First experimental sutureless laser anastomosis of the large bowel

Large bowel anastomoses were successfully performed without sutures on New Zealand white rabbits using 1,064 nm, 0.4-W power pulsating Nd:YAG laser to create tissue welding. PURPOSE: The aim of this study was to assess long-term results of our experimental data and summarize our experimental work on laser colon anastomosis. METHODS: This experimental study investigated long-term integrity, degree of narrowing, animal body weight change, visual findings, microscopic appearance, and collagen concentration of laser colon anastomoses, compared with those of conventional sutured anastomoses at thirty and ninety postoperative days. RESULTS: Two animals in the laser group died without leakage. Postsurgical course in all remaining rabbits studied was uneventful. Bursting pressures in the two groups were equivalent, but the laser group exhibited a consistent narrowing tendency. However, laser anastomoses demonstrated fewer and milder adhesions, and animals showed a better recovery of body weight. Histologically, laser anastomoses showed better layer-to-layer reconstitution without foreign body response and with less fibrosis. Difference in collagen (hydroxyproline) concentration did not reach statistical significance. CONCLUSION: The nature of tissue welding via laser remains undefined, but there is definitely a future for laser bowel anastomosis.     

Experimental laser anastomosis of the colon

PURPOSE: Our previous experimental work showed the feasibility of colon anastomosis using laser; however, it also revealed a narrowing tendency after laser anastomosis. Long-term observation of the postoperative course of laser anastomosis was planned to assess this point. METHODS: Clinical observation and histologic examination of transverse colotomies (average, 21.2 mm) in New Zealand white rabbits (n=12) closed with a 1,064-nm neodymiumyttrium aluminum garnet (Nd:YAG) laser were carried out up to the third postoperative month, compared with closure of colotomies using a single layer of interrupted sutures of 5-0 Maxon^® (Davis & Geck, Pearl River, NY) in a control group (n=12). RESULTS: Whereas the narrowing tendency was observed up to one month after the operation in the laser group (P<0.05), it disappeared at three months following the operation without causing abnormal weight loss during the experiment. Simultaneously, there was again a marked decrease in adhesion formation following laser anastomosis (P<0.01). Collagen fibers were observed earlier in the laser group. CONCLUSIONS: An earlier commencement of collagen synthesis after laser anastomosis was proved. A narrowing tendency, which was observed from seven days to one month postoperatively, disappeared at three months after laser anastomosis without exerting any effect on growth.Supported from private sources (Colorectal Service), by the Colorectal Unit Research Fund, and by a St. Vincent's Hospital Research Grant.     

First sutureless closure of a colotomy: Short-term results of experimental laser anastomosis of the colon

To assess the possibility of laser anastomosis of the colon, experimental laser closure of colotomies was performed. Transverse colotomies (average 20.7 mm) in New Zealand white rabbits (n = 20) were closed with a 1,064-nm Nd:YAG laser at a pulsating 0.5-W wave of power, using guy sutures to approximate the tissue edges. The laser energy was applied through a specially designed hand piece and hand-held 600- m gas-cooled noncontact quartz fiber to produce a satisfactory tissue welding. Similar colotomies were closed using a single layer of interrupted sutures of 5–0 Maxon ^® (Davis & Geck, Pearl River, NY) in a control group (n=20). Bursting pressure and index of narrowing were recorded immediately after anastomosis and at 1, 4, and 7 days following surgery. Bursting pressure of the laser-welded closure at 1 day was significantly lower than that of the sutured controls (P <0.01); however, all rabbits recovered uneventfully. There was a marked decrease in adhesion formation following laser anastomosis (P < 0.05). Conversely, one control rabbit showed functional stenosis at 4 days. Histologic study revealed an accelerated healing in the laser group. The index of narrowing was significantly higher in the laser group than in the control group (P <0.05). The completely water-sealed laser anastomosis reduces adhesions and is comparable to conventional suture anastomosis of the colon.This work was supported by private sources (Colorectal Service), by the Colorectal Unit Research Fund, and by a research grant from St. Vincent's Hospital.     

