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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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Fig. 75.5 Left ureter lesion,
observed after conversion,
due to a technical diffi cult
left hemicolectomy for
cancer
M.A. Cuesta
accounting for 14 of 70 (20.0 %) injuries. The location of ureteral injury was not
specifi ed in 46 of the 70 (65.7 %) cases. When location was specifi ed, injuries most
often occurred at or above the pelvic brim, accounting for 10 of the total 70 (14.3 %).
Electrocautery was involved in 17 of the 70 (24.3 %) cases of ureteral injury, but in
34 of the 70 (48.6 %) cases, the surgical laparoscopic instrument involved was not
reported. A laparotomy was used to repair the ureteral injury in 43 of 70 (61.4 %)
cases. Laparoscopically assisted vaginal hysterectomy was the leading procedure in
which injury occurred, and instruments involved in electrocoagulation were associated with the most injuries incurred during laparoscopic surgery.
Moreover, recently, the COLOR II group published the short-term outcomes of a
randomized study comparing the laparoscopic versus the open approached for rectal
cancer. Ureter injury has been reported in 1 % of the intervention, equal in both
groups [ 5 ].
Ureter lesion discovered during the operation should be solved together with the
urologist during the operation (Fig. 75.5 ). Lesions diagnosed in a late period should
be also treated together with the urologist. Treatment includes from double J-stent
and dilatation to percutaneous nephrostomy and eventually nephrectomy.
75 Case on Ureter Lesion During Laparoscopic Low Anterior Resection
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413
References
1. Lent V, Pichlmaier H, Baumbusch F, et al. Urologic errors in surgical procedures. Chirurg.
2008;79:854–8.
2. Soong YK, Yu HT, Wang CJ, et al. Urinary tract injury in laparoscopic-assisted vaginal hyster-
ectomy. J Minim Invasive Gynecol. 2007;14:600–5.
3. Ostrzenski A, Radolinski B, Ostrzenska KM. A review of laparoscopic ureteral injury in pelvic
surgery. Obstet Gynecol Surv. 2003;58:794–9.
4. Léonard F, Fotso A, Borghese B, et al. Ureteral complications from laparoscopic hysterectomy
indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300
patients. Hum Reprod. 2007;22:2006–11.
5. Van der Pas MHGM, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal
cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol.
2013;14(3):210–8.
Chapter 76
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Case on Late Ileoanal Pouch Anastomosis
Fisteling (Vaginal and Perineal)
Miguel A. Cuesta
Keywords Ileoanal pouch • Fistula • Pouch-vaginal fi stula • Perineal fi stula •
Pouchitis
First Patient
Diagnosis and Indication for Surgery
A 26-year-old man underwent 5 years previously a laparoscopic-assisted panproctocolectomy with an ileoanal pouch anastomosis (IAPA) because of an intractable
ulcerative colitis (UC) with a protective loop ileostomy. After 6 weeks, the ileostomy was closed and patient started having frequent stools, was treated by diet and
Loperamide until gaining an optimum of 4–6 defecations a day.
Postoperative Course: Identifi cation and Treatment
of Complication
Patient was doing well, could work in the construction company of his father, and
up until 5 years later, he developed a perineal abscess, which initially drained spontaneously, as well as getting a suprasphincteric fi stula (Fig.
this complication, we considered the presence of an indeterminate kind of colitis or
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_76,
© Springer International Publishing Switzerland 2014
76.1a, b ). Because of
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Fig. 76.1 ( a ) MRI showing a
suprasphincteric fi stula to the
pouch. ( b ) MRI,
suprasphincteric fi stula to the
pouch
M.A. Cuesta
a
b
of a Crohn’s disease that had been improperly determined 5 years previously.
Review of pathology remained inconclusive. An endoscopy of the pouch showed
important pouchitis as treated by antibiotics (Fig. 76.2 ). The biopsy was negative
for granuloma. The fi stula was treated conservatively by means of a seton, but leakage from the fi stula increased. Thoughts arose about repair, such as closing the fi stula by a gracilis muscle plasty or an ileostomy. The patient’s desire was very clear
“to continue without defi nitive ileostomy”. Two months later, he suddenly became
sick with fever and a new perineal abscess. Despite the drainage of the abscess with
different tracks, the patient became septic with respiratory insuffi ciency and he had
to be ventilated mechanically for 10 days. A CT scan showed no pelvic abscesses.
Because of the extensive perineal infection occurring during this period, we decided
to perform a laparotomy with excision of the pouch and creation of an ileostomy
(Illustration 76.1 ). Pathology showed chronic and acute pouchitis without granulo-
mas. They could not typify the fi ndings as Crohn’s disease. Steadily but slowly the
patient recovered and the perianal fi stulas closed. He is currently working again and
no signs of Crohn’s disease have appeared.
