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274 A.M. Abcarian and H. Abcarian
but the RUF is caused by subsequent prostatectomy, the outcome is better than
those in which the fistula occurs after external beam radiation or brachytherapy
[19].
Recurrence after repair of high suprasphincteric/extrasphincteric is uncommon
due to virgin territory for surgery in patients who have had multiple prior unsuccessful operations. The important point is to maintain the external drainage via
mushroom or Mallicot catheter for up to 2 weeks allowing the rectal wall repair to
heal before removing the catheter.
Recurrence after coloanal or ileoanal anastomotic repair can be minimized with
attention to meticulous technical detail. Other techniques such as pouch advancement advocated by surgeons in Cleveland Clinic can be utilized for such recurrences or as an alternative to the York Mason approach.
Sacoccygeal hernia has been reported by Arnaud and colleagues and is
anatomically related to disruption of the pelvic floor (levator ani) repair. This
complication has not been reported in any other series but if it were to occur,
documentation of the defect with pelvic CT or MRI is important. The defect can
then be repaired using biologic or synthetic mesh.
Personal View Due to the complexity of the operation, there is no extensive
body of literature reporting large patient series. Also in recent years, TEM, TAMIS,
and other platforms have offered alternative interventions to York Mason procedure. However, the procedure is still ideal for rectourethral fistulas, extrasphincteric
fistulas, and low anastomotic leaks. Also the sphincter sparing (modified York
Mason) procedure offers excellent exposure and is ideal for excision of retrorectal
(presacral) developmental cyst. The York Mason procedure is an excellent
addendum to the armamentarium of a colorectal surgeon. It is associated with
reasonably low complication, no significant long-term morbidity and no mortality.
With appropriate of patient selection the success rate can be very high (85%).
References
1. Kilpatrick FR, Mason AY. Post-operative recto-prostatic fistula. Br J Urol. 1969;41(4):649–
54.
2. Mason AY. The place for local resection in the treatment of rectal carcinoma. Proc R Soc
Med. 1970;63(12):1259–62.
3. Bevan AD. Carcinoma of the rectum: treatment by local excision. Surg Clin North Am.
1917;1:1223–39.
4. Corman ML. Carcinoma of the rectum. In: Colon and Rectal Surgery. 6th ed. p. 963.
5. Mason AY. Surgical access to the rectum: a transsphincter exposure. Proc R Soc Med.
1970;63:91–4.
6. Prasad ML, Nelson R, Hambrick E, Abcarian H. York Mason procedure for repair of
postoperative rectoprostatic urethral fistula. Dis Colon Rectum. 1983;26:716–20.
7. Wood TW, Middleton RG. Singe-stage transrectal transsphicteric (modified York-Mason)
repair of rectourinary fistulas. Urol. 1990;35(1):27–30.
8. Abel ME, Nelson RL, Prasad ML, Abcarian H, et al. Parasacrococcygeal approach for the
resection of retrorectal developmental cysts. Dis Colon Rectum. 1985;28:855–8.
15 York Mason Procedure 275
9. Singer MA, Cintron JR, Schoetz DJ, Abcarian H, et al. Retrorectal cyst: rare tumor frequently
misdiagnosed. J Am Coll Surg. 2003;196:880–6.
10. Allgöwer M. Sphincter-splitting approach to the rectum. Am J Surg. 1983;145(1):5–7.
11. Allgöwer M, Dürig M, van Hoschstetter A, Huber A. The parasacral sphincter-splitting
approach to the rectum. World J Surg. 1982;6(5):539–48.
12. Huber A, von Hochstetter A, Allgöwer M. Anatomy of the pelvic floor for
translevatoric-transsphincteric operations. Am Surg. 1987;53(5):247–53.
13. Huber A. Transsphincteric approach to the rectum. Ann Chir Gynaecol. 1986;75(2):106–10.
14. Arnaud A, Fretes IR, Joly A, Sarles JC. Posterior approach to the rectum for treatment of
benign lesions. Int J Colorectal Dis. 1991;6(2):100–2.
15. Qui HZ, Guo-Le L, Xiao Y, Wu B. The use of posterior transsphincteric approach in surgery
of the rectum: A Chinese 16 year experience. World J Surg. 2008;32(8):1976–82.