Healing of ischemic colonic anastomosis: Fibrin sealant does not improve wound healing

Fibrin adhesives have been advocated as a protective sealant in high-risk colonic anastomoses to prevent leakage. To assess the effect of fibrin glue sealing on the healing ischemic anastomosis, we compared the healing of sutured colonic anastomoses in the rat, with and without fibrin adhesive (Groups IA and IB), and ischemic anastomoses with and without fibrin adhesive (Groups IIA and IIB). On days two, four, and seven, 10 animals in each group were sacrificed. Adhesion formation was scored, and the in situ bursting pressure was measured. The collagen concentration and degradation were estimated by measuring hydroxyproline. Adhesion formation was more prominent in Groups IB, IIA, and IIB on day four only; abscesses were noted in the ischemic group in four rats. Anastomotic bursting pressure was significantly lower in sealed (IB) and ischemic anastomoses (IIA) than in normal anastomoses (IA) on day four. Sealing of ischemic anastomoses did not change bursting pressures on days two, four, and seven. The relative decrease of collagen in the sealed anastomoses is significantly higher on day four only. It is concluded that sealing of normal colonic anastomoses in the rat has a negative effect on wound healing. Ischemia at the anastomotic site results in weaker anastomotic strength on day four postoperatively. Also in ischemic anastomoses, fibrin sealant does not improve wound healing during the first seven days. Adhesion formation on ischemic intestinal anastomoses was not prevented by fibrin sealing.     

Fibrin glue improves the healing of irradiated bowel anastomoses

Many surgeons are reluctant to construct a bowel anastomosis with irradiated intestine. Previous studies have demonstrated diminished tensile strength of rat small bowel anastomoses that have been irradiated intraoperatively. To determine whether fibrin glue, a known tissue adhesive, improves the healing of these anastomoses, 69 male Sprague-Dawley rats were randomized into three anastomotic groups: Group 1, sutured ileal anastomosis without radiation or fibrin glue; Group 2, irradiated sutured ileal anastomosis without fibrin glue; and Group 3, irradiated ileal anastomosis with fibrin glue added to the suture line. Groups 2 and 3 received a single dose of 2,000 R intraoperatively. At seven days, the rats were sacrificed and the anastomotic segment was tested for breaking (tensile) strength. Anastomotic collagen content was evaluated using a hydroxyproline assay. Tensile strength results demonstrated that Group 2 was significantly weaker than Groups 1 and 3 (P=0.001) and that the hydroxyproline content of Group 3 was significantly greater than that of Group 2 (P=0.015). These results show that the addition of fibrin glue to an intraoperatively irradiated small bowel anastomosis improves healing, as demonstrated by both tensile strength and hydroxyproline content studies.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.This work was supported in part by the Bowman Research Fund.     

Effect of an omental wrap on the healing and vascularity of compromised intestinal anastomoses

Adult Wistar rats were used to investigate the ability of an omental wrap to limit leakage from compromised intestinal anastomoses. Under ketamine anesthesia, a section of small bowel was divided and then reanastomosed using a control anastomosis, a deficient anastomosis, or an ischemic anastomosis, plus or minus the addition of a wrap of omentum. Initially 10 rats were randomly assigned to each group. Nineteen of the 20 rats with unwrapped compromised anastomoses died within six weeks, compared with five deaths in the rats protected by an omental wrap (Fisher's exact test;P < 0.01). The experiment was then repeated with a sample of rats from each anastomotic group being sacrificed for histologic examination on days 2 to 7, 10, 14, and 42. At the time of sacrifice a dye was injected into the omental vasculature to determine its contribution to the healing anastomosis. An anastomosis could be demonstrated between omental and bowel wall vessels by the third postoperative day. At one week the infarcted bowel edges were being resorbed and the omentum formed a fibrotic cylinder aligning the separated ends of bowel wall. At six weeks the scar became more contracted and the bowel mucosa had started to grow onto its luminal surface. It is concluded from this study that the omental wrap is protective to a compromised anastomosis by providing a biologically viable plug to prevent early leakage and a source of granulation tissue and neovasculature for later wound repair.     

Use of laparoscopic techniques in colorectal surgery

PURPOSE: This study evaluated the feasibility and safety of laparoscopic bowel surgery performed by colorectal surgeons not previously experienced in laparoscopic biliary or appendiceal surgery. METHODS: Thirty-two patients underwent ileocolic resection/anastomosis (n=12), loop ileostomy (n=7), colostomy (n=4), ileostomy takedown/ileorectal anastomosis (n=3), subtotal colectomy/ileorectal anastomosis (n=2), sigmoid resection (n=2), or other procedures (n=2). No curative cancer surgery was undertaken. RESULTS: Time to first bowel movement was one to eight (median, four) days. Length of stay ranged from 4 to 11 (median, 6) days. There were no major complications seen in follow-up from 6 to 15 (median, 7) months after surgery. CONCLUSIONS: Large intestinal and distal ileal surgery using laparoscopic techniques, performed by surgeons with training only in laparoscopic intestinal surgery, is feasible and safe. Faster recovery and need for less postoperative analgesia in laparoscopic surgery compared with conventional surgery cannot be surmised from this study. A randomized study design is needed to evaluate many of the differences between conventional and laparoscopic intestinal surgery.     

