Suture dehiscence may represent a threatening complication of rectal surgery, and for sure entails the main cause of mortality and morbidity. For years it has been thought that surgical complications had to be treated surgically. Nowadays the continuous research of minimally invasive approaches has allowed the development of several endoscopic options for possible management of these kind of complications. The first case shows a patient who had undergone neoadjuvant chemoradiotherapy for rectal cancer followed by total mesorectal excision and loop ileostomy. He developed a fistula in the immediate postoperative time, to which a progressive stenosis of the anastomosis was associated. Previous conservative management failed to achieve closure of the fistula. Further endoscopic attempt with standard hemoclips were also unfruitful. When the patient came to our observation we applied on the small orifice (about 3 mm) an Over-The-Scope-Clip which due to its characteristics of wide opening and large amount of tissue entrapment obtained a mechanical closure of the orifice followed by fibrotic healing. The second case shows a patient with an early anastomotic fistula and stenosis after anterior resection for rectal cancer. After fluoroscopic study of the anastomosis and advancement of a guide wire we treated the case with a fully covered metallic stent which was easily kept in place by the substenotic lumen. The stent was removed after 4 weeks and a regular healing of the rectal wall beneath could be observed. The third case shows a patient who experienced an acute dehiscence of the surgical suture after a Delorme procedure for rectal prolapse. The wide and deep cavity communicated to the vagina through a fistula. After accurate debridment and flushing with antiseptic solution, and Endovac therapy was attempted, substituting the sponge every 48 h initially and less frequently then. We verified the closure of the fistula 2 weeks later, with complete healing 2 more weeks later, and complete closure of the perirectal cavity 8 weeks after the beginning of the treatment. In conclusion, flexible endoscopy offers today a variety of effective opportunities to manage rectal dehiscence complications of surgery.
Endoscopic management of acute and chronic rectal dehiscence
AREZZO, Alberto;MORINO, Mario
2011-01-01
Abstract
Suture dehiscence may represent a threatening complication of rectal surgery, and for sure entails the main cause of mortality and morbidity. For years it has been thought that surgical complications had to be treated surgically. Nowadays the continuous research of minimally invasive approaches has allowed the development of several endoscopic options for possible management of these kind of complications. The first case shows a patient who had undergone neoadjuvant chemoradiotherapy for rectal cancer followed by total mesorectal excision and loop ileostomy. He developed a fistula in the immediate postoperative time, to which a progressive stenosis of the anastomosis was associated. Previous conservative management failed to achieve closure of the fistula. Further endoscopic attempt with standard hemoclips were also unfruitful. When the patient came to our observation we applied on the small orifice (about 3 mm) an Over-The-Scope-Clip which due to its characteristics of wide opening and large amount of tissue entrapment obtained a mechanical closure of the orifice followed by fibrotic healing. The second case shows a patient with an early anastomotic fistula and stenosis after anterior resection for rectal cancer. After fluoroscopic study of the anastomosis and advancement of a guide wire we treated the case with a fully covered metallic stent which was easily kept in place by the substenotic lumen. The stent was removed after 4 weeks and a regular healing of the rectal wall beneath could be observed. The third case shows a patient who experienced an acute dehiscence of the surgical suture after a Delorme procedure for rectal prolapse. The wide and deep cavity communicated to the vagina through a fistula. After accurate debridment and flushing with antiseptic solution, and Endovac therapy was attempted, substituting the sponge every 48 h initially and less frequently then. We verified the closure of the fistula 2 weeks later, with complete healing 2 more weeks later, and complete closure of the perirectal cavity 8 weeks after the beginning of the treatment. In conclusion, flexible endoscopy offers today a variety of effective opportunities to manage rectal dehiscence complications of surgery.
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