Experience of a specialist centre in the management of anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma

Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

Computed Tomography Findings at 6th Month Related to Chronic Anastomotic Complications After Rectal Surgery

Objective

This study aimed to assess a radiologic test and clinical findings as risk factors of chronic complications after anastomotic leakage (CCAL) in rectal surgery.

Summary of Background Data

Anastomotic leakage (AL) is the most important complication that is related to chronic complications like unhealed chronic sinuses, strictures, and infections.

Methods

This retrospective study included patients who developed anastomotic leakage (AL) after undergoing extraperitoneal anastomosis. Patients with the following characteristics were excluded: (1) patients with no anastomoses, (2) patients undergoing multiple resections due to synchronous colorectal lesions, (3) patients with no curative resections of the primary lesions, and (4) patients experiencing immediate postoperative mortality. Finally, 72 patients were analyzed in this study. The patients were divided into the no chronic complication (NCC) group and the chronic complication (CC) group.

Results

Of the 72 included patients, 17 (23.6%) had CCAL. The patients in the CC group more frequently had radiotherapy and lower tumor compared to the patients in the NCC group. A total of 52 (52/55 [94.5%]) and 4 patients (4/17 [23.5%]) in the NCC group and the CC group achieved bowel continuity 3 years after the primary surgery, respectively (P < 0.0001). According to the multivariate analysis, CT findings at the sixth postoperative month and tumor height were associated with CCAL (P < 0.0001 and P = 0.046, respectively).

Conclusion

This study showed that CT findings at the 6th postoperative month and tumor height were possibly associated with CCAL.

Post surgical rectovaginal fistula: who really benefits from stoma diversion?

To analyze the role of stoma diversion and timing of stoma maintenance in the healing of post-surgical Recto Vaginal Fistulae (psRVF). A retrospective analysis of a prospectively maintained registry. All patients with a psRVF diagnosed at IRCCS Sacro Cuore-Don Calabria Hospital of Negrar di Valpolicella from January 2002 to December 2016 were analyzed. The baseline treatment was a fecal diversion. Patients were divided into two groups according to healing time: < 6 months (Group 1) or > 6 months (Group 2). 2043 women underwent rectal resections in the study period. We recorded 37 patients with psRVF (1.8%). Nineteen women (51.3%) healed (Group 1) within 6 months. The median time of psRVF recovery in group 1 was 99.7 days. Concomitant local treatment of the fistula did not influence the healing rate (p 0.8). Colostomies were significantly higher in group 1 (p 0.003). The size of the psRVF influenced the success rate of fistula healing with loop stoma (p 0.07). A multivariate analysis the presence of fever and pelvic abscess (pelvis sepsis) were significantly associated with diversion failure (p 0.035). A step-up approach with the maintenance of loop stoma at least for six months for all patients with psRVF could be changed. Patients with larger fistula and pelvic sepsis at index procedure should be addressed earlier to a specific second-level treatment.

Endoscopic Sinusotomy Using Needle Knife Technique for Treatment of H-Pouch With Leak and Sinus

A 62-year-old patient with a history of ulcerative colitis and total colectomy with ileal pouch-anal anastomosis was referred to our pouch center for rectal pain, loose stool, and perianal swelling. He was diagnosed with chronic fistula and anastomotic stricture for which he had excision of J-pouch and creation of H-pouch. Surveillance workup after surgery revealed pouch sinus, which was treated with needle-knife sinusotomy (NKSi). This is the first case in the literature of an H-pouch complicated with anastomotic sinus successfully treated with NKSi. We propose using NKSi as the preferred technique for pouch sinuses.

Endoscopic sinusotomy versus redo surgery for the treatment of chronic pouch anastomotic sinus in ulcerative colitis patients

BACKGROUND AND AIMS

Pouch sinus may be a serious adverse event in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic sinusotomy (ESi) and redo pouch surgery in the management of pouch sinus.

METHODS

All consecutive ulcerative colitis patients with chronic pouch sinuses treated with ESi versus redo surgery from 2006 to 2016 were identified. The primary outcomes were recurrence-free and surgery-free survivals. The secondary outcome was postprocedural adverse events.

RESULTS

This historical cohort study included 226 patients (ESi, n = 141; redo surgery, n = 85). Complete healing of the sinus was achieved in 75 patients (53.2%) and partial healing in 23 patients (16.3%) with ESi, and an initial complete healing (ie, no anastomotic leak before ileostomy closure) was obtained in 80 patients (94.1%) receiving redo surgery. Sinus recurrence after complete healing was seen in 17 patients (22.7%) treated with ESi and 28 patients (32.9%) treated with surgery (P = .15). Subsequent surgery was needed in 34 patients (24.1%) with ESi therapy and 18 patients (21.2%) with initial redo surgery (P = .70). Kaplan-Meier recurrence-free and surgery-free survivals after initial procedures showed no statistical difference between the 2 groups (P = .42 and P = .65, respectively). The rate of adverse events in the ESi group was significantly lower than that in the surgery group (2.5% vs 43.5%, P < .0001).

CONCLUSIONS

Recurrence-free and surgery-free survivals were comparable between patients treated with ESi and redo surgery, whereas pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.

