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stapler was inserted in the afferent loop. Using a double stapling technique the anastomosis was completed laparoscopically.
W.A. Bemelm a n
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperatively, a full diet was permitted at the fi rst day after surgery. At the 5th
postoperative day, she started to vomit, and physical examination showed a distended, but soft abdomen. Initially, she was treated with iv fl uids and nasogastric
drainage. Because of elevated temperature and C-reactive protein, a CT scan with
rectal and intravenous contrast was done the day thereafter. The CT scan revealed
limited contrast leakage at the right side of the colorectal anastomosis and signs of
small bowel obstruction.
A relaparoscopy was performed using the prior trocar sites. Blunt trocars were
inserted. A diffuse purulent peritonitis was found. Extensive laparoscopic rinsing
with warm saline was done and gradually the laparoscopic exposure improved. A
partially sealed of anastomotic gap of 0.5 cm was found and an internal herniation of
the small bowel via the mesenteric gap underneath the afferent colonic loop.
The small bowel was repositioned. A loop ileostomy was fashioned laparoscopically. The loop was opened externally and the efferent bowel loop was cannulated with
a Foley catheter. An anesthesia ventilation tube was inserted in the anus. Next the large
bowel was lavaged with saline until the lavage fl uid coming out of the anus was clear.
The fl uid leaking through the anastomotic gap was removed by laparoscopic suction.
A surgical drain was positioned next to the anastomosis using one of the trocar sites.
Seven days later she could be discharged without any further complication. Four
months later the ileostomy could be closed.
Discussion
Anastomotic leakage must be suspected if a patient cannot tolerate a normal diet
within a couple of days and has signs of infection. For this reason, earlier diagnosis
and reintervention might be expected after a laparoscopic operation. This earlier
reintervention might prevent severe generalized peritonitis and systemic sepsis.
Confi rmation of a anastomotic leak is best done by CT scan with intravenous and
enteral contrast.
During laparoscopic reintervention, the previous trocar wounds are used for
insertion of a blunt trocar, e.g., TrocDoc trocar ® (Storz; Tubingen, Germany), establishing the pneumoperitoneum [ 1 ]. The whole reintervention is performed laparo-
scopically, and the minilaparotomy used for specimen retrieval at the fi rst operation
can be opened only when necessary.
89 Case on Laparoscopic Approach of Anastomotic Leakage After Laparoscopic Resection
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Illustration 89.1 Afferent
loop exteriorized as an end
stoma
Rinsing
Loop
ileostomy
489
Reposition
Lavage
Drainage
The operative procedure consists of inspection and exploration, then culturing
and rinsing the abdominal cavity. Ileoanal, coloanal, and low colorectal anastomoses are diverted by creating a loop ileostomy and irrigation of the rest of the colon.
In patients with intra-abdominal located anastomoses with major breakdown, the
afferent loop needs to be exteriorized as an end stoma (Illustration 89.1 ). An end
colostomy is created in those with anastomotic leakage after left-sided resections
and an end ileostomy is created after right-sided resections.
If longstanding peritonitis with pus pockets and infl ammatory adhesions precludes adequate irrigation, an option is to insert a hand port via the (earlier used)
Pfannenstiel incision to facilitate irrigation and blunt separation of the bowel loops.
Wind et al. [ 2 ] showed that laparoscopic reintervention for anastomotic leakage
after primarily laparoscopic surgery is feasible and safe, with no conversions or
intraoperative complications observed. They demonstrated that a laparoscopic
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W.A. Bemelm a n
reintervention tends to be associated with less postoperative morbidity, a faster
recovery and fewer abdominal wall complications.
References
1. Bemelman WA, Dunker MS, Busch OR, et al. Effi cacy of establishment of pneumoperitoneum
with the Veress needle, Hasson trocar and modifi ed blunt trocar (TroDoc): a randomized study.
J Laparoendosc Adv Surg Tech A. 2000;10:325–30.
2. Wind J, Koopman AG, Van Berge Henegouwen MI, et al. Laparoscopic reintervention for
anastomotic leakage after primary laparoscopic colorectal surgery. Br J Surg
2007;94:1562–6.
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Case on Leakage Distal Anastomosis
After Low Anterior Resection
with Protective Ileostomy
Marta Gutierrez Moreno , Jurriaan B. Tuynman , and Miguel A. Cuesta
Keywords Rectal cancer • Radiotherapy • Low anterior resection • Laparoscopy •
Protective ileostomy • Leakage anastomosis
Diagnosis and Indication for Surgery
A 67-year-old woman was diagnosed of having a mid-rectal carcinoma at 9 cm of
the anal verge. By colonoscopy the tumor was biopsied, and two other polyps found
and resected at 35 and 55 cm. The two polyps were benign, middle grade of dysplasia, and the rectal tumor adenocarcinoma. On CT scan and MRI, the tumor was
staged as T3N1M0 (Fig. 90.1 ) and proposed to be treated by short scheme radio-
therapy of 5 × 5 Gy to be followed 6 weeks later by LAR. Patient was continent
before operation. Complying with recent national studies, no mechanical preparation was administered with exception of two enemas the previous night and another
the early morning of operation.
