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77 Case on Anorectal Adenocarcinoma in Colorectal Crohn’s Disease
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b
c
d
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e
Fig. 77.3 ( a , b , c , d , e ) External aspect of the tumor and cylindrical APR resection
Discussion
Looking at the history of this patient, it is important to know more data about the
risks factors for dysplasia and carcinoma and the incidence for adenocarcinoma of
the rectum and anus in Crohn’s colitis patients.
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a
cd
Fig. 77.4 ( a , b , c , d ) TRAM fl ap creation and vascularization of the fl a p
b
M.A. Cuesta and H.A.H. Winters
a b
Fig. 77.5 ( a , b ) Tram fl ap closing the perineal wound
Sjodhal et al. studied the incidence of rectal and anal cancer in Crohn’s patients
in Sweden [ 1 ]. During 1987–2000, rectal or anal cancer was diagnosed in 335
Crohn’s patients in Sweden (153 males, 182 females). In other words, approximately three Crohn’s patients per million inhabitants were diagnosed with rectal or
anal cancer each year during that time period, which amounts to 1 % of the total
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number of cases. Present knowledge from the literature implies that there is an
increased risk of rectal and anal cancer only in those Crohn’s patients having severe
proctitis or severe chronic perianal disease. However, the rectal remnant must also
be considered a risk factor. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer
at diagnosis. They suggest that six high-risk groups should be recommended for
annual surveillance after a duration of having Crohn’s disease for 15 years including extensive colitis, chronic severe anorectal disease, rectal remnant, strictures,
bypassed segments, and sclerosing cholangitis.
Maykel et al. studied the incidence of dysplasia and adenocarcinoma in specimens of patients operated on because of Crohn’s colitis, thereby trying to identify
risks factors associated with dysplasia and adenocarcinoma [ 2 ]. Two hundred
twenty-two patients of which 138 females who underwent surgical resection for the
treatment of Crohn’s colitis were included in the study. There were fi ve cases of
dysplasia (2.3 %) and six cases of adenocarcinoma (2.7 %). Three patients with
dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy, while the other cases were discovered incidentally on pathologic examination
of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years), longer disease
duration (16.0 vs. 10.1 years), and the extent of the disease. They concluded that
patients having severe Crohn’s colitis and requiring surgery are at signifi cant risk
for developing dysplasia and adenocarcinoma, particularly when diagnosed at an
older age, after a longer disease duration, and with more extensive colon
involvement.
References
1. Sjödahl RI, Myrelid P, Söderholm JD. Anal and rectal cancer in Crohn’s disease. Colorectal
Dis. 2003;5:490–5.
2. Maykel JA, Hagerman G, Mellgren AF, et al. Crohn’s colitis: the incidence of dysplasia and
adenocarcinoma in surgical patients. Dis Colon Rectum. 2006;49:950–7.
Chapter 78
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Case on Recto-Vaginal Fistula After LAR
Cristina Mendez and Miguel A. Cuesta
Keywords Rectal cancer • Low anterior resection • Protective ileostomy •
Rectovaginal fi stula • Neoadjuvant radiotherapy
Diagnosis and Indication for Surgery Identifi cation
of Complication
A 67-year-old female patient with a previous history of hysterectomy because of
uterine fi broid was diagnosed having a mid-rectal adenocarcinoma, stage T3N1M0.
By CT scan of her thorax and abdomen, no metastases were found, and the patient
was proposed for short neoadjuvant radiotherapy, 5 × 5 Gy, followed by low anterior
resection after an interval of 6 weeks. Her colon was mechanically prepared. At
operation, TME was performed open, without incidences, followed by a mechanical
end-to-side anastomosis protected by a temporarily loop ileostomy. On the 5th postoperative day she initially had vaginal loss of blood, and then leakage of fecal material through her vagina developed. By rectal and vaginal examination, the fi stula
was established at 7 cm from anus, probably at the level of the posterior fornix.
A CT scan confi rmed the diagnosis (Fig. 78.1a,b,c,d ). There were no abscesses.
Patient was referred to us for treatment.
C. Mendez , M.D. ()
Department of Surgery , Virgen del Rocio , Sevilla , Spain
e-mail: c.mendez10@hotmail.com
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_78,
© Springer International Publishing Switzerland 2014
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a
C. Mendez and M.A. Cuesta
c
d
b
Fig. 78.1 ( a – c ) Imaging by CT scan (and with enema) with rectal contrast the AVF. ( d ) Enema
with evidence for recto-vaginal anastomosis
Treatment of Complication: Operation
With assistance of the gynecologist, the patient underwent an exploration under
anesthesia. Colposcopy revealed a large fi stula of 3 cm between the anterior aspect
of the vaginal stump and the anastomosis, located at 7 cm from the anal canal. There
was no stenosis of the anastomosis and a proctoscopy showed no recurrence of
cancer. Patient had normal sphincters and had no problems with the feces continence. Cancer control by CT scan of thorax and abdomen showed no metastases.
A plan was designed to mobilize the splenic fl exure through laparotomy, dissecting
the descending colon, the fi stula, and the rectum distal of anastomosis until the pelvic fl oor. This was carried out without much fi brosis around the fi stula, the fi stula
was taken down, and the defect in the vagina was closed by the gynecologist. At the
level of the pelvic fl oor the distal rectum was divided, and we decided to perform a
pull-through procedure in order to avoid any anastomosis in front of the vaginal
suture line. The pull-through procedure was successful and after interposition of
omentum between vagina and neorectum, presacral space was drained and the laparotomy was closed. After 1 week, under anesthesia the superfl uous loop was shortened and fi xed by stitches at the level of the anus (Fig. 78.2 ). By rectal examination,
78 Case on Recto-Vaginal Fistula After LAR
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Fig. 78.2 Pull-through
before to be shortened
there was no stenosis and the loop was good vital. Patient could go home 2 days
later under the proviso that at the outpatient clinic we could by rectal examination
treat the tendency towards stenosis. Also, the gynecologist could check the vagina
and could observe the healing, thereby administering estrogen crème against atrophy. At last, 3 months after the fi rst operation, the ileostomy could be reversed.