The ileosigmoid knot

The ileosigmoid knot (ISK) is a rare cause of intestinal obstruction. Unfamiliarity with the condition could have disastrous consequence at surgery. Over the past 20 years, we have encountered seven cases. Analyzing the data gathered from these, and on reviewing the literature, we found it possible to arrive at a preoperative diagnosis in two patients. Four patients were women, two of whom developed the obstruction in the postpartum period. One of the males was found to have an inflamed Meckel's diverticulum included in the knotting. The symptoms and the clinical findings were nonspecific. The characteristic x-ray findings of a double closed loop obstruction, was seen in only three patients. Resection of gangrenous bowel with anastomoses was feasible in four. Unlike in other series, primary anastomosis of the large gut was undertaken. There were two deaths early in the series. Guidelines to the management have been suggested.     

Is mechanical bowel preparation necessary before primary colonic anastomosis?

The necessity of preoperative or intraoperative mechanical bowel preparation of the colon, before primary anastomosis, has been recently challenged in clinical elective and emergency situations. PURPOSE: This experimental study in dogs investigated the safety of segmental resection and primary anastomosis in the unprepared or loaded colon. METHODS: Two segments of the descended colon were resected and anastomosed in each animal. Group I (12 anastomoses) received preoperative mechanical bowel preparation; the colon was not prepared in Group II (16 anastomoses); in Group III (12 anastomoses), a preliminary distal colonic obstruction was produced, and during the subsequent resection the colon was loaded. Postoperatively, animals were observed clinically, and anastomoses were assessed at autopsy on the ninth day. RESULTS: All animals recovered uneventfully. At autopsy there was no evidence of anastomotic leakage. CONCLUSIONS: In light of recent clinical reports and this experimental study, the ritual of mechanical bowel preparation should be further scrutinized.     

Effect of intraoperative radiation on the tensile strength of small bowel anastomoses

Increasing interest in the use of preoperative or intraoperative radiation therapy for cancer has led to concerns regarding tissue healing and integrity subsequent to treatment. This is especially so for intestinal anastomoses incorporating irradiated bowel, where poor healing may lead to anastomotic disruption and sepsis. One hundred thirty Sprague-Dawley rats were randomized into five groups as follows: both limbs, one limb, or neither limb of an anastomosis received 2,000 R of radiation intraoperatively. A fourth group had a segment of small bowel irradiated, with no anastomosis; a fifth group had the gut exposed by celiotomy. The control groups and all anastomoses underwent tensile strength measurements on the seventh postoperative day, with findings as follows: no anastomosis, no irradiation, 143.75 g; no anastomosis, irradiated, 114.50 g; anastomosis, no irradiation, 85.273 g; anastomosis, one limb irradiated, 78.100 g; anastomosis, both limbs irradiated, 59.00 g. There was no statistical difference in tensile strength of the anastomosis between when neither limb and when just one limb was irradiated. However, when both limbs were irradiated, the loss of strength was statistically significant ( P =0.002). Irradiation damage scores were assigned using Black et al. 's histologic scoring system. These scores were not significantly different between the irradiated segments. Inflammation and fibrosis scores for the anastomoses were also not significantly different. These results indicate that, in rats, anastomotic healing is impaired only when both limbs of the anastomosed intestine are irradiated. The normal strength of the anastomosis with only one limb irradiated cannot be explained by differences in inflammation, fibrosis, or radiation damage and is caused by an undetermined factor.Poster presentation at the meeting of The American Society of Colon and Rectal Surgery, St. Louis, Missouri, April 29 to May 4, 1990.This work was supported in part by the Bowman Research Fund.     

What happens to the Valtrac® anastomosis of the colon?