76 Case on Late Ileoanal Pouch Anastomosis Fisteling (Vaginal and Perineal)
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Fig. 76.2 Endoscopy of the
pouch showing pouchitis
with fi stula opening
Second Patient
A 40-year-old lady had previously been treated because of ulcerative colitis by
means of panproctocolectomy and IAPA. Seven years later, she experienced small
leakages of intestinal contents through her vagina. Patient was referred to discuss
with her about the option to close the fi stula. After examination, the fi stula appeared
to be very tiny, localized proximal of the sphincters, leading to small losses through
her vagina, and that not on all days. So, we proposed her to close the fi stula by
means of an interposition of bulbocavernous muscle and Martius plasty protected
by a temporarily ileostomy (Illustration 76.1 ). She refused to undergo the ileostomy
because of her limited complaints.
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Third Patient
An 18-year-old young man had been referred to us because of intractable ulcerative
colitis. He underwent a panproctocolectomy followed by an IAPA and protective
ileostomy. After closure of the ileostomy, the patient developed chronic pain at the
perianal region and diarrhea. Endoscopy of the pouch showed pouchitis, to be
treated conservatively. One year of conservative treatment and analysis followed, in
which patient had continuous problems to maintain his weight and do his studies.
A second opinion was asked from an experienced surgeon who opened the possibility of chronic infection around the pouch with a 3-cm rectum anastomosed to the
pouch. Patient accepted a new operation under this diagnosis.
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M.A. Cuesta
Illustration 76.1 In case of fi stulas ( arrow ) forming after IAPA, after an attempt to treat them
conservatively, the only real treatment will be to create a defi nitive ileostomy. Frequently, surgeons
will leave the anus of the patient after dismantling the ileoanal anastomosis. This will lead to frequent abscesses at the top of the stump that requires frequent drainage and may lead to chronic
sinus and diffi cult solution
76 Case on Late Ileoanal Pouch Anastomosis Fisteling (Vaginal and Perineal)
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At operation, the pouch was dissected free from the pelvis, the rectal rim shortened, and after regaining enough length the pouch was anastomosed to the anus. No
abscesses were found. Cultures were negative. Presacral space was drained. Yet,
complaints returned and fi nally the patient was treated by a defi nitive ileostomy,
successfully commencing with his studies.
419
Discussion
Indications for panproctocolectomy and IAPA appears to be an intractability of the
UC, malignancy, or suspicion for in UC and familial adenomatous polyposis coli
(FAP). Some authors will also have performed an IAPA by Crohn’s colitis after
relapse of the disease for many years. Problems arise when patients start forming
fi stulas years after an IAPA. Surgeon and gastroenterologist will then immediately
think about the possibility of a wrong diagnosis and will ask the pathologist for a
review. Intermediate colitis is another possibility here, forming 10 % of all colitis.
In case of fi stulas forming after IAPA, after an attempt to treat them conservatively,
the only real treatment will be to create a defi nitive ileostomy. Frequently, surgeons
will leave the anus of the patient after dismantling the ileoanal anastomosis. This
will lead to frequent abscesses at the top of the stump that requires frequent drainage and may lead to chronic sinus and diffi cult solution.
Lolohea et al have reviewed the incidence and treatment of the ileal pouch anal–
vaginal fi stula [ 1 ]. Fistula between an ileal pouch and the vagina is an uncommon
complication and its optimal management has not been determined because of its
low incidence. Pouch-vaginal fi stula occurs in 6.3 (range, 3.3–15.8) percent of
female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors
are the most common contributors. Management depends on the level of the fi stula,
the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical
treatment is suggested, including interposition of tissue and ileostomy and defi nitive ileostomy after excision of the pouch.
Johnson et al. reviewed the outcome and different treatment of these fi stula in
their institution [ 2 ]. They defi ned treatment success as no recurrence of the fi stula
anymore with an optimal functioning pouch and no ileostomy. 24 of 619 (3.9 %)
women who had primary ileal pouch-anal anastomosis developed a pouch-vaginal
fi stula. Local and/or combined abdomino-perineal repairs were performed in 22 of
29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs, 52.9 vs. 7.9 %, respectively, at 10 years
after repair. Overall, 50 % (11/22) of patients who underwent surgical repair of a
pouch-vaginal fi stula had a successful result with a functioning pouch and no recurrence of the fi stula, and 21 % (6/29) of patients required pouch excision. They concluded that the management of pouch-vaginal fi stula after ileal pouch-anal
anastomosis is associated with a high recurrence rate. Combined abdominoperineal
repair appears to offer better results than those of local procedures.
