Procedure
Indications
Coloanal anastomosis
Straight
Colonic J pouch
Rectal cancer
Large rectal polyp
Rectovaginal fistula
Rectourethral fistula
Radiation proctitis
Hirschsprung’s disease (adult)
Slow transit constipation with megarectum
Ileal pouch-anal anastomosis
Ulcerative colitis
Familial adenomatous polyposis
Crohn’s disease (select cases)
Hereditary colon cancer syndrome
Congenital defects of colonic motility
Perineal proctectomy
Rectal prolapse
Transanal endorectal pull-through
Hirschsprung’s disease (children and adult)
Transabdominal endorectal pull-through
Swenson
Duhamel
Soave
Hirschsprung’s disease (children)
Severe/high imperforate anus (children)
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).
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 | Intraoperative factors Blood loss Blood transfusion Duration of surgery Choice of minimally invasive approach Manipulation of tissue |
Patient factors | |
Age Smoking Alcohol and illicit drug use Body mass index Visceral obesity Anesthesia severity assessment | Anesthesia severity assessment (ASA) Nutritional status Prior abdominal surgery Medications Antiplatelet therapy Systemic anticoagulation |
Disease factors | |
Inflammatory bowel disease Metastatic cancer Medications Steroids Immunomodulators and biologics | Radiation therapy Emergency surgery Extraperitoneal anastomosis |
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 surgeon must take into account the clinical acuity and severity of the complication. A current awareness of nonoperative, as well as 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 intervention. 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 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 exploration 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].
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 anastomosis. 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 increase the chance of successful restoration of gastrointestinal continuity.
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 setting of a contained pelvic leak, treatment options 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 carries 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 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 anastomosis 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].
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 coloanal 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 urgently 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 who require excision may face a completion colectomy with an ileoanal anastomosis.
Alternatively, a salvage technique for the colorectal or coloanal anastomosis is the Deloyers procedure. The proximal colon is completely mobilized and rotated, while preserving the ileocolic junction and the ileocolic artery. An anastomosis is then created between the right or proximal transverse colon and the rectum or anus (Fig. 16.1). In one series from 1998 to 2011, Manceau et al. [66] performed this technique on 48 patients, 11 of which had previous failed colorectal or coloanal anastomoses. Results were excellent. No patients developed anastomotic leakage, and more than 80% of patients had good functional results with fewer than four bowel movements per day. As confirmed by others [67–69], the Deloyers procedure represents a safe and valid alternative to total colectomy with ileorectal anastomosis.
Fig. 16.1
The Deloyers Procedure (Adapted from [109]). a The proximal colon is available for a colorectal or coloanal anastomosis, but without mobilization will not reach the pelvis. b After mobilization of the right colon and preservation of the ileocolic pedicle, the colon is rotated 180° to place the cecum in the right upper quadrant and the proximal transverse colon into the pelvis for a tension-free anastomosis
In a subsequent series of 50 patients who underwent redo surgery specifically after failed colorectal or coloanal anastomoses, all patients were able to have a successful reanastomosis. The authors note that this may require full mobilization of the remaining colon, with ligation of the middle colic vessels and a right colon to rectal or anal anastomosis (Deloyers procedure) in order to create a tension-free anastomosis [70].
In summary, an early, expeditious diagnosis and treatment of anastomotic disruption may allow for local, less invasive methods to adequately treat the leak, ultimately preventing long-term anastomotic failure. Resection and reanastomosis should be considered the treatment of last resort for a persistent extraperitoneal anastomotic leak or chronic sinus.
Anastomotic Stricture
Anastomotic strictures usually occur in the setting of pelvic sepsis, but may also develop from anastomotic tension, ischemia, or Crohn’s disease. Symptoms range from mild difficulty evacuating to near complete obstruction. A recent large study of 2361 consecutive colorectal anastomoses over 17 years revealed a 3.2% incidence of symptomatic stricture. Ileal pouch-anal strictures, on the other hand, are more common (10–40%) [15, 71–75]. Surgical technique may lead to differences in the type and length of the stricture. Stapled IPAA are typically associated with shorter, web-like strictures, whereas mucosectomy with hand-sewn anastomoses produce longer, more fibrotic strictures [74]. Successful transanal drainage to treat a colorectal anastomotic leak is associated with future stricture in up to 33% [47].