16. Poirier M, Abcarian H. Transsphincteric (York Mason) parasacrococcygeal approach:
outcomes of an old procedure with expanded indications. Submitted.
17. Fengler SA, Abcarian H. The York Mason approach to repair of iatrogenic rectourinary
fistulae. Amer J Surg. 1998;173:213–7.
18. Munoz M, Nelson H, Harrington J, et al. Management of acquired rectourinary fistulas:
outcome according to cause. Dis Colon Rectum. 1998;41:1230–8.
19. Dal Moro F, Mancini M, Pinto F, et al. Successful repair of iatrogenic rectourinary fistulas
using the posterior sagittal transrectal approach (York-Mason): 15 year experience. World J
Surg 1006;30(1):107–113.
Pull-Through Procedures
16
Kristin Vercillo and Jennifer Blumetti
Introduction
Operations that include complete or distal proctectomy with restoration of
gastrointestinal continuity at or below the level of the anorectal junction are referred
to as pull-through procedures. These resections may include mucosectomy or
intersphincteric resection of the proximal anal canal. Depending on the length of the
patient’s anal canal and the most distal extent of the resection, these anastomoses
typically occur less than 5 cm from the anal verge.
Indications and types of pull-through procedures are shown in Table 16.1. The
operations can be performed through a transabdominal or transanal approach,
depending on the disease process, resection, and intended reconstruction. In adults,
the most common pull-through procedures are coloanal and ileal pouch-anal
anastomoses (IPAA), typically done for rectal cancer and inflammatory bowel
disease, respectively. Perineal proctectomy is performed less commonly. In infants
and young children, the transanal endorectal pull-through, introduced in the late
1990s, has become standard for the management of Hirschsprung’s disease [1–3].
This one-stage procedure involving resection of the aganglionic segment and
pull-through of the normal ganglionic colon has also been shown to be safe and
effective in adolescents and adults diagnosed with Hirschsprung’s disease as well
[4]. Although the traditional transabdom inal endorectal pull-through procedures,
such as Swenson, Duhamel, and Soave, for Hirschsprung’s disease are less
K. Vercillo
Colon & Rectal Surgery Resident, Stroger Hospital of Cook County,
Chicago, USA
J. Blumetti (&)
Colon & Rectal Surgery Residency Program, Stroger Hospital of Cook County,
1900 W. Polk St., Room 406, Chicago, IL 606012, USA
e-mail: jblumetti5@gmail.com
© Springer International Publishing AG 2017
H. Abcarian et al. (eds.), Complications of Anorectal Surgery,
DOI 10.1007/978-3-319-48406-8_16
277
278 K. Vercillo and J. Blumetti
Table 16.1 Pull-through procedures and their indications
Procedure Indications
Coloanal anastomosis
Straight
Colonic J pouch
Ileal pouch-anal anastomosis Ulcerative colitis
Perineal proctectomy Rectal prolapse
Transanal endorectal pull-through Hirschsprung’s disease (children and adult)
Transabdominal endorectal pull-through
Swenson
Duhamel
Soave
Rectal cancer
Large rectal polyp
Rectovaginal fistula
Rectourethral fistula
Radiation proctitis
Hirschsprung’s disease (adult)
Slow transit constipation with megarectum
Familial adenomatous polyposis
Crohn’s disease (select cases)
Hereditary colon cancer syndrome
Congenital defects of colonic motility
Hirschsprung’s disease (children)
Severe/high imperforate anus (children)
common today, they remain the procedure of choice for high imperforate anus in
children, and many adult s will present to a colorectal surgeon with complications
from these operations later on [5–8].
Standard techniques to fashion the pull-through include both hand-sewn and
stapled anastomoses. Historically, a hand-sewn anastomosis was the standard
practice. Hand-sewn anastomoses can be interrupted or running, single- or
double-layered, and with a variety of absorbable and nonabsorbable sutures.
Intersphincteric resection or mucosectomy require a hand-sewn technique [9, 10].