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M.A. Cuesta
Brown et al. reviewed the outcome of the ileoanal pouch in patients with Crohn’s
disease and indeterminate colitis [ 3 ]. Between 1982 and 2001, 1,270 patients under-
went a restorative proctocolectomy: 1,135 had ulcerative colitis, 36 had Crohn’s
disease, 21 had indeterminate colitis, and 78 had another diagnosis. Pouch complications were signifi cantly more common in patients with Crohn’s disease (64 %)
and indeterminate colitis (43 %) compared with patients with ulcerative colitis
(22 %). Similarly, 56 % of patients with Crohn’s disease had their pouch excised or
defunctioned, compared with 10 % of patients with indeterminate colitis and 6 %
with ulcerative colitis. The functional results in patients with Crohn’s disease with
a successful pouch were not signifi cantly different from those with indeterminate
colitis or ulcerative colitis. Although complication rates may be higher in patients
with indeterminate colitis compared with ulcerative colitis, the overall pouch failure
rate is similar. On the other hand, more than one-half of patients with Crohn’s disease will require pouch excision or diversion. They concluded that it is diffi cult to
identify patients with Crohn’s disease who are likely to have a successful outcome
after restorative proctocolectomy. Thus, Crohn’s disease should remain a relative
contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.
References
1. Lolohea S, Lynch AC, Robertson GB, Frizelle FA. Ileal pouch-anal anastomosis-vaginal fi s-
tula: a review. Dis Colon Rectum. 2005;48:1802–10.
2. Johnson PM, O’connor BI, Cohen Z, McLeod RS. Pouch-vaginal fi stula after ileal pouch-anal
anastomosis: treatment and outcomes. Dis Colon Rectum. 2005;48:1249–53.
3. Brown CJ, Maclean AR, Cohen Z, et al. Crohn’s disease and inderterminate colitis and the ileal
pouch-anal anastomosis: outcomes and patterns of failures. Dis Colon Rectum.
2005;48:1542–9.
Chapter 77
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Case on Anorectal Adenocarcinoma
in Colorectal Crohn’s Disease
Miguel A. Cuesta and Henri A.H. Winters
Keywords Colorectal Crohn’s disease • Adenocarcinoma rectum • TRAM fl ap
Diagnosis and Indication for Surgery
A 57-year-old man presented, who was known since 15 years to have a colorectal
Crohn’s disease. Because of complicated perianal fi stulas and stenosis in descending
colon, a left colonic resection had been performed 10 years previously with creation
of a colostomy, leaving 15 cm of rectum as stump. Although fi stulas became quite
prevalent, yet the patient had minimal complaints for a considerable period of time.
Eighteen months ago he developed pain in the anus and discharge of blood and
mucus.
By inspection there was a tumor around the anus with important chronic skin
irritation. Study of the rectum was diffi cult because of supra-anal stenosis and on
the CT scan and MRI, imaging suggested the existence of an extensive adenocarcinoma of the distal rectum and anus, without metastases in the lymph nodes of groins
(Fig. 77.1a, b ). Under anesthesia, biopsies were taken showing adenocarcinoma.
A PET CT scan showed a local hotspot but no distance metastases. Decision was
taken for doing a long chemo-radiotherapy followed 6 weeks later by a cylindrical
abdominoperineal resection with closure of perianal wound by means of a Tranverse
Rectus Abdominis Myocutaneous (TRAM) fl ap. Chemoradiation consisting of
daily administration of Capecitabine and 5 days weekly radiation fractions of 2 Gy
to a total amount of 50 Gy in 5 weeks.
M. A. Cuesta , M.D. ()
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
H. A.H. Winters
Department Plastic Surgery , VU University Medical Center , Amsterdam , The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_77,
© Springer International Publishing Switzerland 2014
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ab
Fig. 77.1 ( a, b ) MRI diagnosis of adenocarcinoma distal rectum and anal area
M.A. Cuesta and H.A.H. Winters
Fig. 77.2 Skin incision for
TRAM fl a p
Operation
Operation was performed together with plastic surgeon. Operation went without
complications (Figs. 77.2 , 77.3 , 77.4 , and 77.5b ). Pathological examination showed
a long adenocarcinoma, radical resected with 10 out of 23 lymph nodes affected by
cancer. Resection margins were free.
Six months later, the patient developed an epileptic attack being diagnosed for
having two metastases in the left lobe of the brain. Palliation radiotherapy was
given, but the patient died 3 months later without signs of local recurrence.
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