Postoperative Intraabdominal Septic Complications in Crohn’s Disease

In patients with Crohn’s disease (CD) undergoing abdominal surgery, the reported postoperative intraabdominal septic complications including abscess and sepsis ranged from 2.7% to 16%. Following bowel resection, the overall incidence of severe intraabdominal septic complications, ranges between 6% and 13%. For ileocecal resections specifically, the rate of postoperative abdominal septic complications increased from 7% to 40%. For ileocolonic resection, postoperative intraabdominal septic complications differ between one-stage and two-stage procedures, rates 9% and 12%, respectively. Postoperative intraabdominal septic complications have a detrimental influence on the long-term outcome after intestinal resection in patients with CD, leading to increased number of reoperation and resulting in up to 50% of postoperative death.

The reported risk factors associated with a higher risk of postoperative intraabdominal septic complication include poor nutritional status, the presence of intraabdominal abscesses at the time of surgery, and systematic inflammatory status. In addition, preoperative use of corticosteroids and anti-TNF biologics are the risk of intraabdominal septic complications in patients with CD. Other reported risk factors of postoperative intraabdominal septic complications include low albumin levels and CD-related surgery history. However, it is controversial whether the preoperative use of anti-TNF biologics is indeed associated with postoperative infectious complications.

A postoperative intraabdominal septic complication can be suspected in patients with CD who have unexplained fever and/or an abdominal mass and could be demonstrated in those with abdominal drainage of abscess. Radiographic studies including computed tomography (CT) and magnetic resonance imaging (MRI) are important not only for the detection of abscesses but also for the identification of any associated fistulas, a finding which can guide the management of postoperative intraabdominal septic complications. CT and MRI are considered as the most sensitive and specific imaging tests for detecting postoperative abscesses. However, CT is preferred to be the initial diagnostic test of choice for detecting intraabdominal abscesses. Abdominal ultrasonography, with its lower cost and the lack of ionizing radiation, may be a reasonable diagnostic alterative for detecting intraabdominal abscesses.

Preoperative management, consisting of nutritional support, intravenous antibiotics, weaning off corticosteroids, immunomodulators, or biologics, and percutaneous drainage of abscess, is important in reducing postoperative intraabdominal septic complications. In patients at risk, construction of diverting stoma may help reduce the risk of postoperative intraabdominal septic complications. Traditionally, treatment of postoperative abdominal abscesses in CD includes use of antibiotic, percutaneous, or surgical drainage. Immunosuppressive therapy, which may be used to prevent recurrence of CD after adequate abscess drainage, should be withheld from patients with postoperative abscesses. After the initiation of antibiotic treatment, we should address the issue that whether abscess can be adequately drained. If abscess requires drainage, percutaneous route should be attempted first . Percutaneous drainage has been reported to be performed successfully in 74%–100% of cases in postsurgical CD-related abscesses, and is increasingly performed. ( Fig. 24.1 ). Anastomotic leak may cause abscess or enterocutaneous fistula ( Fig. 24.2 ). In addition, to percutaneous drainage, endoscopic drainage via placement of a pigtail stent through the leak may be attempted. This can be followed by an attempt of closure of the leak with over-the-scope clip system (please see Chapter 16 ).

Ileocolonic anastomosis leak leading to psoas abscess ( green arrows ) after resection for Crohn’s disease. (A) Abscess cavity shown with contrast administered via a catheter; (B) The abscess on CT; (C) Needle aspiration ( red arrow ) of the abscess.

Ileosigmoid anastomosis leak leading to enterocutaneous fistula after subtotal colectomy for Crohn’s disease. (A) The exit of the enterocutaneous fistula in surgical wound ( green arrow ); (B) The internal opening of the fistula from anastomotic leak ( yellow arrow ); (C) The fistula track on fistulogram ( red arrow ).

For severely ill patients, those who fail percutaneous drainage, or those with acute anastomotic leak, reoperation with anastomosis excision and stoma creation is generally recommended. Therefore, understanding indications and selecting proper patients are important for achieving better results in the treatment of postoperative abscess. A suggested management algorithm for the diagnosis and management of postoperative intraabdominal septic complications in CD patients is presented in Fig. 24.3 .

Proposed algorithm for the management of postoperative intraabdominal septic complications in Crohn’s disease.

