INTRODUCTION

Colorectal surgeries are performed to treat inflammatory bowel disease (IBD), colorectal cancer (CRC), diverticulitis, and rectal prolapse. Patients with IBD can normally achieve a good quality of life with medical treatments. However, most patients with Crohn’s disease (CD) and approximately 20% of patients with ulcerative colitis (UC) fail medical therapies and will need surgical management ( Chapters 1 and 20 ), especially those who experience complications, such as bowel perforation, abscess, stricture, and fistula. The small bowel resection rate of patients with CD after 1, 5, and 10 years of diagnosis are 66%, 77%, and 83%, respectively. A majority of patients with CD eventually undergo elective surgeries. Patients with acute fulminant colitis (severe inflammation resulting in more than 10 stools per day), colonic dilatation, toxic megacolon (defined as colonic dilatation of greater than 6 cm with additional clinical parameters), colonic perforation, and major hemorrhage, undergo urgent surgery. Patients may also undergo surgery for prophylaxis against colon cancer.

Standard surgical treatment methods for CD include partial resections of the small bowel and/or colon, depending on the site of disease involvement, strictureplasty, and fecal diversion with construction of an ostomy. The surgeries, however, are not curative for CD. For this reason, the bowel should be preserved as much as possible to avoid postoperative short gut syndrome. Standard surgical methods for ulcerative colitis were total proctocolectomy (TPC) with end ileostomy before the 1980s. Another procedure that was popular in the late 1960s is continent ileostomy, also known as Kock pouch (K-pouch). K-pouch can improve a patient’s quality of life by maintaining continence and freedom from an external bag. The K-pouch procedure involves the creation of a reservoir with a continent nipple valve exiting the anterior abdomen. Total proctocolectomy with ileal pouch–anal anastomosis (IPAA) was developed in the late 1970s and early 1980s, and it soon replaced the traditional TPC with end ileostomy. The initial stage of TPC-IPAA is the same as the traditional version, which consists of removing the diseased colon and rectum by total proctocolectomy. Subsequently, J-, S-, or W-shaped pouch reservoir is created using small bowel, which is connected to the anus via ileoanal anastomosis. Nowadays, the K-pouch has fallen out of favor and is only used as an alternative if ileal pouch–anal anastomosis cannot be performed after TPC or as salvage pouch surgery in some who failed pelvic pouches.

The treatment strategy for CRC is surgery and/or chemoradiation, depending on the stage of CRC. However, surgical resection of the large bowel is performed based on the site of disease involvement. These surgeries include colectomy (removing part or all of the colon), ileocolonic resection, proctectomy (removing part or all of the rectum), low anterior resection (removing the rectum and part of the sigmoid colon), and abdominoperineal resection (removing the anus, rectum, and part of the sigmoid colon) followed by colocolonic anastomosis, colorectal anastomosis, and coloanal anastomosis (attaching the remaining colon to the anus after a proctectomy), and ileo- or colo-anal pouch (creating a pouch or reservoir from the small bowel or colon to replace and function as the rectum in patients with familial adenoumatous polyposis). These procedures can be done open, laparoscopically, or robotically. As always, patients’ individual needs and general health, and comorbidities also influence the type of colorectal surgery performed.

Diverticulitis is a common condition that outpouchings of the colon wall (diverticulosis) become inflamed or infected. Depending on the severity of diverticulitis, the treatment options range from diet modification, pain medications, antibiotics, and/or surgery. The type of surgical procedure depends on the extent and location of the disease, but options include resection of the diseased colon or percutaneous drainage of abscess resulting from complicated diverticulitis. Occasionally, partial colectomy or segmental colectomy is performed for patients with severe or recurrent diverticular bleeding.

Multiple risk factors, including malnutrition, hypoalbuminemia, anemia, high-dose and/or long-term corticosteroid use, and immunosuppression, may contribute to surgical complications. Dos Santos et al. reported that racial disparities affect the surgical outcomes of IBD patients who undergo surgery; Black, Hispanic, and Asian patients with IBD experience more postoperative complications than white patients with IBD, although the mechanism is unclear. The experience of the surgeon, operation time, and postoperative care are also important risk factors. Preoperative bowel cleaning is debatable, but it does not seem to prevent anastomotic leakage or wound infection. ^,

The surgical adverse sequelae included short-term (within 30 days of surgery) and long-term (after 30 days from surgery) complications. Radiographs, computed tomography (CT) of the abdomen/pelvis, magnetic resonance imaging (MRI) of the abdomen/pelvis, CT enterography, and MRI enterography are widely used to make the diagnosis of small and large bowel diseases. Cross-sectional imaging is not as sensitive as colonoscopy and biopsy in making the diagnosis of IBD in the early stages, because microscopic or mucosal changes are beyond the typical resolution of CT and MRI. However, cross-sectional imaging is greatly helpful in diagnosing advanced IBD, CRC, diverticulitis, and their complications, including fistulas, sinus tracts, inflammatory masses, abscesses, strictures as well as postoperative complications ( Table 9.1 ).

