Coloanal anastomosis : A helpful technique in difficult

situationsBy

Dr/ Mohamed A. NadaLecturer of General Surgery

Ain Shams University

Coloanal anastomosis pioneered in the 1970s by Sir Alan Parks had become part of the operations used to preserve peranal defecation after proctectomy.

Incidence of leakage zero-18% (Cavaliere et al 1991,

Olagne et al 2000, Schmidt et al 2002, Huh et al 2006).

Incidence of stenosis 3-15% (Cavaliere et al 1991, Olagne et al 2000, Luna- Perez et al 2003, Baik et al 2005, Huh et al

2006).

Incidence of incontinence 4-31% (Benchimol et al 1994,

Olagne et al 2000, Baik et al 2005).

CAA is a savior technique of anastomosis when there is any difficulties while performing low rectal resection anastomosis & unfortunately now a days most CR surgeons (young generation) missed how to do CAA.

Aim of the studyto evaluate the outcome of coloanal anastomosis in Ain Shams University hospitals at the period 2008-2011.

Patient & method•A retrospective analysis of a prospectively collected data.•13 patients had had proctectomy and coloanal anastomosis with defunctioning loop ileostomy. •8 males & 5 females .

•8 for benign lesions (2 megarectum, 1 rectocutaneous fistula, 1 benign stricture , 1 recto prostatic fistula, 2 patients with multiple hamartomas and one patient with rectal adenoma).•5 patients with low malignant rectal tumor 3 out of them with preoperative RCT.•Median age:

1. Benign group 29 years.2. Malignant group 45 years.

How to do?Important technical points

Positioning: Trendelenburg lithotomy position.Mobilization of the colon.

The muscular rectal wall divided at the level of the anorectal ring.In the transanal approach: Retraction.

Rectal mucosectomy: The rectal mucosa was stripped from the dentate line to just above the levators.

A straight end-to end CAA was made; four sutures of 3-0 Vicryl, were placed at four directional points with no tension.

Results & Analysis

Why CAA?

Cause of CAA in the benign group (n=8)

The lesion Cause of CAA

Megarectum & hirschsprung (2)

The lesion above dentate line

Benign stricture (1) Thickened distal stump by fibrosis, failed stapled stricturectomy

Rectocutaneous fistula (1)

Severe thickening of the distal rectum (posteriorly)

Recto urethral fistula (1)

Very huge fistula just proximal to the ARJ

Rectal adenoma (1) & rectal hamartomas (2)

The staplers couldn’t reach safely distal to the lesions

Cause of CAA in the malignant group (n=5)

The lesion Cause of CAA

Advanced Ca rectum & neoadjuvant RCT (1)

Huge mass couldn’t resected from the abdomen (APRA &CAA)

Metastatic Ca rectum & neoadjuvant RCT (1)

Ultralow Ca rectum (1)

Very low tumors, no space to introduce the stapler

Malignant ulcer & neoadjuvant RCT (1)

Very thick distal stump, radiation effect

Low Ca rectum (1) Not convinced by the distal safety margin

Analysis of early complicationscomplication

onset categorization

management

Out- come

Total hospital stay

Dehydration & renal impairment

10 days after discharge

Malignant G. & RCT

Medical treatment

improved Readmitted for 8 days

Burst abdomen

9th day PO

Malignant G. & RCT

Surgical intervention

improved 5 weeks

Pelvic abscess & complete dehiscence of the anastomosis

5th day PO

Benign G. (Multiple hamartomas)

End colostomy followed by delayed re-do.

improved 17 days

Late complications

•2 patients developed anastomotic stenosis (anal dilatation in OPC).•3 patients developed mild to moderate degree of incontinence (Wexner S 4-6).

conclusionProctectomy & CAA is• Not a time consuming.• safe.• technically feasible.• accepted rate of complications.• good functional outcome.

There is a time intraoperatively that I have to change my decision from stapled to hand sewn anastomosis•Extensive fibrosis.•Extensive radiation effect.•Failed stapling.•Narrow pelvis.•Inadequate distal safety margin.

So we believe that It’s mandatory from our senior coloproctology surgeons to train there younger fellows on the technique of hand sewn coloanal anastomosis even before being expert on stapled anastomosis because it could be the safest solution for many intraoperative problems.