Procedures such as the perineal proctectomy for rectal prolapse and the transanal
endorectal pull-through for Hirschsprung’s disease are also typically hand-sewn,
although stapled techniques have been described [11]. A recent Cochrane review
[12], analyzed 1233 patients who underwent colorectal resections with colorectal or
coloanal anastomoses and found no differences in all clinically relevant parameters,
including anastomotic leak, both clinically and radiographically, between
hand-sewn and stapled techniques.
The integrity of any anastomosis results from a complex interaction between the
surgeon, the patient, and the disease process. Ultimately, any one factor or a
combination of several may lead to a significant anastomotic complication after a
pull-through procedure (Table 16.2).
Complications following pull-through procedures may be acute (bleeding,
anastomotic disruption) or more insidious (chronic anastomotic sinus, stricture,
prolapse, incontinence, emptying issues). To manage acute and chronic complications appropriately, the surgeo n must take into account the clinical acuity and
severity of the complication. A current awareness of nonoperative, as well as
16 Pull-Through Procedures 279
Table 16.2 Factors influencing anastomotic complications following a pull-through procedure,
(Adapted from [108])
Surgeon factors
Intestinal blood supply
Tension on the anastomosis
Perioperative factors
Hypoxia
Resuscitation
Hypothermia
Patient factors
Age
Smoking
Alcohol and illicit drug use
Body mass index
Visceral obesity
Anesthesia severity assessment
Disease factors
Inflammatory bowel disease
Metastatic cancer
Medications
Steroids
Immunomodulators and biologics
Intraoperative factors
Blood loss
Blood transfusion
Duration of surgery
Choice of minimally invasive approach
Manipulation of tissue
Anesthesia severity assessment (ASA)
Nutritional status
Prior abdominal surgery
Medications
Antiplatelet therapy
Systemic anticoagulation
Radiation therapy
Emergency surgery
Extraperitoneal anastomosis
operative techniques, and their suitable indications to treat these complications is
crucial to minimize risk to the patient and the integrity of the original anastomosis,
while maintaining the best chance for gastrointestinal continuity.
Bleeding
Most bleeding after a gastrointestinal anastomosis is relatively minor and
self-limited, and does not require intervent ion. Rarely, clinically significant hemorrhage from an anastomosis can occur, ranging from 0.3 to 3.5% [13–18].
Transfusion requirements are typically less than 5% [14]. In a study of 1389 stapled
colorectal anastomoses, severe bleeding necessitating intervention occurred in only
seven patients (0.5%) [13]. Six (85.7%) of these seven patients’ bleeding resolved
with nonoperative measures, including endoscopy. No patient developed an anastomotic leak. In another series, transfusion alone with observation was successful in
6 of 17 bleeding patients (43%) [14]. Diagnostic and therapeutic modalities for the
bleeding patient may include observation, endoscopy, and transanal or abdominal
reoperative surgery.
Gentle endoscopic evaluation can be attempted in the stable patient with anastomotic site bleeding. A simple endoscopic washout of the anastomotic site may be
sufficient to stop the bleeding. Martinez-Serrano and colleagues [13] achieved
280 K. Vercillo and J. Blumetti
success in 5 of 6 patients (85.7%) with proctoscopy and washout with 2000–5000
ml of saline. All six patients presented with significant bleeding from the colorectal
anastomosis within the first postoperative day. Another valid option is irrigation of
the anastomosis with an enema of 1:200,000 epinephrine solution. This method
controlled bleeding in 80% of cases of J pouch bleeding following ileal pouch-anal
anastomosis in a series of over 1000 patients [15]. This method is preferred when
there is generalized oozing from the anastomosis rather than a distinct bleeding
point. Endoscopic submucosal injection of 10 ml of diluted epinephrine (1:200,000)
in saline at a discrete bleeding site along the anastomosis can also be performed
with good results [19].
The use of endoscopic hemoclips has been well described for both upper gastrointestinal pathology as well as colon diverticular bleeding [20, 21]. Endoscopic
clipping can be an alternative treatment modality for anastomotic hemorrhage,
although it has been described only in small case series [17, 18, 22]. One case report
describes the successful use of an over-the-scope clip for severe bleeding from a
gastroenteral anastomosis [22]. Over-the-scope clips have also been successfully
utilized for anastomotic dehiscence in low colorectal anastomoses [23, 24]. These
clips should be able to be applied in the case of bleeding from an anastomosis as
well.
