureter diagnosed during postoperative course
because of fever and pain (Fig. 75.4 ).
It is remarkable that peroperative urological lesions are exclusively reported by
gynecologists. Data about urological complications during open and laparoscopic
operations, which are performed by colorectal surgeons, are scarcely reported.
Ureter lesions and bladder lesions can be recognized during an operation and then
repaired, as well as during the postoperative period because of leakage of urine
through the drains. Moreover, during follow-up, dilatations of the ureter and of the
renal pelvis may be seen caused by late ureter stenosis. This late complication forms
a diffi cult differential diagnosis between recurrent cancer and old ureter lesion by
means a clip, hyperthermia, or radiotherapy effect.
World literature published between 1966 and 2003 on ureteral injury during laparoscopic surgery was reviewed [ 1 – 4 ]. A total of 70 reported instances of ureteral
injury during laparoscopic surgery were identifi ed. In 18 of the 70 (25.7 %) cases,
the initial laparoscopic procedures during which ureteral injury occurred were not
described or specifi ed. In cases in which the type of laparoscopic surgery was specifi ed, 14 of the 70 (20.0 %) total cases of ureteral injury occurred during laparoscopically assisted vaginal hysterectomy (LAVH). Ureteral injury was identifi ed
75 Case on Ureter Lesion During Laparoscopic Low Anterior Resection
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Fig. 75.3 Double J-stent
introduced to treat a right
ureter lesion during an
anterior resection
411
Fig. 75.4 CT scan showing
leakage of contrast at the left
ureter after an anterior
resection
intraoperatively in 6 of 70 (8.6 %) cases; postoperatively in 49 of 70 (70.0 %) cases;
and, in 15 of 70 (21.4 %) cases, the time of diagnosis was not specifi ed. In instances
in which the types of injury were described, transection occurred most commonly,
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