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S.S. Gisbertz
Concerning the second patient, no evidence exists for determining the optimal
time for surgery after such a severe period of toxic enteral symptoms—especially
when considering a colorectal anastomosis. Much depends on the nutritional status
of the patient and the extent of the disease. One has to continuously deliberate
regarding the need to remove the malignant disease, the risk of morbidity, and even
mortality due to the contemplated surgical procedure. Consideration must be taken
that most symptoms may have subsided after 2–6 weeks. Furthermore, we take into
account that the optimal time for surgery is approximately 6 weeks after chemoradiation therapy [ 1 , 3 ]. Finally, we note that safely performing an anastomosis in
selected cases has been confi rmed [ 1 , 4 ] .
References
1. Rodríguez ML, Martín MM, Padellano LC, et al. Gastrointestinal toxicity associated to radia-
tion therapy. Clin Transl Oncol. 2010;12:554–61.
2. Onodera H, Nagayama S, Mori A, et al. Reappraisal of surgical treatment for radiation enteri-
tis. World J Surg. 2005;29:459–63.
3. Lim SB, Choi HS, Jeong SY, et al. Optimal surgery time after preoperative chemoradiotherapy
for locally advanced rectal cancers. Ann Surg. 2008;248:243–51.
4. Goligher J. Irradiation proctitis and enteritis. In: Goligher J, editor. Surgery of the anus, rectum
and colon. 5th ed. London: Bailliere Tindall; 1984. p. 1047–57.
Chapter 87
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Case on Complications Following
Cytoreductive Surgery and Heated
Intraperitoneal Chemotherapy
Elisabeth A. te Velde and Victor J. Verwaal
Keywords HIPEC • Cytoreductuive surgery and heated intraperitoneal chemother-
apy • Complications • Anastomosis leakage • Colon cancer • Peritoneal
carcinomatosis
Diagnosis and Indication for Surgery
A 54-year-old male with colorectal cancer was treated with cytoreductive surgery
(CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC)
because of peritoneal carcinomatosis (Fig. 87.1 ). A left hemicolectomy was per-
formed with creation of a colostomy and closure of rectal stump and two more small
bowel resections.
Identifi cation and Treatment of Complication
After the initial surgery, the postoperative course was complicated by anastomotic
leakage and followed by two relaparotomies within a week (Fig. 87.2 ). Thereafter,
a high-output enterocutaneous fi stula developed (Fig. 87.3 ). After 4 months of con-
servative treatment, take-down of the fi stula, abscess drainage, and abdominal
wound by means of component separation technique (Ramirez abdominoplasty)
E. A. te Velde (*)
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: e.tevelde@vumc.nl
V.J. Verwaal
Department of Surgery , Antoni v Leeuwenhoek Hospital , 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_87,
© Springer International Publishing Switzerland 2014
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Fig. 87.1 HIPEC procedure
Fig. 87.2 By inspection,
necrosis small bowel loop
E.A. te Velde and V.J. Verwaal
Fig. 87.3 Temporarily
closure abdominal wall after
multiple laparotomies by
means of a mesh
87 Case on Complications Following Cytoreductive Surgery and Heated Intraperitoneal
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Fig. 87.4 Final aspect after
the component separation
technique (Ramirez plasty)
were performed (Fig. 87.4 ). Patient recovered. Two years after this complication,
the patient is doing well and without signs of recurrence.
Discussion
Peritoneal metastasis has traditionally been thought of as last stop in metastasis cascade and associated with a poor survival. Commonly, these patients would be treated
by systemic chemotherapy, which did not improve their survival signifi cantly—leading to a median survival quotient of approximately 7–12 months. Already, chemotherapy has been studied in the setting of peritoneal metastasis, but only in those
patients with measurable lesions; therefore, the effect of chemotherapy on peritoneal
metastases is mostly unknown. Patients having metastases that are confi ned to the
peritoneum can be treated with CRS and HIPEC. A prospectively randomized trial
has shown that the 5-year survival rate following CRS and HIPEC in a heterogeneous group of patients with peritoneal metastases is equal to that of following surgery for colorectal liver metastases [ 1 ]. After a median follow-up of 8 years and
provided that a macroscopic radical resection was achieved, a 5-year survival rate of
45 % was reached [ 2 ]. Other centers have confi rmed this survival rate [ 3 , 4 ].
Surgical resection of all macroscopic tumor tissue, i.e., resection of all affected
peritoneum—including exenteration, adnex extirpation, omentectomy, and peritoneal stripping on indication—is followed by a rinsing with heated (41 °C) chemotherapy (Mitomycin C ® or Oxaliplatin ® ) in order to eradicate all residual microscopic
tumor tissue. CRS and HIPEC are associated with high morbidity and mortality
rates (15–18 % and 5 %, respectively).