Late results after colonic anastomoses performed with the biofragmentable anastomosis ring (BAR; Valtrac ^®; Davis & Geck, Wayne, NJ) were evaluated in 30 patients who had undergone a left-sided colonic or rectosigmoid anastomosis a mean of 24.5 (range, 12–38) months earlier. Patients were asked about their late postoperative recovery and their bowel habits. A barium enema was performed, and then a flexible endoscopy was done, during which the anastomotic area was evaluated both in macroscopic terms and histologically. One of the patients had died, and three refused to participate in the investigation. Of the remaining 26 patients, one had been reoperated on 22 months after the primary sigmoid resection. The reason for reoperation was an anastomotic stricture. One of the patients was admitted to the hospital during the study and was operated on for reasons not related to the anastomosis. Twenty-four patients underwent the study scheme. All had recovered uneventfully. Sixteen anastomoses could not be identified radiologically and seven not even during endoscopy. Histologically, there was mild-to-moderate fibrosis and scarring in 17 anastomoses, and, in the seven that could not be identified, only normal colonic mucosa was found. The late results of BAR anastomoses are satisfying, and the rate of complications is acceptable.     

Collagen structural organization of healing colonic anastomoses and the effect of growth hormone treatment

PURPOSE: This experimental study was designed to investigate the collagen fibrils of colonic anastomoses in rats and to compare normal healing with rats treated with biosynthetic growth hormone (bGH). METHODS: The healing zone of left colonic anastomoses was studied at days 2, 4, and 6 after surgery by means of scanning electron microscopy. RESULTS: After four days of healing a normal anastomosis was filled with loosely packed and unorganized collagen fibrils, which were organized into collagen fibers after six days. Compared with normal anastomoses, rats treated with bGH showed a more organized healing, characterized by a dense structure of a new-formed collagen framework of fibrils and immature collagen fibers after four days and with bundles of new collagen fibers after six days. CONCLUSIONS: Healing colonic anastomoses are characterized by new-formed collagen fibrils at postoperative day 4, and bGH seems to stimulate structural organization of the anastomotic collagen fibrils into fibers.Supported by the Danish Medical Research Council, Institute of Experimental Clinical Research, University of Aarhus, Novo Nordisk A/S, Gentofte, Denmark, and the Novo Nordisk Foundation.     

Effect of fibrin glue on irradiated colonic anastomoses

INTRODUCTION: The present study was planned to research the effects of fibrin glue on irradiated colonic anastomoses. METHOD: The effect of fibrin glue on irradiated colonic anastomoses was investigated in four identical groups of rats. In Group I (control group) colonic anastomoses were performed without radiotherapy; in Group II, colonic anastomoses were performed five days after radiotherapy; in Group III, fibrin glue was applied to anastomotic line without radiotherapy; in Group IV, fibrin glue was applied to anastomotic line with radiotherapy. The healing of left colonic anastomoses was evaluated through the bursting pressure of the anastomotic segment and the hydroxyproline contents of the anastomosis. RESULTS: Measurements done on the fourth postoperative day revealed that anastomotic healing was impaired in rats that underwent radiotherapy ( P <0.001); fibrin glue had no effect on anastomotic healing in groups with or without radiotherapy. CONCLUSION: In the early phases of anastomotic healing, fibrin glue cannot help remove unwanted effects of preoperative radiotherapy.     

Predicting the functional result of anastomoses to the anus: The paradox of preoperative anal resting pressure

This article examines the effect of ileal pouch-anal (n=134) and coloanal (n=16) anastomoses on resting anal canal pressures in 150 patients. METHODS: Patients underwent anal manometry before ileal pouch-anal anastomosis (IPAA) and coloanal anastomosis (CAA) and again six weeks after ileostomy closure following these procedures. A water-perfused catheter system with four radial ports was used for manometry, pressures being recorded during both station and continuous pull through. RESULTS: Patients with IPAA were younger than those with CAA (34 years vs. 50 years) and had a different ratio of hand-to-stapled anastomosis (12.6 vs. 1.31). All CAA patients had had rectal cancer while IPAA patients suffered mainly from ulcerative colitis (n=114) or familial polyposis (n=10). The mean preoperative resting pressure for all patients was 79 mmHg (75–87, 95 percent confidence limit) and the mean fall in this pressure after surgery was 25 mmHg (–21 to –29, 95 percent confidence limit). There was no difference in preoperative pressure or fall between handsewn and stapled anastomoses, or between IPAA and CAA. CONCLUSION: There was a significant relationship between preoperative pressure and change in pressure that held true for all subgroups (change=–0.7 × preoperative pressure + 31,r=0.69). Analysis of the functional results confirmed that patients with high preoperative pressure are at risk for severe falls after surgery and are not guaranteed a good result. Conversely, patients with low preoperative pressures may actually have an increase with surgery and are not always incontinent. Patients with low preoperative anal resting pressures should not be denied anastomosis to the anus if they are continent.     

Are intersecting staple lines a hazard in intestinal anastomosis?

