INTRODUCTION

Presacral sinus typically results from chronic leaks at the pouch-anal anastomosis, colorectal anastomosis (CRA), coloanal anastomosis, and ileoanal anastomosis for various benign or malignant colorectal disorders. Clinically, the most common settings for presacral sinus are restorative proctocolectomy (RPC) and ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) and CRA for rectal cancer. Most patients with presacral were symptomatic, presenting with fever, night sweats, tailbone pain, urgency, and failure to thrive. While small presacral sinus may heal spontaneously with antibiotic therapy, the majority of patients require surgical intervention, including fecal diversion, resection, and redo anastomosis, pouch-redo, or completion pouchectomy or proctectomy.

Endoscopic sinusotomy (ESi) by incorporating the sinus into the pouch body endoscopically has evolved into a feasible, effective, and safe treatment modality of the presacral sinus in patients with IPAA. ESi is increasingly used for the treatment of presacral sinus in other benign or malignant colorectal disorders.

PREVALENCE AND RISK FACTORS

Restorative proctocolectomy with IPAA is a complex surgical procedure, involving bowel resection, anastomosis, and reconstruction. Short- and long-term mild or severe complications can occur in as high as 60% of patients. Severe, refractory complications can lead to pouch failure with pouch excision, pouch redo, or permanent diversion in 4% to 10% of cases. Standard IPAA involves suturing or stapling the pouch body to the distal rectal stump or anal transition zone (ATZ). The posterior wall of the anastomosis is prone to the development of acute or chronic anastomotic leaks. Acute leaks typically present with abscess and pelvic sepsis, while chronic leaks often result in the formation of the sinus or fistula. A large historical cohort study of 3707 patients, including 2959 with UC, 63 with indeterminate colitis (IC), 150 with CD, with 223 FAP reported various early (<90 days after IPAA) and late (>90 after IPAA) (including presacral sinus) complications. In a median follow-up of 84 months (range, 24–156 months) and FAP, the rates of early-onset pelvic sepsis were 6.3%, 4.8%, 8.7%, and 3.6%; early-onset anastomotic leak were 4.8%, 3.2%, 4.7%, and 4.5%; and early-onset pouch fistula, 1.3%, 1.6%, 1.3%, and 2.2%, in UC, UC, CD, and FAP, respectively. The rates of late-onset pelvic sepsis were 2.7%, 3.2%, 3.3%, and 3.1%; the late-onset anastomotic leaks, 1.5%, 3.2%, 2.0%, and 1.8%, and the late-onset pouch fistula, 2.7%, 3.2%, 8%, and 1.8%, in UC, IC, CD, and FAP, respectively. The results suggest that patients with CD had a higher risk for the development of early- and late-onset complications than those with UC or FAP; and patients with underlying FAP carry a lower risk for late-onset complications than those with underlying IBD. Most patients with early complications require treatment with interventional radiology or reoperation. Endoscopy plays a limited role in the management of early complications. However, endoscopic treatment has become a major treatment modality for late-onset pouch complications, particularly presacral sinus which occurs in 2.8% to 8% of patients undergoing IPAA. ^, Presacral sinus is the most common form of chronic leaks in patients with IPAA. Persistent sinus can cause serious consequences, ranging from delayed ileostomy closure to pouch failure. Presacral sinus can also cause coccyx osteomyelitis even as malignant changes.

The etiology and pathogenesis of pouch sinus are not clear but are believed to be related to anastomotic tension or ischemia. Results from a cohort study of 109 patients with presacral sinus suggest reviewed a male predominance (78.0%). The male gender is associated with a higher risk for multiple post-IPAA complications, including Clostridium difficile infection, chronic antibiotic-refractory pouchitis especially ischemic pouchitis, anastomotic leaks, and pouch sinuses. ^, The common denominator for the male dominance of C. difficile infection, chronic pouchitis, and presacral sinus may be explained by a shorter mensentery and peri pouch accumulation in males ( Fig. 18.1 ). It is possible that the narrower pelvis and a shorter length of the mesentery in males made the surgical procedure, particularly the creation of an anastomosis, technically more challenging than in females. ^, Weight gain after endoscopic intervention for presacral sinus is associated with recurrent pouch sinus.

Large adipose deposits around the pouch in a male patient.

Presacral sinus can occur in resection and anastomosis of the distal bowel for other benign or malignant colorectal disorders, such as lower anterior resection for rectal cancer. In a cross-sectional study 998 underwent a low anterior resection (LAR) with a median follow-up of 43 months (interquartile range [IQR] 35–47) from Dutch Surgical Colorectal Audit, anastomotic leaks were detected in 200 patients (20.0%) after 30 days. A persistent presacral sinus was present in 85 of 893 evaluable patients (9.5%). For those with colorectal cancer (CRC), neoadjuvant radiochemotherapy or chemotherapy, ^, and distal tumor are risk factors for the development of presacral sinus. It appears that the risk for presacral sinus is comparable for transanal versus laparoscopic total mesorectal excision for rectal cancer.

DIAGNOSTIC EVALUATION

A pouch sinus is defined as a chronic blind tract, resulting from chronic pouch-anal anastomotic leak or suture/staple line leaks. ^, A combined assessment of clinical presentation, endoscopic, and radiographic features is often needed to accurately diagnose and classify of presacral sinus. A classification of pouch leaks and their treatment strategies is listed in Table 18.1 .

Clinical Evaluation

Patients with presacral sinus may present fever, chills, night sweats, diarrhea, urgency, abdominal or pelvic pain, coccyx discomfort or tenderness and failure to thrive, and weight loss. Patients with severe presacral sinus may present coccyx osteomyelitis ( Fig. 18.2 ). Patients may also have leukocytosis, anemia of chronic disease, and malnutrition.

Osteomyelitis resulting from pouch leaks.

CLASSIFICATION OF PRESACRAL SINUS

On the sagittal plane, the configuration of the presacral sinus can be “O,” “L,” “T,” “I,” “U,” or “Figure 8,” which can be highlighted on GGE ( Fig. 18.3 ), MRI ( Fig. 18.4 ), or pouchoscopy. On the axial plane, the orientation of the sinus can be in situ, anterior (with or without pouch vaginal fistula or pouch-urethra fistula), or posterior (with or without pouch-cutaneous fistula. A simple pouch sinus is defined as a blind-ending tract arising from an anastomotic leak at the presacral space of the pouch. Complex sinus is defined as multiple sinuses (≥2) or branched sinus. The configurations of pouch sinus impact the feasibility and outcome of endoscopic therapy.

Presacral sinus on gastrografin enema. (A) “L” shaped; (B) “O” shaped; (C) “I” shaped; and (D) “T” shaped.

(Photo courtesy: Shen B. Endoscopic therapy for acute and chronic anastomotic Leaks. In: Shen B (ed.), Pouchitis and Ileal Pouch Disorders . Academic Press, Elsevier; 2019: 396–397). (Photo courtesy: Shen B. Endoscopic therapy for acute and chronic anastomotic Leaks. In: Shen B (ed.), Pouchitis and Ileal Pouch Disorders . Academic Press, Elsevier; 2019: 396–397).

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