M. G. Moreno , M.D. ()
Department of Surgery , Virgen del Rocio , Sevilla , Spain
e-mail: dra_gutierrez_moreno@hotmail.com
J. B. Tuynman • M. A. Cuesta
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_90,
© Springer International Publishing Switzerland 2014
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Fig. 90.1 MRI rectum
carcinoma
M.G. Moreno et al.
Operation
She underwent a laparoscopic low anterior resection with a side-to-end anastomosis. A protective loop ileostomy was created. No intraoperative complications were
noticed. Pathology showed a good response, being pT2N0.
Postoperative Course: Identifi cation and Treatment
of Complication
Treated by fast track, the second postoperative day, the patient had fl atus and already
passed stools. Discharge was planned for the 5th postoperative day, but the patient
referred abdominal pain. The next day her condition became worse with fever,
tachycardia, and increased CRP values up to 300. A CT scan showed leakage of the
anastomosis with fl uid collection around the anastomosis and pneumoperitoneum
(Fig. 90.2 and Fig. 90.3 ). Reoperation followed, showing a fecal peritonitis caused
by anastomosis leakage, half of circumference on posterior side. Patient was hemodynamically unstable during operation and surgeon decided to dismantle the anastomosis and create a colostomy in the left lower abdomen. Patient was postoperatively
septic, she was mechanically ventilated for 4 days, and fi nally she could step by step
be admitted to the normal ward. A long recovery period of 3 months followed. The
dehiscent laparotomy wound became a huge incisional hernia. Nine months after
the operation, a colorectal anastomosis was performed leaving the ileostomy as protection. Three months later, after control of the anastomosis (Fig. 90.4 ), ileostomy
was closed and the abdominal wall repaired by means of abdominal wall plasty, the
so-called component separation technique.
90 Case on Leakage Distal Anastomosis After Low Anterior Resection
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Fig. 90.2 CT scan
pneumoperitoneum
493
Fig. 90.3 CT scan leakage of
the anastomosis
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Fig. 90.4 Control enema,
anastomosis is patent and
there is no leakage
Discussion
M.G. Moreno et al.
Question is what to do with a patient having a leakage after LAR in whom anastomosis was already protected by means of a loop ileostomy? In the patient here presented, the colon was not standard mechanically prepared before operation. It is
clear that in this way the colon had remained full of stools. Theoretically, the ileostomy will not protect the low anastomosis from stools once leakage happens.
Three interesting studies shed light on this subject. First, Matthiessen et al.
described in a randomized study the value of defunctioning stoma to protect the
LAR anastomosis [ 1 ]. The study included a total of 234 patients undergoing LAR
in two groups with or without defunctioning stoma. In all patients, the colon was
mechanically prepared (MBP). A total of 19.2 % of symptomatic leakages were
recorded, whereby 10.3 % in the stoma group and 28 % with no-stoma group.
Moreover 8.6 % patients needed a reoperation in the stoma group versus 25.4 % in
the no-stoma group. Their conclusion was that a defunctioning loop stoma decreased
the rate of symptomatic anastomotic leakage and is therefore recommended in low
anterior resection for rectal cancer.
Second, the national Dutch study included a total of 1,431 patients to be randomized with and without mechanical preparation for colon and rectum surgery. Primary
point of the study was anastomotic leakage, and at the 24th day postoperatively, the
rate of leakage was found not to differ between the two groups, of which 4.8 % of
those who had mechanical preparation and 5.4 % in those who did not. Patients with
mechanical preparation and leakage had fewer abscesses than those not prepared.
Moreover, other septic complications and mortality did not differ between the two
90 Case on Leakage Distal Anastomosis After Low Anterior Resection
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495
groups [ 2 ]. The conclusion of this study was that classical mechanical preparation
can be abandoned.
As a part of this trial, a sub-study was done with 449 patients who underwent a
LAR with and without mechanical preparation, whereby 7.6 % leakages were found
with MBP and 6.6 % without. There were no differences in protective ileostomies
given during initial operation and the only factors related to leakage were the ASA
classifi cation and male gender. Conclusion was that MBP has no infl uence on incidence of anastomotic leakage in low colorectal surgery. Furthermore, omitting MBP
in combination with diverting ileostomy was found to have no infl uence on the
incidence of anastomotic leakage, septic complications, and mortality rate [ 3 ].
The third study, the French multi-institutional randomized study (GRECCAR
study) [ 4 ], contrarily dealt with the effect of MBP or of no MBP on the morbidity
and mortality of patients undergoing a sphincter-saving rectal resection because of
distal rectal cancer. A total of 178 patients, including 89 in both groups, were
included in the study. The overall and infectious morbidity rates were signifi cantly
higher in no-MBP versus MBP group, whereby 44 % versus 27 % and 34 % versus
16 %, respectively. Regarding both anastomotic leakage and major morbidity rates,
there was no signifi cant difference between no-MBP and MBP group: 19 % versus
10 % and 18 % versus 11 %, respectively. Mortality rate (1.1 % versus 3.4 %) and
mean hospital stay (16 versus 14 days) did not differ signifi cantly between both
groups. This study demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any signifi cant increase of anastomotic leakage rate. Thus, it suggests continuation of MBP
before elective rectal resection for cancer.