Postoperative Intraabdominal Septic Complications in Restorative Proctocolectomy With Ileal Pouch

Pelvic septic complications after restorative total proctocolectomy and ileal pouch-anal anastomosis (IPAA) include abscess, sepsis, and fistula, which are the main causes of pouch failure. The high risk of development of sepsis or pelvic abscess remains to be a major challenge for construction of IPAA. The overall incidence of pelvic sepsis in the early postoperative period ranges from 5% to 7%. The incidence would increase from 15% to 24% following the pouch construction. Pelvic abscesses are also seen at a frequency of 4.8%–8% after IPAA. High-dose corticosteroid usage prior to surgery and patients with ulcerative colitis (UC) have been well demonstrated to be risk factors for the development of pelvic sepsis/abscess after undergoing total proctocolectomy and IPAA.

Patient with pelvic septic complications may present with symptoms and signs of sepsis, wound infection, and abdominal pain. CT scan can diagnose abscess and help guide its treatment. Pelvic septic complications can be managed with antibiotic treatment and drainage, including CT-guided interventional techniques and surgical drainage. However, only a minority of patients may be treated nonsurgically, and a majority of patients would require laparotomy for drainage of abscess and control of sepsis. The successful treatment of pelvic sepsis/abscess after IPAA generally requires a combined approach with colorectal surgeon, endoscopist, the interventional radiologist, and patient and family.

Examination under anesthesia (EUA) with endoscopy to identify potential anastomotic breakdown and fistula has been the standard of care for the initial management of pelvic sepsis after IPAA. In most cases, pelvic abscess can be drained by a transgluteal or direct path through the ilea pouch. For perianal drainage, the use of an 18-gauge needle to access the fluid collection, followed by and placement of 0.035-inch J-tip guide wire to thread through the needle, and advancement of a12-Fr pigtail catheter over the wire and into the fluid collection, is recommended. The catheter should be flushed several times a day with small amounts of saline solution to maintain patency. In clinical practice, it should be noted that, even after drainage has ceased or imaging has demonstrated resolution of the fluid collection, complete healing of the source of the leak, commonly a dehiscent suture line, may not occur. Therefore, before removing the catheter, an evaluation for persistent leak with fistulogram is recommended. For an abscess which persists despite repeated treatments with catheter drainage and antibiotics, a nonhealed leak should be considered and a further and more surgical intervention may be required. For patients which CT-guided drainage or minor surgery have failed or for those who deteriorate quickly with signs of generalized peritonitis, laparotomy is ultimately required, and reoperation is reported in approximately 24%–63% of the patients. Our suggested approach to postoperative management of septic complications in IPAA is outlined in Fig. 24.4 .

Proposed algorithm for the management of postoperative intraabdominal or pelvic septic complications in ileal pouch.

Postoperative Anastomotic Bleeding Surgery for CD

Purported risk factors associated with an increased risk for postoperative anastomotic bleeding were underlying disease and type of anastomosis. Stapled anastomosis is reported to carry a higher risk for postoperative anastomotic bleeding. End-to-side, circular, double-stapled ileocolonic anastomosis is prone to be associated with an increased risk of anastomotic bleeding compared with patients having other techniques of anastomosis.

Immediate postoperative anastomotic bleeding can usually be managed conservatively with close clinical observation, as it often stops spontaneously and severe bleeding is rare. For persisted bleeding, appropriate management includes diagnostic testing to locate the source of bleeding and a careful planning of therapeutic strategy. Although early postoperative colonoscopy, flexible sigmoidoscopy, or pouchoscopy seems to be aggressive, hemostasis via the endoscopy, including electrocoagulation, clipping, and mucosal sclerosis, is generally safe and effective in skilled and experienced hands. Colonoscopy also offers several advantages, including minimum invasiveness, requirement of no general anesthesia, avoidance of postoperative complications, and cost-effectiveness with a reduced length of hospital stay, as compared with reoperation. For those with anastomosis inaccessible to the endoscopic therapy, negative endoscopic evaluation, or massive bleeding, selective mesenteric angiography, or reoperation should be considered. The endoscopic or radiological interventions rarely cause intestinal ischemia or perforation. However, possible anastomotic disruption and subsequent leakage due to endoscopic electrocoagulation at the early postoperative stage should be kept in mind. Therefore, those receiving endoscopic or angiographic interventions should be closely monitored.