Endoscopic Treatment of Ileal Pouch Sinus

BACKGROUND AND AIMS

Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus.

METHODS

All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival.

RESULTS

A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases.

CONCLUSIONS

NKSi is an effective and safe procedure for treating pouch sinus.

Characteristics of 18F-fluorodeoxyglucose uptake in anastomotic sinus and fistula following rectal cancer surgery

PURPOSE

To assess the characteristics of 18F-fluorodeoxyglucose (FDG) uptake in persisting anastomotic sinus and fistula following rectal cancer surgery.

METHODS

Eight patients with anastomotic sinus and fistula were retrospectively studied.

RESULTS

A total of 13 anastomotic sinuses (n=11) and fistulas (n=2) were observed. Sixteen FDG-positron emission tomography/computed tomography studies for 13 lesions performed and 26 uptake patterns were evaluated. Twenty-one lesions were found to have diffuse increased uptake, whereas four lesions had focal uptake. There was only one lesion without FDG uptake.

CONCLUSIONS

Increased FDG uptake is frequently observed in anastomotic sinus and fistula, which should be known to avoid making wrong diagnosis.

Persistent Asymptomatic Anastomotic Leakage After Laparoscopic Sphincter-Saving Surgery for Rectal Cancer: Can Diverting Stoma Be Reversed Safely at 6 Months?

BACKGROUND

Anastomotic leakage after rectal cancer surgery raises the problem of the timing of diverting stoma reversal.

OBJECTIVE

The purpose of this study was to assess whether stoma reversal can be safely performed at 6 months after laparoscopic sphincter-saving surgery for rectal cancer with total mesorectal excision in patients with persistent asymptomatic anastomotic leakage.

DESIGN

This was a retrospective analysis of a prospective database.

SETTINGS

The study was conducted at a tertiary colorectal surgery referral center.

PATIENTS

All of the patients with anastomotic leakage were treated conservatively after sphincter-saving laparoscopic total mesorectal excision for rectal cancer.

MAIN OUTCOME MEASURES

The main study measure was postoperative morbidity.

RESULTS

A total of 110 (26%) of 429 patients who presented with anastomotic leakage and were treated conservatively were diagnosed only on CT scan (60 symptomatic (14%) and 50 asymptomatic (12%)). During follow up, 82 (75%) of 110 anastomotic leakages healed spontaneously after a mean delay of 16 ± 6 weeks (range, 4-30 weeks). Among these patients, 7 (9%) of 82 developed postoperative symptomatic pelvic sepsis after stoma reversal. Among the 28 patients remaining, 3 died during follow-up. The remaining 25 patients (23%) presented with persistent asymptomatic anastomotic leakage with chronic sinus >6 months after rectal surgery. Stoma reversal was performed in 19 asymptomatic patients, but 3 (16%) of 19 developed postoperative symptomatic pelvic sepsis after stoma reversal (3/19 vs 7/82 patients; p = 0.217), requiring a redo surgery with transanal colonic pull-through and delayed coloanal anastomosis (n = 2) or standard coloanal anastomosis (n = 1). Regarding the 6 final patients, abdominal redo surgery was performed because of either symptoms or anastomotic leakage with a large presacral cavity.

LIMITATIONS

This study was limited by its small sample size.

CONCLUSIONS

In the great majority of patients with persistent anastomotic leakage at 6 months after total mesorectal excision, stoma reversal can be safely performed.

Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula

PURPOSE

Redo-surgery with new colorectal (CRA) or coloanal (CAA) anastomosis for failed previous CRA or CAA is exposed to failure and recurrent leakage, especially in case of rectovaginal fistula (RVF) or chronic pelvic sepsis (CPS). In these two situations, transanal colonic pull-through and delayed coloanal anastomosis (DCAA) could be an alternative to avoid definitive stoma. This study aimed to assess results of such redo-surgery with DCAA for failed CRA or CAA with CPS and/or RVF.

METHODS

All patients who underwent DCAA for failed CRA or CAA with CPS and/or RVF were reviewed. Success was defined as a patient without any stoma at the end of follow-up. Long-term functional results were assessed using the low anterior resection syndrome (LARS) score.

RESULTS

24 DCAA were performed after failed CRA or CAA with CPS (n = 15) or RVF (n = 9). Sixteen (67%) patients had a diverting stoma at the time (n = 5) or performed during DCAA (n = 11). After a mean follow-up of 29 ± 19 months, success rate was 79% (19/24): 5 patients had a permanent stoma because of recurrent sepsis (n = 2), anastomotic stricture (n = 1), or poor functional outcomes (n = 2). Functional outcomes were satisfactory (no or minor LARS) in 82% of the successful patients.

CONCLUSION

In case of failed CRA or CAA with CPS or RVF, DCAA was associated with a 79% success rate. It could therefore be proposed as an alternative to standard redo-CRA or CAA when the risk of recurrent sepsis and failure with subsequent definitive stoma is thought to be high.

Failing to reverse a diverting stoma after lower anterior resection of rectal cancer

BACKGROUND

A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma.

METHODS

This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma.

RESULTS

We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P < .001) and age older than 65 (odds ratio 2.76, 1.08 to 7.48, P < .036).

CONCLUSIONS

Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.