Another reason for administering MBP in those patients undergoing laparoscopic
approach will be the manageability to handle move the colon free of feces during
laparoscopic surgery. In spite of contradictory aspects of these trials, it seems logical to give MBP to patients undergoing LAR for rectal cancer with protective
ileostomy.
References
1. Matthiessen P, Hallbook O, Rutegard J, et al. Defunctioning stoma reduces symptomatic anas-
tomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter
trial. Ann Surg. 2007;246:207–14.
2. Contant CM, Hop WC, van t’ Sant HP, et al. Mechanical bowel preparation for elective colorec-
tal surgery: a multicentre randomized trial. Lancet. 2007;370:2112–7.
3. Van t’ Sant HP, Weidema WF, Hop WC, et al. The infl uence of mechanical bowel preparation
in elective lower colorectal surgery. Ann Surg. 2010;251:59–63.
4. Bretagnol F, Panis Y, Rullier E, et al. Rectal cancer surgery with or without bowel preparation:
The French GRECCAR III multicenter single-blinded randomized trial. Ann Surg.
2010;252:863–8.
Chapter 91
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Case on Leakage Distal Anastomosis
After Low Anterior Resection (LAR)
Without Protective Ileostomy
Marta Gutierrez Moreno , Jurriaan B. Tuynman , and Miguel A. Cuesta
Keywords Rectal cancer • Radiotherapy • Laparoscopic Low anterior resection •
Leakage anastomosis • CT scan • Ileostomy
Diagnosis and Indication for Surgery
A 70-year-old male patient—representative of an Asian enterprise—was diagnosed
of having a mid-rectal adenocarcinoma, staged as T3N0M0, hence being treated by
neoadjuvant radiotherapy, 5 × 5 Gy, and proposed to be operated 6 weeks later. On
proctoscopy and MRI, the tumor was located at 8 cm from anal verge. He was in
very good physical shape and had no known diseases nor any use of medication.
Operation
Operation was performed after a mechanical preparation by using two enemas. A
laparoscopic TME was performed after mobilization of splenic fl exure and anastomosed end-to-side fashion. Technically, anastomosis was performed without tension and donuts were intact. No protective loop ileostomy was created.
M. G. Moreno , M.D. ()
Department of Surgery , Virgen del Rocio , Sevilla , Spain
e-mail: dra_gutierrez_moreno@hotmail.com
J. B. Tuynman • M. A. Cuesta
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_91,
© Springer International Publishing Switzerland 2014
497
498
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M.G. Moreno et al.
Postoperative Course: Identifi cation and Treatment
of Complication
The 3rd day after operation, he developed fever, and under diagnosis of pneumonia, a thorax X-ray was performed showing an important pneumoperitoneum
(Fig. 91.1a ). On the CT scan with rectal contrast a leakage of anastomosis was
seen with perianastomotic abscess (Fig. 91.1b ). The same day, the surgeon decided
to approach him by relaparoscopy. During laparoscopy, a posterior leakage was
seen on the lateral aspect of the anastomosis with vital edges, the defect being
approximated by stitches. Also, a defunctioning loop ileostomy was created.
Postoperative course was complicated again by high fever, worsening of clinical
condition, and sepsis. Two days later, a new CT scan showed again the leakage of
anastomosis and abscesses in the pelvis with fl uid collections in the right abdomen
(Fig. 91.1c ). After discussion in the multidisciplinary meeting, the surgeon decided
to dismantle the anastomosis and create a defi nitive colostomy on the lower left
abdomen.
Subsequently, the patient had two stomas. During the new postoperative period,
a new CT scan was performed because of a new period of fever. A large right paracolic abscess was diagnosed and subsequently percutaneously drained (Fig. 91.2 ).
Patient did recover. After a period of 6 months, a new operation was performed to
close the ileostomy and repair the incisional hernia. After these operations he went
into retirement.
Discussion
Discussion pertains the protective effect of ileostomy (or transverse colostomy) on
the LAR anastomosis. The protection effect of stoma is an item already treated in
the case 90. Matthiessen et al. reported in their randomized study that patients
undergoing LAR with a protective stoma or without a protective stoma experience
a signifi cant lower leakage rate (10.3 % versus 28 %) and less necessity for reoperation (8.6 % versus 25.4 %) [ 1 ]. Moreover, there is much discussion about the mor-
bidity (and mortality) caused by these protective stomas, and the type of stoma,
ileostomy or transverse colostomy [
especially pertaining to those patients of male gender, smokers, and having undergone neoadjuvant chemoradiotherapy, it is advisable to protect the LAR anastomosis by a loop ileostomy. Probably the best will be to initiate a well-designed
randomized trial studying patients randomized for having an ileostomy or not and
with MBP or not.
1 – 3 ]. It is the general belief that after LAR,
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