For those patients who have proximal fecal diversion, evaluation of the anastomosis prior to ileostomy reversal with a contrast enema study is crucial to assess for subclinical persistent leak or stricture. Endoscopy should be considered as well; it is not only diagnostic, but also potentially therapeutic.
In the setting of ileal pouch-anal reconstruction for presumed ulcerative colitis, an anastomotic stricture should raise suspicion for rectal cuff inflammation secondary to colitis or undiagnosed Crohn’s disease, particularly in the setting of adjacent pouchitis. If Crohn’s disease is diagnosed, strictures may respond to medical therapy with immunomodulators or biologics. Additionally, patients with a history of ulcerative colitis suffering from “cuffitis” as a component of their stricture will often respond to steroid or mesalamine enemas [76].
In general, most strictures respond well to nonoperative therapy. For the low distal anastomoses that accompany a pull-through procedure, the ease of access to the stricture site makes digital exam and the use of Hegar dilators relatively simple and often successful, either at home or under general anesthesia. Were and colleagues [77] reported 21 of 256 (8.2%) consecutive patients who underwent low anterior resection and developed an anastomotic stricture. Stricture symptoms presented after a mean of 7.7 months. This group utilized endoscopic Savary dilators, with bougies of increasing diameter (10–19 mm), over a series of sessions. Of 15 patients available for follow-up, ten achieved normal defecation with complete resolution of symptoms. Five patients had only partial improvement in symptoms, with three requiring reintervention. No complications occurred. A normal defecation pattern was never regained if more than three dilations were necessary [77].
Dilation can also be performed with the aid of endoscopic pneumatic balloons with high success rates (80–97%) [78–81]. Arauko and Costa [78] used pneumatic balloon dilation in 24 symptomatic patients with benign colorectal anastomotic stricture using a through-the-scope balloon technique. Dilation was successful in 22 (91.7%) patients, with a mean number of 2.3 treatment sessions. No complications occurred. A larger study over 17 years revealed a 97.4% success rate with endoscopic balloon dilation in 76 patients with a symptomatic colorectal anastomotic stenosis [81].
Successful pneumatic balloon dilation of ileal pouch inlet and outlet strictures has been reported as well [79, 80]. A large series of 150 patients with IPAA and stricture were followed after endoscopic balloon dilation [79]. A total of 646 strictures were identified and endoscopically dilated over 406 pouchoscopies from 2002 to 2010. Technical success of dilation was achieved in over 87%, with 80% having symptom improvement over a mean of 9.6 years. Major complications were low, with two perforations (0.46%) and four bleeds requiring transfusion (0.98%). Overall, balloon dilation was demonstrated to be reasonably safe in this patient population, although pouches with multiple strictures or acute angulations were technically more challenging [79].
Similar to the management of anastomotic leak, endoscopic stents may be used in the treatment of strictures, but have limited utility as pull-through anastomoses are too distal to allow placement of a stent. Other reported options that have proved successful include the combination of electroincision (radial incisions of the scar) with pneumatic balloon dilation [82], and dilation with concomitant corticosteroid injection [83].
If nonoperative treatments fail, or if the stricture is severe, surgical approaches such as mucosal or dermal advancement flaps should be considered if technically feasible. Ileal mucosal advancement flaps have been advocated for short pouch strictures that appear as a fibrous ring [84]. Further details on specific procedures or indications for surgery for anastomotic stricture can be found in the chapter on treatment of Anal Stenosis.
Prolapse
Patients may develop recurrent rectal prolapse following perineal proctectomy, or de novo prolapse as a complication of a coloanal or ileoanal anastomosis. Prolapse of the ileoanal pouch, either mucosal or full thickness, is uncommon. Joyce et al. [85] reported an incidence of 0.3% in 3176 patients who underwent ileal pouch surgery at a large tertiary referral center. Full-thickness prolapse was more common (63.6%) than mucosal prolapse (36.4%). In contrast to primary rectal prolapse, there was no female predominance [85]. Most pouch prolapses occur within two years of the original procedure [86].
Patients with pouch prolapse present with a sense of obstructed defecation, seepage, pain, and external prolapse of tissue [25]. If prolapse is suspected, asking the patient to sit on the toilet and strain may assist with diagnosis. The first line of treatment for minor mucosal prolapse is stool bulking agents and biofeedback therapy to avoid excessive straining. If this fails, then the surgeon should attempt a local perineal procedure analogous to the Delorme’s procedure, in the form of pouch advancement with excision of the redundant mucosal tissue.
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