To determine the safety of intersecting staple lines, 22 pigs were operated upon with a functional end-to-end enteroanastomosis 40 cm distal to the ligament of Treitz using linear stapling devices. The procedure was repeated on the colon, where a colocolostomy was created. The blood flow at intersecting staple lines and single-row staple lines for each anastomosis was studied with the reference organ method 24 hours after the first operation. The purpose was to evaluate whether there is a reduction in blood flow at the site of intersecting staple lines, causing an increased risk for anastomotic leakage. The reduction in mean blood flow in crossing compared with noncrossing staple lines was 6 percent (–5–17 percent) for small bowel anastomoses and 7 percent (–6–19 percent) for colonic anastomoses. An equivalence test showed that, if a reduction in blood flow exists between crossing and noncrossing staple lines, it is most likely less than 30 percent (P <0.001) for both small bowel and colonic anastomoses. This experimental study demonstrates that intersecting staple lines in small bowel and colonic anastomoses do not reduce anastomotic blood flow to a dangerous level.This study was supported by grants from Johnson & Johnson Sweden AB and The Medical Faculty, Lund University, Lund, Sweden.     

Experience with the use of the circular stapler in rectal surgery

This report provides our personal experience along with a general overview of the use of the circular stapler in rectal surgery. To determine the results of our experience with the use of the circular stapler for construction of anastomoses following resection, a series of 215 anastomoses performed in 214 patients was reviewed. The patients ranged in age from 33 to 88 years. There were 116 men and 98 women. Indications for operation included malignancy, diverticular disease, villous adenoma, Crohn's disease, and rectal procidentia. The types of operation performed included removal of varying portions of the large bowel. The anastomosis was performed in a uniform manner with the EEA ^® (United States Surgical Corp., Norwalk, CT) and more recently the CEEA (United States Surgical Corp., Norwalk, CT). The operative mortality was 0.47 percent, with the death being unrelated to the anastomosis. Intraoperative complications encountered included bleeding, difficult extraction, instrument failure, incomplete doughnuts, deficient anastomoses, and miscellaneous problems. Early postoperative complications included one leak and a number of complications unrelated to the anastomoses. Anastomotic stenosis developed in 27 patients, but only 8 were permanent and only 3 of these were symptomatic. Two of these patients were treated with balloon dilatation. Anastomotic recurrences developed in 131 percent of patients. Our experience gained with the circular stapling device and that reported in the literature have shown it to be a reliable method of performing anastomoses to the rectum in a safe and expeditious manner.This study was conducted with support from The Sir Mortimer B. Davis Jewish General Hospital Foundation and The American Physician Fellowship.     

Efficacy of radioprotective agents in preventing small and large bowel radiation injury

PURPOSE: A variety of adjuvant treatments and cytoprotective agents have been proposed to lessen the toxicity of radiation therapy. The following study was designed to evaluate the benefit of six agents or combinations using anastomotic bursting strength as a measure of transmural radiation injury. METHODS: The 40-Gy study consisted of the following. Seventy-two male Sprague-Dawley rats were divided into eight equal groups: nonradiated control, radiated untreated control, and six radiated treated groups. The radioprotective treatments included ribose-cysteine (RibCys), WR-2721, glutamine, vitamin E, MgCl₂/adenosine triphosphate, and RibCys/glutamine in combination. Radiated animals received 40 Gy to the abdomen. Two weeks after radiation, all animals underwent small bowel and colonic resection with primary anastomosis. Animals were sacrificed one week postoperatively, at which time anastomoses were evaluated and bursting strengths determined. The 70-Gy study consisted of the following. The same protocol was repeated for five groups of nine rats divided into nonradiated, radiated untreated, and three radiated treated groups receiving RibCys (8 mmol/kg), RibCys (20 mmol/kg), and WR-2721. All radiated animals received 70-Gy doses. RESULTS: In the 40-Gy group, there were 10 radiation-related deaths and 6 anastomotic leaks among 70 rats studied. None of the differences between groups were significant. Nonradiated control group small bowel and large bowel anastomotic bursting pressures were significantly elevated compared with all radiated groups. Compared with radiated controls, there were significant improvements in small bowel bursting strength in the RibCys, WR-2721, RibCys-glutamine, and vitamin E groups and significant improvement in colonic bursting strength in MgCl₂/adenosine triphosphate, WR-2721, and RibCys groups. In the 70-Gy group, all nine nonradiated control rats survived. All eight untreated radiated control rats died, four of eight WR-2721 animals died (P=0.03), all RibCys (8 mmol/kg) animals died (P=0.03), and three of nine treated with RibCys (20 mmol/kg) survived (P=0.08). CONCLUSIONS: WR-2721 and RibCys gave consistent protection against large and small bowel radiation injury. The lower incidence of treatment-related toxicity and potentially equal or greater radioprotective effects may make RibCys more clinically useful than WR-2721.Supported by the 1993 ASCRS/ETHICON Surgical Research Fellowship Award and the Minneapolis Medical Research Foundation. Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Anastomotic compression button: A new mechanical device for sutureless bowel anastomosis