Postoperative Ileal Pouch Bleeding

The clinical features of postoperative pouch hemorrhage vary depending on timing, severity, and patient factors. Pouch bleeding has not been found to be associated with gender, pouch configuration, and anastomotic type. Acute pouch bleeding can occur during surgery or during the early postoperative period, with a proximately 66% of bleeding occurring within a week after pouch construction.

The operative skills of the surgeon may help reduce the risk for postoperative pouch bleeding. The stapled linear line of the pouch body and the circular suture line are common sites of postoperative pouch bleeding. Biological staple line reinforcement, suturing the staple line, and firing staples 1 min after the closure of the linear staple may reduce the risk for pouch hemorrhage. In addition, regular checking anastomosis a few minutes after firing the stapler may help to find delayed anastomotic hemorrhage. Finally, routine pouchoscopy after pouch construction can identify and reduce the risk of clinically significant pouch bleeding, especially at immediate postoperative period. The authors have been using those techniques in routine practice and found them to be useful to reduce the risk for pouch bleeding.

Diagnostic and therapeutic strategies for postoperative pouch bleeding include close, conservative clinical observation, and endoscopic management. Minor self-limited bleeding is expected in patients undergoing pouch construction. For patient with persistent hemorrhage but being clinically stable, irrigation of the pouch with a 1:200,000 adrenaline solution, which can be performed at bedside, is the initial treatment, and he or she would have a 80% of chance to stop bleeding. However, if the patient has any signs of hemodynamic instability or fails the initial treatment, endoscopic evaluation should be performed, in operating room or endoscopy suite. Once the bleeding site is identified, endoscopic hemostasis with electrocoagulation, clipping, or mucosal sclerosis may be effective. If the pouch hemorrhage is generalized oozing, epinephrine enemas are recommended. Endoscopic management with cauterization, clips, or epinephrine injection has been shown to have a success rate of 96% in stopping bleeding.

When a marked delayed pouch bleeding occurs, other pouch-related postoperative complications such as ileal-anal anastomosis breakdown and pelvic sepsis should be highly suspected. If pouch hemorrhage results from anastomotic leak, urgent surgery with anastomosis suture should be performed, and drainage through the anastomosis such as a penrose drain, mushroom, or even Foley catheter transanal placement is recommended. An abdominal surgical intervention or pouch excision is rarely required because endoscopic treatment for specific bleeding and the liberal use of epinephrine enemas for diffuse bleeding are highly successful measures.

Our proposed algorithm for the management of postoperative anastomotic bleeding in IBD surgery is listed in Fig. 24.5 .

Proposed algorithm for the management of anastomotic bleeding after IBD surgery. IBD , inflammatory bowel disease.

Postoperative Anastomotic Leaks in CD

In patient with CD requiring surgical intervention, management strategies include attempt to wean off systemic corticosteroids, preoperative enteral or parental nutrition support, and percutaneous drainage of abscesses before definitive surgery, which may help reduce the risk. In CD, anastomosis following bowel resection can be constructed into end-to-end, side-to-side, or end-to-side configurations; however, limited available data suggest that the configurations of anastomosis with staples or sutures is not associated with an increased or decreased risk for postoperative anastomotic leak. Few studies, however, showed that a stapled side-to-side anastomosis may reduce the overall rate of postoperative complications and reoperation. For intraoperative maneuvers, it was reported that oversewing staple lines may reduce major anastomotic complications such as anastomotic leaks in patients with CD undergoing ileocolonic resection. However, it is generally believed that preoperative optimization is more important than the selection of sutured or stapled anastomosis, and even more important than technical skills in CD-related surgery.

Treatment of anastomotic leak in CD includes conservative medical therapy, percutaneous drainage, and operative intervention, depending on the type of surgery and clinical status of the patient. Generally speaking, management strategy is the use of antibiotics and placement of bowel rest immediately after the diagnosis of anastomotic leak. Anastomotic leak in patients with CD usually requires additional surgical intervention, especially for severely ill patients and for those with acute peritonitis, and the affected anastomosis should be taken down as early as possible. For patient whose affected anastomosis is to be preserved (anastomotic preservation), defunctioned ileostomy with fecal diversion is often required. However, image-guided percutaneous drainage, which is effective and safe and is associated with a decreased morbidity and reduced length of hospital stay, has become an attractive alternative to reoperation. Nonetheless, the treatment strategy should be individualized based on the presentation and type or nature of the leak.

