complications and management in colon and rectal surgery

Colorectal Surgical Complications & Management

FAZL Q PARRAYMS,FICS,FMAS,FACRSIAdditional Professor Department of SurgerySher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar-190011,J &K, INDIAE-mail:fazlparray@rediffmail.com

All Surgeons are Human beings.

Humans are prone to mistakes right from Adams time.

Complication –unintentional harm done to a patient .

It leads to lot of morbidity and even mortality.

Remember even the best surgeons get complications

U can decrease the complications to zero if u don’t operate

Surgeon, however, should aim at minimizing his complications by:

• Self Audit• Independent Audit• Knowing ,assisting and learning the craft• Scientific management of the complications• Proper referral

• Mesenteric vessels-not troublesome• Internal Iliac Vessels-Direct finger pressure;

Catch up with resuscitation.• Sacral Plexus bleeds-dangerous

Pressure Saline packs 24-48 hrs Thumbtacks Occluder Pins Argon beam coagulator• Anastamotic bleeding Transfusion 1:100,000 saline/epinephrine solution Re-exploration

Bleeding

• Anastomotic leakage occurs in 5 - 15% after colorectal surgery

• Leads to substantial morbidity and mortality

• Many factors determine AL Patient related Surgery (treatment) related

Soeters/de Zoete /Dejong/Williams/Baeten Dig Surg 2002;19;150-155

Anastamotic Leak

Risk factors for AL

Multivariate analysis• Male sex increased risk of AL; 13 fold in LAR

• Lower than 10 cm anastamosis (3.5 fold increase compare with higher than 10 cm)

• ASA group 4 (2.5 fold increase risk of AL to compare with ASA 1-3

D.Pavalkis, Medicina, 2001, 39:421-425

Obesity and AL

• 584 elective colorectal surgery for cancer

• 158 (27%) were obese (BMI>27)

• Hemicolectomies – no difference

• AR resulted in AL in 16% of obese and 6% of non-obese patients (p<0.05)

• For obese patients in AR group diabetes mellitus and ASA status were significant risk factors for AL

St.Benoist & all, Am J Surg, 2000, 179, 275-281

Age and AL

• . Prospective multicentric study, 75 German hospitals, 3756 patients <65; 65-79; >80

• Left sided cancers 76.2%, 76.7%, 54.8%

• AL requiring surgery 4.2%, 3.1%, 1.5% (p>0.05)

• AL not requiring surgery 1.5%, 2.3%, 1.2% (p>0.05)

F.Marusch at all, Int J Colorectal Dis, 2002, 17:177-184

• Preoperative Albumin level <3.5 g/dl• Intraoperative blood loss of >200ml• Operative time >200 mts• Intraoperative transfusion requirement• Margin involvement in disease process • Proximal diversion should be considered for patients with 3

intraoperative risk factors

Telem DA et al Arch Surg. 2010;145(4):371-376

Risk factors for AL

• Proximal diverting Stoma reduces the severe consequences of AL but not the incidence of leak.

• Suggested, that all anastamosis at 6 cm or less from anal verge should be protected.

N.D. Karanjia etal, Br. J. Surg. 1991; 78:196-198

Protective stoma not recommended for all routinely. Male gender, low anastamosis, coronary artery disease, preoperative radiotherapy, and smoking

are the major risk factors of anastamotic leakage. Mozafar M etal.Iranian Journal of cancer prevention. Vol 2, No 1 (2009)

Protective stoma

Protective stoma

• Avoids anastamotic leakage following ISR for

ultra-low rectal cancer• Alleviates the anal incontinence in the early

postoperative period• Conducive to the restoration of anal function. Zuo ZG etalZhonghua Wai Ke Za Zhi. 2010 Oct 1;48(19):1479-83

Risk factors for AL

• Anastamotic leakage is a serious early complication following surgery for rectal cancer.

• The height of the anastamosis and neoadjuvant therapy are the main predictors of an increased risk.

