complications and management in colon and rectal surgery
DESCRIPTION
I am sharing this presentation of Dr Fazl of Srinagar. He presented this at BHUTRANSCRIPT
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:[email protected]
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