Endoscopic electrocoagulation using hot biopsy forceps has been utilized in the
treatment of anastomotic bleeding, although care must be taken in the early postoperative period [18]. Cirocco and Golub [14] successfully applied endoscopic
electrocoagulation in six patients with unremitting bleeding from a colorectal
anastomosis. However, one patient did develop an anastomotic fistula following
this technique. Lou et al. [ 17 ] reported the endoscopic management of anastomotic
bleeding in six patients following low anterior resection for rectal cancer, four of
which were successfully treated with electrocoagulation alone.
Most patients with anastomotic bleeding can be managed successfully with
nonoperative therapies. Lian and colleagues [16] reported a 96% success rate in the
setting of bleeding ileal pouch-anal anastomoses using cauterization, clips, or
epinephrine injection. If nonoperative measures fail, then surgical intervention will
be necessary. Transanal oversewing of the anastomosis is the ideal option for
surgical control of bleeding in the setting of pull-through procedures. If hemostasis
and a secure anastomosis cannot be maintained, then anastomotic revision with
resection and re-stapling is an option [18]. In the setting of significant
intra-abdominal bleeding, transabdominal explor ation and hemostasis with resection of the anastomosis may be necessary. The surgeon should always consider the
possibility that postoperative bleeding may be secondary to a disrupted suture or
staple line of the coloanal or ileoanal anastomosis. If this separation is caught early
before pelvic sepsis has supervened, it may be controlled with transanal placement
of sutures to repair the defect [25].
16 Pull-Through Procedures 281
Anastomotic Disruption
Anastomotic leak remains a major complication of intestinal surgery that increases
postoperative morbidity, mortality, and resource utilization [26, 27]. Overall incidence varies widely in the literature, occurring in 3–23% of patients, with low
colorectal and coloanal anastomoses posing the highest risk [28–30].
The presentation and severity of anastomotic leak following a pull-through
procedure is diverse. Some patients present with hemodynamic instability and
peritonitis, while others have a more insidious course. Management is guided by the
patient’s clinical picture and type of leak, with the goal being preservation of the
anastomosis, if possible, and restoration of gastrointestinal continuity with good
functional outcomes.
Operative Interventions
Hartmann’s procedure is no longer considered the treatment of choice for anastomotic leak after a pull-through procedure, with the focus now on preservation of the
anastomosis [31–33]. Although a Hartmann’s procedure may still be required in the
unstable patient with profound sepsis or ischemia [34], the likelihood that the patient
will undergo subsequent reversal of the colostomy is less than 50% [35–37].
Many contemporary surgeons now advocate the use of a “divert and drain”
approach for those patients requiring reoperation for a leaking extraperitoneal
anastomosis [27, 33, 38–40]. This strategy involves proximal fecal diversion with
loop ileostomy, if not already present, and pelvic drain placement without
manipulation of the anastomos is. Healing rates with this technique have ranged
from 54 to 100% [31, 41]. Further repair of the anastomosis is not typically
required. This treatment modality results in a much higher likelihood of stoma
reversal than resection [42]. Diversion and external drainage can be supplemented
as needed with additional nonoperative interventions, which are described below.
Although a simple transanal suture repair of the anastomotic defect may seem
appealing, this method is not well supported in the literature. The opposition to this
technique is based on possible exacerbation of the problem by creating further
ischemia of the disrupted segment [43]. However, single case reports have been
described with either the standard transanal technique or transanal endoscopic
microsurgery [44, 45].
With the increasing incidence of laparoscopic colorectal operations today, a
laparoscopic approach to reoperation may be performed. 16 of 18 patients who
required reoperation for anastomotic leak were managed laparoscopically with
ileostomy and operative drainage in one study [32]. Eighty percent of those patients
were able to undergo subsequent stoma reversal. Should reoperation be necessary
for an anastomotic leak, the procedure must minimize manipulation of the anastomosis, which will limit morbidity and incre ase the chance of successful restoration of gastrointestinal continuity.