Ileal Pouch Leak

For pouch leak, the best strategy is prevention. Patients receiving high-dose systematic corticosteroids, those with severe or fulminant UC or toxic megacolon should undergo 3-stage procedure, i.e., subtotal colectomy with end ileostomy, followed by pouch construction and loop ileostomy and finally closure of the loop ileostomy. Surgical techniques for reducing anastomotic leak include ensuring good blood supply, early detection of signs of ischemia of pouch and proper managment, and no tension on the anastomosis. A temporary loop ileostomy should be made in case of any question about the integrity of the pouch or anastomosis. A loop ileostomy in IPAA procedure may not reduce the risk for anastomotic leak but fecal diversion plays an important role in reducing pelvic septic complications if anastomotic leak occurs.

The management strategy of IPAA leaks varies largely depending on the timing and nature of the leak and the presence or absence of diverting ileostomy. For patients without an ileostomy, if clinical presentations are localized to the pelvis or perineum, an insertion of a 30F rectal catheter above the anastomosis, placement of the bowel rest, and administration of antibiotics are recommended. If the leak is associated with pelvic abscess, the latter should be drained transanally or percutaneously. However, those with generalized peritonitis should require a defunctioning ileostomy. For those with a diverting ileostomy, oral intake can be continued, and a rectal tube is usually unnecessary if there is no sign of pelvic abscess/sepsis. However, if generalized peritonitis is present in those with a defunctioning ileostomy, other causes of peritonitis must be investigated.

The treatment strategies for acute and chronic leaks after pouch surgery are also different. For acute leaks or those with associated pelvic abscess or sepsis, surgical intervention and/or imaging-guided drainage is often needed. Endoscopic treatment is increasingly used in chronic leaks or anastomotic sinuses, although acute anastomotic leaks are occasionally treated with endoscopy also. The over-the-scope clipping device or “bear claw” is reported to be effective and safe to close the tip of the “J” leak. However, major leaks often require a defunctioning ileostomy if one is not already in place. Before ileostomy closure, patients whose leak is detected only radiographically (without symptoms) should receive close observation with repeat pouchogram.

For patients who do not respond to antibiotic therapy, imaging-guided drainage, rectal tube drainage or endoscopic treatment, or the patients become clinically unstable, surgical intervention is required. The reported rate of laparotomy for anastomotic leak after IPAA procedure is as high as 55%. Surgical mortalities for anastomotic leaks include abdominal washout and placement of drains. A diverting loop ileostomy, may be performed. If the anastomotic defect is easily visualized, less than 50% in circumference, and the tissue around are in good condition, primary repair of leak may be attempted. The worse situation is the requirement of pouch excision, which is performed in the setting of gross pouch ischemia or an unsalvageable pouch. If complete ileoanal anastomotic disruption occurs, combined pouch excision and abdominal-pelvic pouch reconstruction may lead to a functioned pouch in experienced hands.

If the pouch outlet can be adequately mobilized, transanal repair with a defunctioning ileostomy can be performed in patients who have had a handsewn anastomosis. However, in those with leaks originated from pouch suture lines away from the anastomosis (the “pouch leak”), direct transabdominal repair can be made, and a pouch reconstruction may be performed. Additionally, patients with a leak from the tip of the “J” of the pouch who have failed endoscopic treatment often require surgical treatment with an abdominal approach. Advances in techniques and increased experience of colorectal surgeons with the procedure may be the contributing factors for the growing number of pouch salvage surgery for the treatment of anastomotic leaks.

Ileal Pouch Sinus

Pouch sinus, which commonly located at the site of pouch-anal anastomosis, is typically long-term adverse sequelae of pouch-related anastomotic leak. Although some patients may be asymptomatic, many of them can present with pelvic sepsis, pouchitis, CD of the pouch, or refractory cuffitis. Patients with pouch sinus usually have perianal pain, pelvic pressure and discomfort, and tailbone pain. Severe and complex sinus may lead to systematic symptoms such as fever, weight loss, and anemia, and chronic deep pouch sinus can even result in osteomyelitis of tailbone and pouch-vaginal or pouch-vesicular fistulas anteriorly.

