Delayed Anastomotic Dehiscence after Low Anterior Resection for Rectal Cancer

1
Delayed Anastomotic Dehiscence after Low Anterior
Resection for Rectal Cancer

• Torfi Hoskuldsson, MD
• Dr. Robert Sticca, MD
• University of North Dakota

2
Anastomotic Leak

• definition varies between studies
• clinical
• fever
• ileus
• diarrhea before pod 7
• 400 mL in drain by pod 3
• leukocytosis after pod 7

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Anastomotic Leak

• Bruce reviewed 97 studies
• 56 different separate definitions for g.i. leaks
• upper g.i. - 13
• hepatopancreaticobiliary - 14
• lower g.i. - 29
• cutoff at pod 30
• cutoff at hospital discharge

4
Anastomotic Leak

• radiological imaging
• contrast enema
• CT scan with rectal contrast
• Goligher performed routine rectal contrast
  studies of anastomoses
• 51 dehiscence rate
• asymptomatic leaks are between 6-30

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Potential Risk Factors for Anastomotic Leak

• neoadjuvant radiation therapy
• steroid therapy
• diabetes
• malnutrition
• male gender
• level of anastomosis
• technical factors
• blood supply
• tension
• condition of bowel ends
• stapled vs. hand sewn - both acceptable

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Three Patients with Delayed Dehiscence

• 40 patients underwent LAR at Altru from 2003 -
  2008
• three presented greater than one month after a
  successful operation, with signs and symptoms of
  leak (7.5)

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3 Patients

• Ages - 60-67
• 2 males, 1 female
• all had hypertension
• 2 had preoperative chemotherapy, one of those had
  preoperative radiation therapy

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3 Patients

• Stage II - IV
• low anterior resection
• discharge home - pod 6-9
• symptoms - fevers, bleeding, pain
• diagnosis of dehiscence - 7 to 12 months after
  operation

9
3 Patients
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Outcome of Patients

• Pt. A had LAR with loop ileostomy
• 36 days later diagnosed with posterior rectal
  dehiscence after workup for fevers
• 7 months later pt clinically well
• flex sig showed a healed rectal pouch
• underwent ileostomy closure
• 4 months later, pt with fevers and discomfort
• colonoscopy - anastomotic dehiscence had recurred

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Outcome of Patients

• Went to specialized referral center
• attempt at transrectal unroofing failed
• continued to have recurrent pelvic abscesses
• underwent abdominoperineal resection 2 years
  after diagnosis

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Outcome of Patients

• Pt. B had 8 months of conservative treatment
  after diagnosis of dehiscence
• fevers, chills, incontinence of stool
• sigmoidoscopy - large posterior rectal cavity
• diverting loop colostomy
• 14 months later underwent APR for persistant
  chronic drainage and pelvic pain

13
Outcome of Patients

• Pt. C had posterior rectal fistula with open
  cavity into presacral space at 12 months after
  operation
• transverse loop colostomy
• continued to have persistant drainage
• passed away 4 years after original operation due
  to metastatic disease

14
3 Patients
15
3 Patients
16
3 Patients
17
Delayed Anastomotic Leak

• search on medline with various search words
• a few articles mentioned this phenomenon in their
  studies, but no specifics about that patient
  population

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Fate of Anastomotic Sinuses

• Arumainayagam assessed the incidence and outcome
  of anastomotic sinuses
• Retrospective study in which outcome potentially
  curative rectal cancer cases over a 7 year span
  was assessed.
• 100 patients identified
• 86 had gastrograffin enema performed prior to
  ileostomy closure

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Fate of Anastomotic Sinuses

• 13/86 (15) - 13 had radiological leak
• 5 (6) had postoperative symptoms
• 8 (9) had para-anastomotic sinus
• Pre-operative radiotherapy was more common in
  sinus group compared to non-sinus group
• Groups not different with respect to chemotherapy

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Fate of Anastomotic Sinuses

• Natural history of para-anastomotic sinus
  patients
• 3 healed spontaneously at 4, 5, and 10 months
• 2 Hartmanns procedures for symptoms
• 1 died 18 months after surgery
• 1 had ileostomy closure, no problems
• 1 had fibrin glue injected into sinus

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Anastomotic Sinus

• Whitlow described 6 patients
• ileal pouch-anal anastomosis - 4
• low colorectal anastomosis - 2
• Length of time between anastomosis and diagnosis
  ranged from one to five months
• Sinus deroofing performed one to eight months
  after diagnosis
• Sinus resolved within one month in 5, the other
  in 12 months

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Anastomotic Sinus
23
Anastomotic Sinus

• Swain assessed 7 patients with anastomotic
  sinuses
• 4 had low anterior resection
• they were symptomatic
• all 7 received fibrin glue injected into sinus
• no sinus recurrences after 3-15 month followup

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Anastomotic Leak

• August described a series of three patients who
  developed delayed complications
• 2 anastomotic leaks occurred 1 year after LAR
• 1 developed a colocutaneous fistula after right
  hemicolectomy
• All three had been started on bevacizumab(Avastin)

25
Conclusion

• Delayed anastomotic leak is probably more common
  than appreciated
• May be related to radiation
• Difficult to treat with conservative measures
• Patients may end up needing APR as definitive
  treatment

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Acknowledgements

• Jay MacGregor
• Staff at Altru medical records
• Geralyn Lunski