The anastomotic compression button is a new mechanical device that uses three interlocking polypropylene buttons to produce a sutureless bowel anastomosis. The device is unique in that it allows application of the buttons via a device similar to the popular intraluminal stapler, but it leaves no staples or foreign body of any kind in the bowel wall. The authors compared the 25-mm anastomotic compression button with the 25-mm intraluminal stapler in the colon of dogs. After 28 days, the mucosal blood flow, burst pressure, and anastomotic indices were found to be identical between the anastomotic compression button and the stapler. The anastomotic compression button was easier to use, and microscopic examination showed less ulceration, fibrosis, and inflammation, and better re-epithelialization at the anastomotic compression button site. The anastomotic compression button appears to have the potential to be a superior method compared with stapled anastomoses in the colon.Supported by Deknatel, A Division of Pfizer Incorporated, Fall River, Massachusetts.     

Strictureplasty for ileocolic anastomotic strictures in Crohn's disease

PURPOSE: Because of the limited experience, the use of strictureplasty for a strictured ileocolic anastomosis associated with Crohn's disease was reviewed. METHODS: We reviewed 22 patients who had a strictureplasty to treat symptomatic ileocolic anastomotic strictures related to Crohn's disease. The median interval between a previous ileocolic anastomosis and strictureplasty was 2 years (range, 1 to 26 years). The median age was 39 years and there were 15 males and 7 females. The median followup was 2 years. RESULTS: Strictureplasty on a strictured ileocolic anastomosis was either a Heineke-Mikulicz (n=15) or a Finney (n=7) strictureplasty. Fifteen (68 percent) patients needed 47 additional strictureplasties in other sites of the small bowel and 5 (23 percent) patients had synchronous small bowel resection mainly for separate areas of phlegmonous disease. Only five (23 percent) patients did not have a synchronous procedure on the small bowel. There was no mortality or major septic complications. After surgery, relief of obstructive symptoms was noted in all patients. The median weight gain at six months after surgery was 3 kg (range, –5 to +10 kg) and 75 percent of the patients were weaned off steroids. Symptomatic recurrence occurred in two (9 percent) patients from new strictures at sites unrelated to previous strictureplasties; only one needed reoperation for recurrence. Patency of the strictureplasty on ileocolic anastomosis in asymptomatic patients was confirmed by small bowel contrast study (n=12) and colonoscopy (n=4). CONCLUSIONS: Strictureplasty preserves small bowel length and may be a viable alternative to repeat ileocolic resection in suitable cases     

Anastomotic-vaginal fistula after colorectal surgery

The most feared complication of anterior and low anterior resection is anastomotic dehiscence. Although most leakages remain clinically silent, some may lead to formation of a colovaginal fistula. At the Lahey Clinic Medical Center, the records of nine patients with colovaginal fistula as a complication of colorectal surgery were reviewed to determine clinical characteristics and optimal management. The mean age was 63.7 years (range, 47–72 years). The initial indications for surgery were carcinoma of the rectum (n=4), diverticular disease (n=3), and closure of the colostomy after Hartmann's procedure (n=2). Hysterectomy had been performed earlier in seven patients (78 percent). The end-to-end anastomosis (EEA ^®)stapling device was used in five patients, and four patients had a handsewn anastomosis. The fistula developed within 23 days after surgery and usually originated within 8 cm of the anal verge. Two patients underwent immediate diverting transverse colostomy. None of the seven patients who were initially managed medically had spontaneous closure of the fistula. High fistulas were successfully treated by colorectal resection in two patients, whereas low fistulas healed after transanal repair without colostomy in two patients. These results suggest that previous hysterectomy predisposes to development of a colovaginal fistula after colorectal surgery. Not all patients require fecal diversion. Colorectal resection for high fistulas and transanal repair for low fistulas appear to be viable options for treatment.Read at the meeting of the New England Society of Colon and Rectal Surgeons, Newport, Rhode Island, April 5 to 7, 1991.