Complications and management in Colon and Rectal surgery
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Complications and management in Colon and Rectal surgery

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I am sharing this presentation of Dr Fazl of Srinagar. He presented this at BHU

I am sharing this presentation of Dr Fazl of Srinagar. He presented this at BHU

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Complications and management in Colon and Rectal surgery Complications and management in Colon and Rectal surgery Presentation Transcript

  • FAZL Q PARRAY MS,FICS,FMAS,FACRSI Additional Professor Department of Surgery Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar-190011,J &K, INDIA E-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
  • • 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
  • 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
  • • 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)
  • • 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
  • • 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 reoperation. • 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.
  • • • • • • • • 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
  • • 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
  • • 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
  • • • • • 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.
  • • 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%
  • • 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
  • • 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
  • Upper third • Uretero-ureterostomy (end to end) • Uretero-calicostomy • Transuretero-ureterostomy Middle third • Uretero-ureterostomy • Transuretero-ureterostomy • Boari flap Lower third • Neoimplantation • Psoas hitch Total loss of ureter • Ileal interposition • Autotransplantation • Nephrectomy
  • • 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.
  • • • • • • Amputation of the lower pole of kidney Ureter end debrided, spatulated Interrupted 4-0 polyglactin Catheter: 2 days Stent – 6 weeks
  • • 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
  • Running suture 4-0 Polyglactin Ureteral stent 6 weeks Catheter 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 .
  • • 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.
  • Sympathetic roots form Hypogastric Plexus (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
  • 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.
  • Nerve sparing resection Mesorectum Improves Q OL in Rectal Cancer
  • Nerve sparing resection Incidence of impotence following AP resection 15-92% Nerve preserving surgery – better potency rates 14-73% Mesorectum
  • • 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
  • • 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%).
  • • 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.
  • • • • • • • • 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 LUTS Urethral catheter for few days; adequate analgesia; early mobilization Alfa-blockers TURP
  • • 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
  • 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
  • • 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.
  • • 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
  • • 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
  • • 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.
  • • Infection rates are high(1010anaerobes &10 8 aerobes/gm of stool). • Present Usually on 5thPOD;Erythema,warmth,tende rness,fever,purulent discharge. • Manage by opening a part of incision to allow drainage. • Antibiotics given if cellulitis is present.
  • • Necrotic tissue-Debride n allow healing. • Large wounds-Debridefollowed by VAC closure. • Deep infections-debridement under GA. • Invasive wound infectionClostrid Perf,B-hemolytic . • Atypical presentation-minimal skin changes. • Fever and severe wound pain. • Drainage of Grey fluidnecrotizing infection.
  • • 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%.
  • • 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.
  • 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. 2008;34(6):498-504 Cancer Treatment Reviews. Oct
  • 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