For patients with clinical presentations suspected of pouch sinus, a careful endoscopic examination should be performed with attention to the ileoanal anastomosis and the tip of the “J.” In addition, to detect the sinus opening, sinus tract the complexity, depth, and possible complicating abscess, a combined assessment of pouchoscopy, contrasted pouchogram, EUA, and pelvic MRI, is often needed.

Treatment options of pouch sinus includes periodic surgical or endoscopic incision to open the sinus tract. According to Cleveland Clinic experience, approximately 50% of the patients with sinus can be treated with endoscopy. Fibrin glue injection of the sinus may be attempted to manage pouch sinus. Endoscopic needle-knife therapy, which can be performed in patients with or without protecting diverting ileostomy, is reported to be safe and effective for the treatment of simple, shallow (<5 cm in depth) presacral sinus in experienced hands. Shen et al. developed an endoscopic needle-knife sinusotomy to treat presacral anastomotic sinuses with a success rate of 80%. Defunctioning loop ileostomy may be performed to help the healing of sinus, and it may take up to 9–12 months before these sinuses heal. However, some patients with a long sinus track would be candidates for a redo pouch procedure, if the nonsurgical methods have failed.

Pouch Fistula

Pouch-related fistula mainly consists of fistulous connection between the ileal pouch and vagina, anus, or perineum, occurring in 4% of patients, is another highly morbid complication of restorative proctocolectomy with IPAA. Several factors including the underlying disease, operative technique, and postoperative pelvic sepsis are associated with the development of pouch-related fistulas. The main originate of pouch-related fistula includes appendage, pouch reservoir, afferent limb, and pouch-rectal anastomosis. Each of the above sources can fistulize into different areas such as abdominal wall, vagina, bladder, and small bowel, and the most commonly seen is pouch-vaginal fistula (PVF). In female patients, the reported frequency of PVF ranges from 2% to 16%, most often at the pouch-anal anastomosis (77%), followed by the body of the pouch (13%). PVF can lead to major postoperative complications such as pelvic sepsis and are associated with a high risk for pouch failure.

PVF often occurs within in 6–12 months after restorative total proctocolectomy but can present within the first 3 months postoperatively. Diagnosis of PVF is mainly based on symptoms, however, EUA, endoscopic findings, and radiographic examinations including MRI, CT, and water-contrasted pouchogram play an important role in differential diagnosis and detection of the source of fistula. Regardless of the etiology of PVF, surgical intervention including local approach (perineal or transvaginal) or abdominal repair is often required. The origin of the fistula from the pouch should be determined before undergoing surgical repair of fistula. Abdominal repairs including primary repair of the vaginal defect, resection of the retained rectum, mucosectomy, and construction of new ileoanal anastomosis below the level of fistula, are for fistulas above the ileoanal anastomosis, while local approach involving transanal creation of full-thickness flaps is for fistula below the level of ileoanal anastomosis. The reported healing rate of pouch-related fistula undergoing operative treatment is 64%, while the overall healing rate of PVF is 47%. Accumulated data indicated that abdominal repairs can lead to a primary healing of 67%–80%, and local approach has a lower primary closure rate of 35%–60%. However, for those with persistent PVF or those with severe symptoms, initial diverting ileostomy and even pouch excision with end ileostomy may be needed. Although surgical intervention such as transanal ileal advancement flap may be effective in some cases, multiple surgical interventions may be needed, due to its recurrent nature. Recurrence of PVF may present up to 1.5 years after the initial surgical repair and might be treated with secondary and even tertiary surgeries, with, however, the degree of efficacy being decreasing. One should keep in mind that the diagnosis of CD is considered in a patient with recurrent PVF, as additional medical therapy such as TNF antagonists may be needed.

Other pouch-related fistulas include appendage-cutaneous and pouch-bladder fistula. Appendage-cutaneous fistula can be prevented or reduced by limiting the length of the appendage. If appendage-cutaneous fistula occurred, the resection of the appendage and reclosing of the blind end is compromised. Surgical intervention including fistulectomy with primary closure of both pouch and bladder can lead to a better outcome in patients with pouch-bladder fistula.