ACUTE OR CHRONIC ANASTOMOTIC LEAKS

The most common cause of morbidities after colorectal surgery is due to anastomotic leaks, noting a mortality rate of 6% to 22%. It typically occurs within the first 2 weeks after surgery. Delayed anastomotic leak after 30 days can happen, although it is rare. Common risk factors for anastomotic leak include male gender, smoking, diabetes, obesity, malnutrition, anemia, concurrent use of corticosteroids or immunosuppressants, and radiation. The surgeon can minimize the risk of leak significantly by avoiding the prolonged surgical time, vascular ischemia, and tension at the anastomotic site. Anastomosis type may be associated with different risks of anastomosis leaks. Some surgeons favor end-to-side anastomosis for that reason. Kanazawa observed that leaks from stapled anastomosis were significantly lower than those from hand-sewn anastomosis, with a hazard ratio of 4.255 ( P = .002).

Anastomotic leaks can be classified as free or contained. Free leaks cause more damage, as enteric contents flow freely throughout the abdominopelvic cavity, causing abdominal pain, fever, leukocytosis, hypotension, paralytic ileus, peritonitis, sepsis, and septic shock. In comparison, contained leaks cause limited contamination of the abdominopelvic cavity and may only result in localized peritonitis. Anastomotic leaks can be acute and chronic and the latter can lead to sinuses or fistulas.

It is difficult to detect an anastomotic leak after surgery. Den Dulk used a standardized clinical scoring system known as the Dutch leakage score to reduce delay in the diagnosis of an anastomotic leak from 4 to 1.5 days on average. The clinical features used in the scoring systems were symptoms (i.e., fever, heart rate), nutritional status, and laboratory findings (e.g., high C-reactive protein, leukocytosis, and renal dysfunction).

The most sensitive examinations to detect anastomotic leaks are fluoroscopy with water-soluble contrast agents and CT abdomen and pelvis with rectal contrast. On fluoroscopic contrast enema, the contrast is administered via a soft, thin rectal tube via the anus or stoma in a retrograde fashion. The anastomotic leak location and size can be easily found by tracking the extravasation of contrast ( Fig. 9.1 ). One pitfall of contrast enema is that the tip of the rectal tube should be lower than the anastomotic site to avoid false negative results. In our institution, diluted 50% gastrografin is the contrast agent of choice to evaluate for leaks, since free barium may contaminate the abdominopelvic cavity and result in chronic chemical peritonitis. CT with rectal contrast not only detects anastomotic leaks, but also diagnoses other conditions, including abscess, peritonitis, enteritis, intestinal obstruction, and bowel ischemia.

A 21-year-old female with a history of ulcerative colitis and colon cancer status post proctocolectomy with ileoanal anastomosis. Postoperative contrast enema (A) demonstrates a small amount of contrast extravasation from the anastomotic site ( yellow arrow ), most likely J-pouch anastomotic leak. The leak is confirmed by CT abdomen and pelvis (B, C). A small loculated air-fluid collection with extravasated contrast is identified adjacent to the J-pouch anastomosis ( yellow arrow ), suggestive of the leak.

Treatment for anastomotic leak includes antibiotics, bowel rest, percutaneous or endoscopic drainage of the abscess if amenable, or repeat surgery. Early diagnosis is important to prevent complications of abscess, sepsis, or fistula formation.

FISTULA AND ABSCESS

Anopouch or anorectal fistula is a tunneled tract opening between the anal canal and the skin surface near the anus. An abscess is a collection of pus. Fistula and abscess often coexist in patients with IBD or postoperative conditions. Similarly, anorectal, perianal, or perirectal fistula and abscess can result from colorectal surgery for CD, CRC, and diverticular diseases. Intra-abdominal sepsis occurs in up to 10% of patients with CD after an abdominal operation involving anastomosis. Ileal pouch fistula occurs in approximately 4.7% of patients with restorative proctocolectomy with IPAA.