Serious complications following HIPEC are intestinal leakage and fi stula. During
the resection of all affected peritoneum, the serosa of the intestines is often damaged. These serosa defects should be meticulously repaired and sutured after the
rinsing with heated chemotherapy. Patients treated by cytoreductive surgery
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E.A. te Velde and V.J. Verwaal
combined with HIPEC are especially at risk for developing postoperative fi stulas,
because of possible microscopic residual tumors and due to extensive effect of former surgery and chemoradiation. Patients missing an intact peritoneal surface after
CRS and HIPEC and with intestinal leakage often will not have specifi c clinical
signs of peritonitis.
The percentage of fi stula after CRS and HIPEC varies between 0 and 26 % [ 5 ].
A series of all 306 patients treated with CRS and HIPEC at the National Cancer
Institute Amsterdam from 2000 to 2007, revealed 59 patients (19 %) with enterocutaneous fi stula. The 30-day mortality rate for this group was 0 %. These patients
were treated for pseudomyxoma peritonei in 39 % and for peritoneal carcinomatosis
in 61 % of the cases [ 6 ].
Importantly, fi stulas can lead to postponed adjuvant chemotherapy treatment and
therefore might infl uence prognosis.
References
1. Verwaal VJ, Van Ruth S, De Bree E, et al. Randomized trial of cytoreduction and hyperthermic
intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients
with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21:3737–43.
2. Verwaal VJ, Bruin S, Boot H, et al. 8-year follow-up of randomized trial: cytoreduction and
hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with
peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008;15:2426–32.
3. Hagendoorn J, Van Lammeren G, Boerma D, Van der Beek E, Wiezer MJ, Van Ramshorst B.
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcino-
matosis from colorectal and gastrointestinal origin shows acceptable morbidity and high sur-
vival. Eur J Surg Oncol. 2009;35:833–7.
4. Yan TD, Morris DL. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for
isolated colorectal peritoneal carcinomatosis: experimental therapy or standard of care? Ann
Surg. 2008;248:829–35.
5. Elias D, Goere D, Blot F, Billard V, Pocard M, Kohneh-Shahri N, et al. Optimization of hyper-
thermic intraperitoneal chemotherapy with oxaliplatin plus irinotecan at 43 degrees C after
compete cytoreductive surgery: mortality and morbidity in 106 consecutive patients. Ann Surg
Oncol. 2007;14:1818–24.
6. Burgers PTPW, van der Hoeven JAB, te Velde EA, et al. Kliniek en behandeling van postopera-
tieve enterocutane fi stels na cytoreductieve chirurgie gecombineerd met HIPEC. Ned Tijdschrift
v Oncologie. 2009;4:173–81.
Chapter 88
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Case on Postoperative Bleeding
of a Colorectal Anastomosis
Miguel A. Cuesta
Keywords Colon cancer • Diverticulitis • Laparoscopic resection • Sigmoid •
Rectal cancer • Bleeding anastomosis
First Patient
Diagnosis and Indication for Surgery
A 70-year-old man was diagnosed having a proximal rectal cancer staged as
T3N0M0 at 13 cm of the anal verge. At that time, he was a healthy person, not taking any particular medicine. It was proposed to perform a laparoscopic low anterior
resection.
Operation
The operation went without technical problems and after mobilization of the
splenic fl exure, a circular stapled side-to-end anastomosis was performed on him.
Donuts were held to be intact, and the methylene-blue test showed no leakage taking place.
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_88,
© Springer International Publishing Switzerland 2014
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M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
of Complication
At the 1st postoperative day, the patient started passing stools with some clots and
at the 2nd postoperative day it became clear that he was passing clots as well as
fresh blood. His hemoglobin count decreased 2 points and the surgeon decided to
perform a proctoscopy for inspecting the anastomosis. A bleeding was located at the
anastomosis, 7-cm of the anal verge, which became treated by adrenalin injection
and a clip. The bleeding then stopped.
Second Patient
Diagnosis and Indication for Surgery
A 56-year-old lady was diagnosed having a sigmoid stenosis as caused by recurrent
sigmoid diverticulitis. She had been treated conservatively for the past 3 years, but
the coming on of colics and constipation induced us to take a decision to operate
her. She was at that time still a healthy patient and only took oral medication for her
Diabetes Mellitus type 2.
Operation
A laparoscopic sigmoid resection was performed after mobilization of the splenic
fl exure, with a side-to-end anastomosis. The rectal superior artery was preserved for
a better vascularization of the rectum.
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperatively, the 1st day she passed stools and clots without a decrease of her
hemoglobin rate. The 2nd postoperative day she developed tachycardia and her
hemoglobin had decreased three points. We decided to perform an angiography
CT-scan, but no blush became visible. A sigmoidoscopy did show a multitude of
clots and gastroenterologist could not visualize a bleeding point. Because she was
considered hemodynamically unstable, we decided to reoperate. Through an
enlarged Pfannenstiel incision, anastomosis was observed and a clot in the anastomosis was found to be present. Furthermore, the anastomosis was resected and a
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new anastomosis was created in the same fashion. The ensuing postoperative period
was uneventful.
485
Discussion
The point of discussion is what to do about postoperative bleeding?
Customary advice at the moment of anastomosis is to go about inspecting the
anastomosis for bleeding and leakage. The problem arising during laparoscopic
colorectal surgery is the impossibility of inspecting the anastomosis if the surgeon
has not examined a low anastomosis by using a fl exible sigmoidoscope.