• A diverting stoma diminishes the consequences of risk and reduces the need for emergency re-operation.

• Moran BJ,Acta Chir Iugosl. 2010;57(3):47-50

• Use is controversial.

• RCT and meta analysis failed to establish any benefit.

• In the absence of data suggesting any harm we prefer to use drains in Colorectal Surgery.

Pelvic Drains and AL

• 655 patients; 39 AL (6%)• Fever>38O C on day 2• Absence of bowel action on day 4• Diarrhea before day 7• Drainage more than 400 ml 0-3 day• Renal failure on day 3• Leukocytosis after day 7

Alves A & all, J AM Coll Surg, 1999, 189:554-9

Suspicion of AL

• Pelvic abscess, localised collections (transanal USG, CT)

• Controlled leaks with distal patency-Conservative• Broad Spectrum Antibiotics; TPN?• Increasing leaks; Defunction with stoma• Peritonitis-Emergency surgery Stoma; Take down anastamosis; Hartmans; Paul

Mickuliz• Try to preserve a low anastamosis.• Whenever in doubt; go for a stoma

Management of AL

• Our parents decided not to teach us Chinese. It was an era when they felt we would be better off if we didn't have that complication. Maya Lin

• The urogenital tract is most at risk of injury during surgery for locally invasive colorectal malignancy

• Advanced inflammatory bowel conditions

• Previous history of pelvic irradiation

• Presence of fibrosis or adhesions

• Previous pelvic surgery

• Radical pelvic lymphadenectomy

Urogenital Complications

4 specific points:• Ist-High ligation of IMA-Junction of

upper third and middle third ureter• 2nd-Mobilization of upper mesorectum

near Sacral Promontory.• 3rd-Anterolateral dissection between

lower rectum, pelvic side wall, bladder base.

• 4th-Cephalhead part of perineal phase at uretrovesical junction.

Ureteral Injuries

Types of Ureteric Injury

• The Golden Rule is Early recognition• Time of diagnosis is most important independent

factor determining outcome• Best prognosis in those diagnosed intra-op and

treated appropriately• Only 30-45% of iatrogenic ureteral injuries

diagnosed early• Nephrectomy early diagnosis 2.4% late diagnosis 18.4%

Recognition of ureteric injury

• Surgical exploration of retro peritoneum with direct visualization of wall of ureter

• Ligature• Contusion• Hemorrhage• Disruption• IV indigo carmine or methylene blue with

inspection for Ureteral dye leakage

Intra op Identification

• Ultrasound dilatation of upper urinary system

• IVP delayed renal function• Ureteric dilatation or deviation• Extravasation of contrast• Non-visualisation of ureter• Contast CT dilated upper urinary system• Urinoma• Retrograde most sensitive radiographic

study; allows stent placement• Aspirate from drain or wound for Cr and

Urea estimation

Diagnosis of missed injuries

Upper third •Uretero-ureterostomy (end to end)•Uretero-calicostomy•Transuretero-ureterostomyMiddle third •Uretero-ureterostomy•Transuretero-ureterostomy•Boari flapLower third •Neoimplantation•Psoas hitchTotal loss of ureter•Ileal interposition•Autotransplantation•Nephrectomy

Uretero-ureterostomy

• Uretero-ureterostomy (end-to-end anastamosis).

• Ureteral end should be debrided and freshened.

• The end are spatulated.• Internal JJ stent.• Closure interrupted 4-0 Polyglactin.• Bladder catheter – 2 days.• Stent – 6 weeks.

Ureterocalicostomy

• Amputation of the lower pole of kidney• Ureter end debrided, spatulated• Interrupted 4-0 polyglactin• Catheter: 2 days• Stent – 6 weeks

Transuretero-ureterostomy

• Upper part of effected ureter transposed across midline.

• 1.5 cm ureterotomy, medical aspect of contralateral Ureter .