Pouch fistulas can be classified based on the time of occurrence relative to pouch creation as early and late subtypes. Early pouch fistula develops within 12 months of pouch creation, while delayed pouch fistula develops 12 or more months after surgery. Pouch fistula can involve different locations, including the body of the pouch, pouch-anal anastomosis, vagina, bladder, and perineum or perianal region. Patients with abdominal fistulas and abscesses may have abdominal pain, fever, chill, leukocytosis, skin irritation symptoms (such as redness, tenderness, and itchiness), and foul drainage from the fistula tract.

Fistulogram and sinogram are the studies of choice to evaluate the pouch, peripouch, or perirecta fistulas or enterocutaneous fistula. A fistulogram can be carried out by injecting gastrografin into the fistula via a catheter under fluoroscopic guidance. By tracking the contrast, the fistular tract can be identified ( Figs. 9.2 and 9.3 ). MRI of the pelvis (dedicated perianal abscess protocol with a small field-of-view) is the gold standard in fistula imaging. CT or MRI enterography with Volumen (Barium sulfate suspension) and routine CT with oral and intravenous (IV) contrast are also helpful in evaluating fistulous tracts and intra-abdominal abscesses ( Figs. 9.4 – 9.6 ).

A 57-year-old female with Crohn’s disease status post total proctocolectomy for dysplastic polyps was referred for evaluation of enterocutaneous fistula. After successful cannulation of the skin defect with a 10-French Foley catheter, 5 cc of contrast was injected. Anterior posterior (AP) view demonstrates opacification of multiple small bowel loops. Findings are consistent with enterocutaneous fistula.

A 21-year-old male status post proctocolectomy with ileoanal anastomosis. The contrast was injected via an anterior pelvic percutaneous drainage catheter. There is an opacified collection measuring 2.1 × 1.2 cm at the catheter tip ( yellow arrowhead ). This collection is continuous with a curvilinear sinus tract ( green arrow ) extending posteriorly to the J-pouch ( yellow arrow ), which is diffusely opacified. Findings most likely represent a pouch-cutaneous fistula.

A 47-year-old female with ulcerative colitis status post proctocolectomy with J-pouch presenting with refractory cuffitis. Contrast enema demonstrates linear contrast opacification arising from the anterior wall of the anal canal toward the vagina representing a rectovaginal fistula ( yellow arrow ).

Status post J-pouch surgery. There is a rim-enhancing fluid collection posterior to the pouch consistent with an abscess ( Yellow arrows ).

Contrast-enhanced MRI of the pelvis demonstrates a small sinus tract ( yellow arrow ) arising from the distal anastomosis of the J-pouch. The sinus tract was treated with clipping.

The treatment of an abscess is drainage, which can be done radiographically, endoscopically, or surgically. Surgical or in some patients, endoscopic fistulotomy is the first choice of treatment for fistula, with a success rate between 80% and 100%. One of the risks is an operational failure, which may increase the size of the fistula. The abdominal approach may be suitable if the fistula is high or arising from above the anastomosis. For the low fistula, a direct repair can be performed depending on the involvement of the sphincter complex, with or without flaps. Oral or intravenous antibiotics are helpful for the treatment of fistula or abscess, although they have minimal effect by treatment alone.

ANASTOMOTIC BLEEDING

It is less common for postoperative bleeding to occur, as it is difficult to detect and often unrecognized. The risk factors are ischemia, surgical techniques, nonsteroidal antiinflammatory drugs, or anticoagulants. In a retrospective study, Golda et al. found that postoperative anastomotic bleeding was associated with surgical techniques. The study included 350 patients who were divided into three groups according to surgical techniques: group 1 was circular, double-stapled, end-to-end anastomosis (174 patients), group 2 was linear-stapled, side-to-side anastomosis (59 patients), and group 3 was hand-sewn, side-to-side anastomosis (117 patients). Postoperative bleeding was detected in 4.9% of these patients, all of whom were in group 1. They concluded that end-to-side, circular, or double-stapling increased the risk of anastomotic bleeding. A small amount of postsurgical hematoma was difficult to assess clinically, although patients may experience abdominal pain or a drop in hemoglobin.

Computed tomography of the abdomen and pelvis is normally the first-line diagnostic approach to evaluate anastomotic bleeding. The presence of hyperdense material adjacent to the anastomotic site raises suspicion of hemorrhage ( Fig. 9.7 ). Sometimes, hemoperitoneum can also be present ( Fig. 9.7 ). CT angiography is a noninvasive method for diagnosing active gastrointestinal bleeding, with a reported sensitivity of 90%. Technetium-99m labeled red blood cell scintigraphy is a more sensitive study for hemodynamically stable patients with a reported sensitivity of 93%, as it can detect bleeding rates as low as 0.05 to 0.2 mL/min.

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