Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection

Abstract

BACKGROUND: Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE: The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted in a tertiary referral center. PATIENTS: All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS: Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES: Primary end points were procedural characteristics and 90-day major complications. RESULTS: In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS: A limitation of this study is the relatively small sample size. CONCLUSIONS: This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA ANTECEDENTES: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis. OBJETIVO: El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica. DISEÑO: Este es un estudio de cohorte retrospectiva. ESCENARIO: Este estudio se realizó en un centro de referencia terciario. PACIENTES: Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018. INTERVENCIONES: La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional. PRINCIPALES MEDIDAS DE RESULTADOS: Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días. RESULTADOS: En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente. LIMITACIONES: La limitación de este estudio es el tamaño relativamente pequeño de la muestra. CONCLUSIONES: Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.

Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review

“…If severe complications after low colorectal anastomosis occur, colostomy seems to be the only life saving option, but most patients will never been restored, remaining with a definitive colostomy. Redo surgery remains a challenge, even in experienced centers, and restoration of intestinal continuity represents an option in selected fit and motivated patients, with success rate of 68%; while in chronic presacral sinus intersphinteric proctectomy with terminal colostomy might be a possible solution [8] .…”

“…The severity classifications of these complications do not allow us to solve some of the problems that the surgeon has to deal with on a daily basis, especially when they are associated with severe sepsis. Treatment can range from the simple placement of drains, in order to evacuate an infected collection, to the positioning of prostheses to cover fistulas [6] , to the insertion of suction drains, to re-intervention, such as disassembly of the anastomosis and creation of a terminal colostomy [7] and/or intersphinteric completion proctectomy with mininvasive approach [8] . Unfortunately, a large majority of colostomy patients will never been restored.…”

Dealing with Complications of Colorectal Surgery Using the Transanal Approach—When and How?

“…Combining the abdominal top-down dissection and the TAMIS bottom-up dissection with rendezvous at the level of the vesicles generally ensures a very controlled and safe operation. 43 The use of a TAMIS platform significantly contributes to the quality of the debridement and facilitates the dissection of the distal rectal cuff for constructing a redo anastomosis, even with the possibility of a stapled redo anastomosis in patients with a relatively high primary anastomosis.…”

“…Transanal minimally invasive redo surgery compared with conventional treatment showed a restored continuity rate of 72 versus 61% and it was possible to make a stapled anastomosis more often (62 vs. 0%). 43 In addition, the transabdominal part of the operation could be done more often minimally invasive.…”

Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer—a 10‐year experience of a national referral centre

“…This can be the new colonic conduit in the case of a redo anastomosis, while in the non‐restorative setting pelvic filling is obtained by a pedicled omentoplasty or a tissue flap [11–13]. Over the last decade, novel treatment options and techniques have been implemented in an attempt to improve outcomes, such as endoscopic vacuum therapy, transanal minimally invasive surgery (TAMIS) for better access to the area of sepsis deep within the pelvis and fluorescence angiography to verify a well perfused colonic conduit, omentoplasty or tissue flap [14–17].…”