Low Incidence of Pelvic Sepsis Following Hartmann’s Procedure for Rectal Cancer – A Retrospective Multicentre Study

Background Results of previous studies regarding pelvic sepsis after Hartmann’s procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated. Methods Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007–2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model. Results A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20–92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54–35.36) and BMI over 25 kg/m2 (OR 5.26, 95% CI 1.80–19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery. Conclusion Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.

1522 Management of Benign Anastomotic Strictures Post-Rectal Resection: A Systematic Review

Aim Approximately a third of all colorectal cancers diagnosed in the UK each year are rectal in origin and will undergo surgical resection with formation of an anastomosis. Focus is placed on techniques to ensure anastomotic integrity however an anastomotic leak, pelvic sepsis, distance to the anal verge and stapler choice are all established risk factors for the formation of a benign anastomotic stricture. This review aimed to assess the use of endoscopic salvage techniques in an attempt to avoid surgical re-intervention. Method A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were detected by scanning the references of relevant papers. Results A total of 40 papers were included focusing upon balloon dilation, stent insertion, electroincision, stapler stricturoplasty and corticosteroid use. Endoscopic balloon dilatation remains the most commonly used technique in the management of anastomotic strictures, with a low complication rate despite the frequent requirement for repeated dilatations. Although established in the role for malignant obstruction, stent insertion is yet to gain an established role in the benign setting. Conclusions Benign anastomotic strictures can be a significant problem post-rectal resection, impacting upon quality of life and requiring repeated intervention. Endoscopic management should be utilised in the primary setting to avoid surgical re-intervention. Standardisation of these methods is imperative in establishing the best modality of treatment. For refractory strictures a low threshold of suspicion for malignant recurrence should be maintained.

Multidetector Computed Tomography Evaluation of Uncommon Acute Post-Caesarean Section Complications

Introduction. The most common major abdominal surgery in women is caesarean section. Despite being a safe procedure, a variety of complications, both acute and chronic, can occur. About 14.5% of caesarean sections result in complications. Infection followed by postpartum haemorrhage is the most frequent complication. Imaging modalities such as ultrasonography and multidetector computed tomography are often used in the evaluation of suspected uncommon post-caesarean complications. Computed tomography has been found to be a good initial modality for assessing acute postoperative complications after caesarean delivery. The objective of the research was to evaluate the imaging findings and the characteristic visual manifestations of atypical acute complications of caesarean section, other than common complications such as postpartum haemorrhage, wound infection, etc. Materials and Methods. This prospective study was carried out at the Department of Radiodiagnosis and Imaging, Government Medical College, Srinagar from June 2019 to February 2020 in collaboration with the Department of General Surgery and Gynaecology and Obstetrics of the Sher-i-Kashmir Institute of Medical Sciences. All patients with suspected complication in the immediate post-caesarean period were evaluated with contrast-enhanced multidetector computed tomography. Results. Out of 427 patients who underwent caesarean section, 25 patients were suspected of having uncommon acute complications. Out of 25 patients evaluated for suspected immediate post-caesarean complication, only 5 patients had bladder flap hematoma, 8 patients were diagnosed with uterine dehiscence, 6 patients had uterine rupture, 3 patients suffered from ureteral injury, 1 patient had gossypiboma, 2 patients developed pelvic sepsis. Conclusions. Multidetector computed tomography plays an important role in detection and confirmation of multiple acute complications after caesarean delivery and can also help in guiding the management of complications as well.

P268 Ileal Pouch-Anal Anastomosis Complications and Pouch Failure: A Systematic Review and Meta-Analysis

Background Previous studies demonstrated wide variation in postoperative complication rates following ileal pouch-anal anastomosis (IPAA). This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Methods A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from 1 January 2010 to 6 May 2020. A meta-analysis was performed using a random effects model. The relationship between pouch-related complications and pouch failure was assessed using Spearman’s correlations. Results Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95%CI5.56–10.59) and 10.3% (95%CI7.24–14.30) for studies with a median follow-up of ≥5 years and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1–17%), pelvic sepsis (2–18%), fistula (1–30%), stricture (1–34%), pouchitis (11–61%) and Crohn’s disease of the pouch (0–18%). Pelvic sepsis (r=0.51, p<0.05) and fistula (r=0.63, p<0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r=0.77, p<0.01). Conclusion Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to increased risk of pouch failure. Pouch survival may be improved through standardized assessment of anastomotic integrity for early identification and adequate management of anastomotic leaks.

Dorsal approach with tailored partial sacrectomy and gluteal V–Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

Background Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue. Case presentations Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity. Conclusion The dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background. Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods. A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results. Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients’ quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions. The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.