282 K. Vercillo and J. Blumetti
Nonoperative Interventions
Nonoperative interventions can be employed in the vast majority of patients with
proximal fecal diversion, and in select patients without proximal diversion [31, 38,
39]. In the sett ing of a contained pelvic leak, treatment opti ons include transanal or
percutaneous drainage of the pelvic fluid collection along with antibiotics, and/or
newer endoscopic therapies.
Transanal drainage through the anastomosis is a well-described technique in the
management of low colorectal, coloanal, or ileoanal anastomotic leaks. A Foley
catheter may be placed into the leaking anastomosis, secured, and subsequently
irrigated every 6 h [46]. Over the next 1–2 weeks, the cavity ideally decreases in
size and the catheter is removed. Sirois-Giguere et al. [47] reported their experience
with 37 symptomatic anastomotic leaks following low anterior resection for rectal
cancer. The majority of patients (58%) with diverting stomas were managed with
transanal drainage alone, compared with 9% without a diverting stoma. In those
patients, Malecot catheters or closed suction drains were placed across the anastomotic defect. No patients who underwent transanal drainage required a transabdominal intervention, although 50% required an additional local intervention. Of
the treatment modalities applied, transanal drainage was associated with the highest
rate of stoma closure (93%) [47].
With advances in interventional radiology, computer tomography guided percutaneous drainage is now a common approach to manage contained pelvic leaks
[47, 48]. A transgluteal or transabdominal drain can be placed, depending on the
location of the fluid collection. Judicious management of drainage catheters may
improve clinical outcomes. Ideally, the catheter should be flushed several times a
day to maintain patency. When comparing transanal and percutaneous drainage,
one study found no difference in success rates between the two techniques in
patients with ileoanal anastomoses [49]. However, in contrast to internal transanal
drainage, external percutaneous drainage carri es the risk of developing an enterocutaneous fistula, although this occurs rarely [50].
Endoscopic therapies allow for minimally invasive management of anastomotic
defects, and may be used independently or in conjunction with the above drainage
procedures. The application of endoclips may close a leaking anastomosis.
Over-the-scope clips are preferred to standard clips, as standard clips have a low
closure force and are limited in size [51]. Over-the-scope clips employ newer
technology using a nitinol clip loaded at the tip of the endoscope (OTSC, Ovesco,
endoscopy, Tubingen, Germany) [52]. The bowel wall is anchored with the device
and then suctioned as the clip is released. These clips are larger with increased
compression, allowing for more complete closure in the setting of an inflamed,
fibrotic anastomosis.
In a series of 188 patients with gastrointestinal defects, of which 50 involved the
colon and rectum, clinical success with OTSC placement was 92.7%. Twelve of 15
16 Pull-Through Procedures 283
lower gastrointestinal tract leaks healed using OTSC [24]. A smaller series of 14
patients with colorectal anastomotic leaks showed healing in 86% after OTSC. Only
two patients had a diverting stoma at the time of clip placement [23]. The OTSC
system should be used in anastomotic defects less than 1.5 cm in size and the
absence of a pelvic collection [23]. Percutaneous drains can be used as an adjunct to
clip application in the setting of a pelvic abscess, and a diverting stoma is not
required for successful treatment [52].
Endoscopic stenting across the anast omosis has also been used to treat colorectal
anastomotic leaks. Covered metal, plastic, and biodegradable stents have all been
used with 80–100% clinical success [30, 53–55]. They can be left in place for up to
50–60 days, and are removed once the anastomosis heals [30, 54]. However, this
technique is not typically useful following pull-through operations, as the distal end
of the stent must be 5 cm or more from the anal verge [54].
The latest endoscopic technique to manage a colorectal or coloanal anastomotic
leak is a corollary to the application of negative pressure wound vacuum devices for
subcutaneous wound closure. The endosponge is a small vacuum device placed
endoscopically into a defect or cavity. Weidenhagen et al. [56] pioneered this
method, which utilizes an open pored polyurethane sponge (B Braun Medical BV,
Melsungen, Germany), with an attached evacuation tube that is connected to a
vacuum drainage system. The sponge is placed via an introducer sleeve that is fitted
over an endoscope and placed through the anastomotic defect into the pelvic cavity.
