Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal ...Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy(Hartmann's procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.展开更多
BACKGROUND Slow transit constipation(STC)has traditionally been considered as a functional disorder.However,evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic...BACKGROUND Slow transit constipation(STC)has traditionally been considered as a functional disorder.However,evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology.If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment,surgical intervention with subtotal colectomy may be effective.The most unwanted complication of the procedure is anastomotic leakage,however,preservation of the superior rectal artery(SRA)may reduce its incidence.AIM To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.METHODS This was a single-center retrospective observational study.STC was diagnosed after a series of examinations which included a colonic transit test,anal manometry,a balloon expulsion test,and a barium enema.Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018.The operation time,blood loss,time to first flatus,length of hospital days,and incidence of minor or major complications were recorded.RESULTS A total of 32 patients(mean age,42.6 years)who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA.All patients were diagnosed with STC after a series of examinations.The mean operative time was 151 min and the mean blood loss was 119 mL.The mean day of first time to flatus was 3.0 d,and the mean hospital stay was 10.6 d.There were no any patients conversions to laparotomy.Post-operative minor complications including 1 wound infection and 1 case of ileus.There was no surgical mortality.No anastomosis leakage was noted in any of the patients.CONCLUSION Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection.Sparing the SRA may protect against anastomosis leakage.展开更多
文摘Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy(Hartmann's procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
基金This study protocol was reviewed and approved by the Institutional Review Board of the Taiwan Adventist Hospital(TAHIRB No.:105-E-10).
文摘BACKGROUND Slow transit constipation(STC)has traditionally been considered as a functional disorder.However,evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology.If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment,surgical intervention with subtotal colectomy may be effective.The most unwanted complication of the procedure is anastomotic leakage,however,preservation of the superior rectal artery(SRA)may reduce its incidence.AIM To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.METHODS This was a single-center retrospective observational study.STC was diagnosed after a series of examinations which included a colonic transit test,anal manometry,a balloon expulsion test,and a barium enema.Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018.The operation time,blood loss,time to first flatus,length of hospital days,and incidence of minor or major complications were recorded.RESULTS A total of 32 patients(mean age,42.6 years)who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA.All patients were diagnosed with STC after a series of examinations.The mean operative time was 151 min and the mean blood loss was 119 mL.The mean day of first time to flatus was 3.0 d,and the mean hospital stay was 10.6 d.There were no any patients conversions to laparotomy.Post-operative minor complications including 1 wound infection and 1 case of ileus.There was no surgical mortality.No anastomosis leakage was noted in any of the patients.CONCLUSION Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection.Sparing the SRA may protect against anastomosis leakage.