Frequent defecation and some grade of soiling took place, treated by active pelvic
fl oor physiotherapy and thereafter remedied by lavage every 2 days. Patient was
happy with the solution and is still able to be sexually active.
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Discussion
There are three possible causes for the appearance of an anastomosis-vaginal fi stula
after LAR. First, a lesion on the vagina wall during dissection of the recto-vaginal
septum; second, when during the stapled anastomosis a piece of vagina wall is taken
with the anastomosis and will develop a fi stula; and third—the most dramatic—the
introduction of the circular stapler through the vagina and not through the rectum
(Illustration 78.1a ).
The easiest and most practical solution is to create a defi nitive colostomy
(Illustration 78.1b ), but many relatively young women ask for the solution of recon-
structing the vagina if so possible, without a defi nitive stoma. All risks involved
have to be shared with patients. Decisions will be taken during the operation. If
patient is already incontinent or has soiling, a colostomy is the only solution. In
other cases, reconstruction has to be performed, as took place in this patient. A good
alternative is to perform a distal stapled anastomosis (Illustration 78.1c ). But after
this pelvic anastomosis, risks for recurrence of fi stula are still present and therefore
the coloanal or pull-through is a good alternative with interposition of, e.g., omentum plasty (Illustration 78.1d ). Drawback here will be the continence. In the case of
frequent defecation or of incontinence, a colon lavage at home may be a good
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a
C. Mendez and M.A. Cuesta
b
cd
Illustration 78.1 ( a – d ) Different AVF and therapeutic solutions, from defi nitive colostomy to
coloanal anastomosis and pull-through procedure. Arrow is the fi stula
solution. If patient has the uterus in situ, this should be taken out for the
reconstruction.
Matthiessen et al. studied the occurrence and risk factors for this anastomoticvaginal fi stula (AVF) [ 1 ]. All female patients, median age 69.5 years, who devel-
oped a symptomatic AVF ( n = 20) after anterior resection of the rectum for cancer
were identifi ed and compared with those who developed conventional symptomatic
leakage ( n = 32) and those who did not leak ( n = 338). Symptomatic anastomotic
leakage occurred in 52 (13.3 %) of 390 patients. Twenty (5.1 %) had an anastomoticvaginal fi stula (AVF) and 32 (8.2 %) conventional leakage (CL). Patients with AVF
required unscheduled reoperation and defunctioning stoma as often as those with
CL. AVF was diagnosed later and more often after discharge from hospital
78 Case on Recto-Vaginal Fistula After LAR
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compared with CL. Patients with AVF had lower anastomoses and decreased BMI
compared with those with CL. Risk factors for AVF in multivariate analysis were
anastomosis <5 cm above the anal verge preoperative radiotherapy and UICC cancer stage IV. Previous hysterectomy was a risk factor neither for AVF nor for CL.
They concluded that anastomotic-vaginal fi stula forms a signifi cant part of all
symptomatic leakages after low anterior resection for cancer in women. Although
diagnosed later, the need for abdominal reoperation and defunctioning stoma was
not different from patients with CL.
Reference
1. Matthiessen P, Hansson L, Sjödahl R, Rutegård J. Anastomotic-vaginal fi stula (AVF) after
anterior resection of the rectum for cancer–occurrence and risk factors. Colorectal Dis.
2010;12:351–7.
Chapter 79
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Case on Rectovesical Fistula After LAR
Miguel A. Cuesta and R. Jeroen van Moorselaar
Keywords Rectal cancer • Neoadjuvant radiotherapy • Rectovesical fi stula • Low
anterior resection
Diagnosis and Indication for Surgery Identifi cation
of Complication
A 68-year-old man underwent a low anterior resection with a protective ileostomy by
open procedure because of mid-rectum adenocarcinoma after a short radiotherapy
treatment of 5 Gy 5 days. His postoperative course was complicated fi rst of all by a
leakage of the anastomosis (Figs. 79.1 and 79.2 ) treated by drainage and deviating
ileostomy. Secondly he developed fever and urinary tract infection, initially ascribed
to usual infection because of the bladder catheter, being treated by antibiotics, as
indicated by the culture. Moreover, the aspect of the urine was initially muddy, and
the culture included intestinal fl ora and vegetal fi bers (Fig. 79.3 ). Because of persis-
tent fever, a CT scan with rectal contrast was performed showing a fi stula communicating the rectal anastomosis with the bladder (Fig. 79.4 ). Cystoscopy showed the
fi stula 2 cm at the level of the left ureter in the trigonum vesicae with staples inside
the bladder (Fig. 79.5 ). Patient was referred for surgical treatment and together with
the urologist a laparotomy was planned for taking down the fi stula and the stomas.
M. A. Cuesta , M.D. ()
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
R.J. van Moorselaar
Department of Urology , 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_79,
© Springer International Publishing Switzerland 2014
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Fig. 79.1 CT scan, leakage
of anastomosis with
pneumoperitoneum
Fig. 79.2 CT scan, leakage
of anastomosis LAR
M.A. Cuesta and R.J. van Moorselaar
Fig. 79.3 Aspect of the urine
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