The sponge is exchanged every 48–72 h, downsizing the sponge as the cavity size
decreases [56, 57]. The initial series consisted of 29 patients who underwent
endosponge therapy over a median of 34 days. The endosponge was discontinued
when the cavity was less than 1 cm in size. Overall, 28 patients (96.6%) healed the
anastomosis [56].
As transanal and percutaneous drainage may need to be coupled with an
endoscopic technique, combinations of different endoscopic therapies may lead to
successful healing of the anastomotic leak [55, 57]. If one endoscopic modality
fails, additional treatment with another technique is an option. Chopra proposed an
algorithm for endoscopic closure of anastomotic defects [53]. For those patients
with a defect greater than 2 cm, diverting ileostomy with endosponge therapy is
preferred. Treatment of choice for defects less than 2 cm in the mid-rectum is
endoscopic stenting with or without percutaneous drainage of the collection. Fibrin
sealant is preferred for small defects less than 3 ml without abscess. For those with
an abscess only, percutaneous drainage is preferred. Using this algorithm, 77% of
patients had restoration of bowel continuity compared to 57% of surgically managed patients (Hartmann’s procedure or diverting ileostomy alone) [53].
Proponents of early intervention and closure of the leaking anastomosis, such as
those described above, believe that the function of the neorectum will be improved
by earlier healing and less fibrosis. This approach prevents a persistent anastomotic
sinus, and also leads to increased stoma closure rates [2, 4, 5].
284 K. Vercillo and J. Blumetti
Chronic, Non-healing Cavity
Despite control of leak-associated sepsis with transanal or percutaneous drainage of
the fluid collection, there are still some patients whose anastomoses will not heal or
will develop a chronic sinus. These chronic tracts and/or cavities have been shown
to occur in up to 36% of anastomotic leaks [58]. Broder and colleagues [59]
recommend a contrast study prior to removal of a drain to evaluate for persistent
leak. Some patients, up to 8%, are asymptomatic and the sinus is found on contrast
enema prior to diverting ileostomy closure [31, 39]. For those patients with a
diverting stoma in place, a “watch and wait” approach can be used to manage these
sinuses. Some of these chronic sinuses will heal with time. However, the sequelae
of scarring and fibrosis may lead to impaired functional outcomes [60], resulting in
permanent stoma for many patients [58]. Up to 63% of patients with chronic
anastomotic sinuses will require multiple interventions [48, 58].
If the “watch and wait” approach is not successful, additional techniques may be
attempted to salvage the anastomosis. A transanal advancement flap may be used to
close the sinus. The technique of endorectal flap advancement is well described in
the treatment of ileoanal anastomotic sinuses [61, 62]. In a small series of patients
with persistent leaks after surgery for rectal cancer, four patients underwent delayed
repair using an advancement flap [45]. Three endorectal flaps and one dermal flap
were utilized after the sinus opening was excised. 50% had successful local treatment and underwent subsequent ileostomy reversal.
Marsupialization of the anastomotic sinus can be effective in the setting of a
large residual cavity. A common lumen is created using an endoscopic stapler,
electrocautery, or laparoscopic electrocautery scissors to incorporate the sinus into
the bowel itself [63, 64]. This procedure results in epithelialization of the cavity,
and the diverting stoma can then be reversed [63]. This technique has been utilized
successfully in coloan al and ileal pouch anastomoses. Fibrin glue injection can also
be effective in the treatment of chronic presacral sinuses, although only effective for
diminutive, narrow tracts [65].
Reconstruction
If the above methods fail to resolve the leak despite diversion, or if an operative
excision of the anastomosis was already urgent ly necessary, then a new reconstruction is the final treatment option to restore gastrointestinal continuity. Patients
should be counseled extensively on the risks of reoperation including the possibility
of permanent stoma. Most patients with coloanal anastomoses have already
undergone extensive splenic flexure mobilization to allow the proximal colon to
reach the pelvic floor without tension during their initial operations. After excision
of the leaking anastomosis, the remaining proximal bowel is unlikely to reach to the
pelvic floor without tension. Therefore, those with a failed coloanal anastomosis