• Stent, watertight anastomosis (4-0 polyglactin.

• Catheter: 2 days.• Stent – 6 weeks.

Mobilization of the bladder flap (Length: width=3:2)

Anti-reflux implantation through submucosal tunnel

Boari flap 1

Boari flap 2

Running suture4-0 Polyglactin Ureteral stent 6 weeksCatheter 2 days

Remember

• Extreme complication is contrary to art. Claude Debussy

• Frequent in adherant rectosigmoid tumor.

• Recognized usually on table.

• Repair in 2 layers with a catheter in for 7-10 days.

• Late presentations present as pneumaturia, fecaluria, or urine in abdomen.

• Urinary/Fecal diversion followed by reparative surgery .

Bladder Injury

• In APR –Perineal dissection• Injury in membranous or

prostatic portion• Visualization of Foley catheter. Small injuries - repair with 50

suture with catheter in for 2-4 weeks

Large injuries - Suprapubic diversion with delayed repair with gracilis urethral reconstruction.

Urethral Injuries

Sympathetic roots form HypogastricPlexus (B) at level of Aortic bifurcation (A)• Hypogastric nerves (C) lateral

to ureter and internal iliac vessels

• Pelvic autonomic plexus (D) at lateral pelvic wall

• Parasympathetic fibres run along nervi erigentes to reach inferior hypogastric plexus (E) located anterior and lateral to the rectum

ANS Complications

1. Hypogastric plexus (aortic bifurcation) during high ligation of IMA.

2. Injury to the pelvic plexus during lateral dissection.

3. Cavernous nerves/ Nervi erigenti during anterior mobilization of the rectum where the anterior rectal wall is only separated from prostate and seminal vesicles by fascia of Denonvillier’s.

High Risk Areas for Neuronal Damage

Mesorectum

Improves Q OL in Rectal Cancer

Nerve sparing resection

Mesorectum

Nerve sparing resection

Incidence of impotence following AP resection 15-92% Nerve preserving surgery – better potency rates 14-73%

• Superior hypogastric plexus(sympathetic)-High ligation of IMA

• Hypogastric nerves at Sacral promontory-Mobilization of upper mesorectum

Retrograde Ejaculation-Commonest S D Usually resolves in 6-12 months.• Damage to Pelvic nerves-in lateral

dissection• Nervi erigentes or Cavernous nerves –

Anterior dissection-erectile dysfunction

Sexual Dysfunction

• Best treatment is Prevention• Highest risk of Para sympathetic

injury is in the plane anterior to Denonviller’s fascia and flush with the posterior aspect of seminal vesicles and prostate.

• In women-difficult to quantify• Dyspareunia,Inability to produce

Vaginal lubricant and achieve orgasm (10-20%).

Sexual Dysfunction

• Decreased Fertility• >50%; defined as one year of

unprotected intercourse without conception

• Possible explanation is pelvic abdominal adhesions

• Trapped Ovary Syndrome• Prevention-Hitching the ovaries

and adnexa to anterior abdominal wall outside the pelvis/Wrap with anti adhesion barrier.

Female infertility

• Frequent complication of operation on the sigmoid colon and anorectum

• Cause remains uncertain• Inability to pass urine in the supine

position• Pain inhibits micturition• Presence of concomitant BPH and

some degree of LUTSUrethral catheter for few days; adequate analgesia; early mobilization

• Alfa-blockers• TURP

Acute Retention of Urine

• Operative injury to pelvic autonomic nerves• Clinical manifestations vary according to location and

extent of injury• Permanent lesions following complete transaction of

main nerves• Transient dysfunction following traction or diathermy injury of the main nerves or complete transaction of

the peripheral branches• Only 10% of functional urinary complications are permanent

Functional Urinary Complications

Autonomic nerve injury presents as:• Bladder atony with overflow

incontinence and loss of sensation• Urge incontinence due to overactive

bladder• Stress incontinence secondary to

damage to sphincter innervations• Voiding dysfunction secondary to

Detrusor-Sphincter-Dyssynergia• UTI• Mixed picture

Functional Urinary Complications

• Apparent successful micturation following surgery -not always indicative of normal bladder function (Chaudri et al 2006)

• High index of suspicion after difficult surgery

• Ultrasound bladder for residual urine • Urodynamic assessment ASAP in patients

who develop neurogenic bladder• Early detection and appropriate treatment

of paramount importance.

