Late leak from stapled anastomosis presenting as remote abscess

Abstract

Pelvic ileal reservoirs: D. G. Nasmyth et al. 5.6. f.Coran AG. New surgical approaches to ulcerative colitis in children and adults. World J Surg 1985; 9 203-13. Parks AG, Nicholls RJ. 2 3 459-66. 9. 11.Case report 12.13.14. 15.16. 17.Johnston D, Williams NS, Neal DE, Axon ATR. A 53-year-old man underwent anterior resection for a Dukes' B adenocarcinoma (poorly differentiated) of the upper rectum. The anastomosis was performed with an EEA circular stapling device, using the 31 mm head. Two complete rings of intestine were present in the cartridge. He made an uneventful recovery and was discharged on the tenth postoperative day. Three months after surgery he received a course of radiotherapy (4000 rad in 20 doses over 29 days). He remained well until 20 months, when he presented with general malaise and pain and inability to flex his left hip. Although there were no signs of an abscess, pelvic X-rays revealed gas over the left hip.The abscess was drained, releasing a large amount of gas and pus, followed by faeces. His general condition improved, and a defunctioning loop colostomy was performed 2 days later. The distal colon was washed out with irrigating fluid until the effluent from both the rectum and abscess site was clear. Colonoscopy revealed a posterior dehiscence with local abscess formation. Biopsies showed granulation tissue, starch granulomata and normal rectal mucosa from adjacent bowel.Excision of the anastomotic area of bowel, and a colo-anal sleeve anastomosis was performed as a delayed procedure 3 months later. The old abscess cavity posterior to the dehiscence was packed with mobilized omentum. Two months after this procedure, and after a normal distal loop barium enema, his colostomy was closed. He remains well 2 years following this procedure. Present address: Queen Elizabeth Hospital, Birmingham, U K 3 November 1985 DiscussionStapling devices are being used more frequently for not only the 'difficult' anastomoses in sphincter-saving resections, but also in more accessible sites. In a review of the subject, Williams' showed variation in leak rates from 3.4 per cent to 40 per cent (the larger figures include subclinical radiological diagnoses). The consequences of these included peritonitis, fistula formation or abscesses. Fielding et al.' reported three cases of late disruption of initially satisfactory stapled anastomoses. These all occurred within three weeks of operation. A complete staple ring was seen on X-ray in all cases immediately postoperatively, and this was found to be disrupted at later investigation. Disruptions have been reported up t o 12 months postoperatively3. This problem has not been confined to the large bowel. Late disruptions of stapled gastrojejunal anastomoses have also been described ' .Although high complication rates have been reported following pre-operative radiotherapy, the Medical Research Council working party4 showed a reduction in anastomotic leak rates. In our case there was n o histological evidence of radiation enteritis.Remote abscesses have not been previ...

Very Early Colorectal Anastomotic Leakage within 5 Post-operative Days: a More Severe Subtype Needs Relaparatomy

“…Generally, early AL is associated with severe general peritonitis responsible for emergency relaparatomy and increased motality rate910. By contrast, late AL is associated with long lasting pelvic abscess11121314. Definition of late AL is generally regarded as leakage occurred one month after surgery121315 or patient’s discharge16 from majorities of literature.…”

Late Disruption of Stapled Anastomosis – When and Why

“…In all of the patients with late disruption of stapled anastomosis reported in the literature the first clinical signs of leakage appeared from a few weeks [1] to several months [2] and up to 1-2 years [3,4] after performance of the anastomo sis. In most of these cases the integrity of the anastomosis was proven by the two methods described.…”

“…Among the few cases of late disruption of stapled anas tomosis reported in the literature [1][2][3][4] the clinical signs of anastomotic leak appeared from a few weeks up to 2 years after performance of the anastomosis. In the case hereby described a 75-year-old man underwent low ante rior resection with an EEA stapler because of rectal carci noma and almost 3 months later was readmitted because of acute abdomen and septic shock, with the finding of fecal peritonitis caused by breakdown of the anastomosis.…”

Late Dehiscence of Circular Stapled Anastomoses

“…In most cases the reason for the anastomotic compli cation remained obscure [8,18,19,21,27], Burke et al [11] blamed a heavy Christmas meal causing complete separation of a stapled esophagojejunostomy 5 weeks postoperatively. Distension of the anastomosis or effort to defecate were stated by Daucé et al [ 13] and Malvy et al [22].…”

“…Recent reports on late dehiscence of stapled circular anastomoses 3 weeks up to 20 months after surgery raised doubt on the reliability of this technique [8,11,13,15,16,18,19,21,22,24,26,28] (table 1). This com plication is unknown in manually sutured anastomoses and still remains unexplained, but a different healing pattern which leads to an impaired mechanical strength is discussed [14], Thus, an experimental study was de signed comparing the bursting pressure of hand-sewn and stapled colonic anastomoses in dogs.…”