Shamiyeh et al. have described the use of the intra-operative endoscopy for the
assessment of circular stapled anastomosis in laparoscopic colon surgery [ 1 ]. The
aim of their study was to evaluate the impact of routine intra-operative endoscopy
on postoperative complications. They considered two groups of patients, the fi rst
group without use of endoscopy and the second group having undergone routine
endoscopy. They assessed each circular-stapled anastomosis with a fl exible endoscope for evidence of bleeding, integrity of mucosa, and leakage. In the group without endoscopy (253 patients), postoperative anastomotic bleeding was detected in
11 patients (4.3 %) and 7 (2.8 %) of these patients required endoscopic assessment
and clipping. In the group involving endoscopy (85 patients), at the time of surgery
the endoscopy showed anastomotic bleeding in fi ve patients (5.9 %), which required
clipping. Moreover, anastomotic leak was observed in two patients (2.4 %); in one
patient the circular staple line was oversewn and in the other patient the anastomosis
was redone. Two (2.4 %) patients in the endoscopic group had postoperative anastomotic bleeding requiring re-endoscopy and clipping.
The consideration at hand is that anastomotic bleeding and leakage can be
detected at an early stage by intraoperative endoscopic assessment of circularstapled anastomosis.
Martinez Serrano et al. analyzed the data of 1,389 colorectal procedures [ 2 ].
Their fi ndings were that severe postoperative hemorrhage took place in 7 (0.5 %) of
all patients. In all the seven patients the anastomosis had been stapled. In six of the
seven patients, bleeding resolved with conservative treatment including endoscopy.
Only one patient required surgical treatment. No mortality and no anastomotic leaks
befell these seven patients.
Linn et al. collected prospectively the data of 143 patients undergoing laparoscopic colorectal surgery with a left-sided stapled anastomosis [ 3 ]. Of these, 72
were operated on for benign disease and 71 for a malignant condition. Postoperative
anastomotic bleeding occurred in six patients (4 %). All were in the benign pathology group, and all had preservation of the inferior mesenteric artery during surgery.
None of the patients required operative intervention for staple line hemorrhage.
Another consideration is that anastomotic bleeding from a stapled anastomosis
in laparoscopic left-sided colorectal surgery appears to be an infrequent
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complication and it may be more common with preservation of the inferior mesenteric artery.
In the series of Malik et al. including 777 patients with severe postoperative
bleeding [ 4 ], repeated operations were necessary for six patients (0.8 %). In the fi rst
three cases involved, conventional reoperation was performed. In the latter three
cases, endoscopic therapy (adrenaline injection, diathermy, or endoscopic clipping)
was used to control the bleeding. No complications that were either patient or anastomosis related occurred as a result of endoscopic therapy.
References
1. Shamiyeh A, Szabo K, Ulf Wayand W, Zehetner J. Intraoperative endoscopy for the assessment
of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan
Tech. 2012;22:65–7.
2. Martinez Serrano MA, Pares D, Pera M, et al. Management of lower gastrointestinal bleeding
after colorectal resection and stapled anastomosis. Tech Coloproctol. 2009;13:49–53.
3. Linn TY, Moran BJ, Cecil TD. Staple line haemorrhage following laparoscopic left-sided
colorectal resections may be more common when the inferior mesenteric artery is preserved.
Tech Coloproctol. 2008;12:289–93.
4. Malik AH, East JE, Buchanan GN, Kennedy RH. Endoscopic haemostasis of staple-line haem-
orrhage following colorectal resection. Colorectal Dis. 2008;10:616–8.
Chapter 89
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Case on Laparoscopic Approach
of Anastomotic Leakage After
Laparoscopic Resection
Willem A. Bemelman
Keywords Crohn’s disease • Laparoscopic colon resection • Leakage anastomosis
• CT scan
Diagnosis and Indication for Surgery
A 32-year-old women with longstanding Crohn’s disease of the left colon required
surgery because of stenosis in the rectosigmoid of the colon causing obstructive symptoms. Endoscopic investigation had showed a narrowed lumen at 20 cm from the anal
verge. Passage of the endoscope was only possible using a pediatric endoscope indicating that the large bowel was segmentally affected from 15 to 35 cm from the anal verge.
Operation
Using a fi ve trocars approach, the affected bowel segment was dissected from medial
to lateral creating a wide submesenteric tunnel to mobilize the left colon adequately.
At that time, routinely the inferior mesenteric artery was ligated. Nowadays, this is
not considered appropriate in benign disease risking compromised vascularization
and leaving a large submesenteric window at risk of internal herniation. A close
bowel dissection of the mesentery is preferred in benign disease.
At the level of the upper third of the rectum, the rectum was transected using a
linear endostapler. The stapled bowel was exteriorized via a small Pfannenstiel incision. The bowel was transected at the upper part of the sigmoid, and the anvil of the
W.A. Bemelman , M.D., Ph.D.
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: w.a.bemelman@amc.uva.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_89,
© Springer International Publishing Switzerland 2014
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