Functional Urinary complications

• Colocutaneous-Conservative; reoperation 3-6 months.

• Colovaginal-Spontaneous closure is rare ,Proximal Stoma

Reparative surgery 6-12 weeks with mucosal flaps,sleeve advancements,redo coloanal anastamosis(Turn bull Cutait pullthrough)

• Chronic presacral abscess or sinus

Fistulae

• may be the end result of leak or ischemia

• Presents 2-12 months post surgery• CT/PET to exclude a recurrence• Low anastamosis managed by regular

dilatation.• High anastamosis-Endoscopic balloon

dilatation• Revision surgery /Permanent fecal

diversion

Anastomotic Stricture

• Recognition and prevention of Bowel Ischemia –important

• Timely intervention- worthwhile.• Remember resolution of complete

obstruction with expectant management is <20%.

• Early obstruction(30 days POP)-Usually by intense inflammatory response; immediate surgery has disastrous consequences.

Small Bowel Obstruction

• Infection rates are high(1010anaerobes &10 8

aerobes/gm of stool).• Present Usually on

5thPOD;Erythema,warmth,tenderness,fever,purulent discharge.

• Manage by opening a part of incision to allow drainage.

• Antibiotics given if cellulitis is present.

Wound Infections

• Necrotic tissue-Debride n allow healing.

• Large wounds-Debride-followed by VAC closure.

• Deep infections-debridement under GA.

• Invasive wound infection-Clostrid Perf,B-hemolytic .

• Atypical presentation-minimal skin changes.

• Fever and severe wound pain.• Drainage of Grey fluid-

necrotizing infection.

Wound Infections

• Result from anastamotic leaks, enterotomies, spillage at surgery.

• Fever ,leukocytosis, pelvic pain 5-7 days.

• US/CT guided drainage through a safe window.

• Success rate usually 65-90%.

Intra-abdominal Abscess

• Major cause of morbidity after APR 11-50%.

• Reason-Dead space.• Prevention-Re approximation of

sc tissue, suction drainage, omental flap.

• Dressing,Debridement,VAC.• Chronic perineal sinus-Closure

of defect,myocutaneous flap.

Perineal wound infection

Cochrane Systemic Review of RCT

• Lap resection of ca colon is associated with long term outcome that is similar to open colectomy.

• Lap surgery for ca upper rectum is feasible but more RCTs need to be conducted to assess long term outcome.

Cancer Treatment Reviews. Oct 2008;34(6):498-504

Lap or Open ?

• 4555 patients were analyzed from 10 RCTS; 2159 in the Laparoscopic Group and 1896 in the Open Group.

• A higher total intraoperative complication rate (OR 1.37, P = 0.010) and a higher rate of bowel injury in the Laparoscopic Group (OR 1.88, P = 0.020).

• No difference in the rate of intraoperative hemorrhage or solid organ injury.

• CONCLUSION:• Laparoscopic colorectal resection is associated with a significantly

higher intraoperative complication rate than equivalent open surgery

Sammour T etal. Ann Surg. 2011 Jan;253(1):35-43.

How to reduce accidents?

• Proper planning• Team work• Surgeons Experience• Volume• Help• Lymph node yield• Follow up

• Update yourse• Don’t add to miseries by inappropriate

management• High index of suspicion• Stomas to be used liberally• Catheters removal- after 5 days in LAR• Proper Selection• Complications-Scientific management and referral

Take Home Message