COMPLICATIONS AFTER COLORECTAL SURGERY WITH A CLOSED RECTAL SEGMENT
Alex Mui*, Kathryn Chuquin, Joel Bauer
Icahn School of Medicine at Mount Sinai, New York, NY
Background:
Division of the rectum with partial or total colectomy and proximal end stoma is commonly performed when a primary anastomosis is at high risk for leak. Complications specific to the closed rectal segment have been rarely reported. This study seeks to identify the rate of complications of these surgeries, specifically closed rectal segment leaks, and risk factors for these complications.
Methods:
This is a retrospective review of patients undergoing a division of the rectum in which the closed rectal segment (CRS) was left in situ at a tertiary academic medical center from March 2002 to July 2017. 72 cases were identified in which the CRS was left in situ. Collected data included demographic and clinical characteristics at the index procedure, surgical approach, and intraoperative and postoperative complications.
Results:
72 patients with complete data were included. Hartmann's procedure was performed in 47 patients (65%), total abdominal colectomy in 21 patients (29%), and other surgeries comprised the remaining 6%. Reasons for surgery were diverticulitis (37.5%), ulcerative colitis (28%), cancer (12.5%), large bowel obstruction (7%), and other (15%). Complications with a Clavien-Dindo score of 2 or greater were identified in 35 patients (48.6%). These included small bowel obstruction, ileus, surgical site infection, deep vein thrombosis, and leak of the CRS. Four patients (5.6%) had a leak of the CRS. Three of these four patients had surgery for for perforated diverticulitis and one for stercoral perforation. Three of the four patients initially presented with sepsis or peritonitis, and two required emergency surgery. All four patients developed an abscess as a result of the leak, however, none of them required return to the OR. Two were treated with IR drainage and antibiotics; one with IR drainage, antibiotics and a transanal tube; one with antibiotics and a transanal tube. Risk factors for CRS leak were identified as preoperative high white blood cell count (18.1 vs 10.9 p=0.02) and preoperative sepsis/peritonitis (75% vs 25.3% p=0.07).
Discussion:
We report an overall complication rate of 48.6% and a CRS leak rate of 5.6% for surgeries resulting in a closed rectal stump left in situ. Risk factors associated with CRS leak were identified as preoperative white blood cell count and preoperative sepsis/peritonitis. The lack of significance of other risk factors on CRS leak may be due to the small size of this study. Importantly, none of the patients with a rectal segment leak required return to the operating room. All were able to be managed conservatively.
We found a high complication rate from surgeries resulting in a CRS, specifically a high rate of leak. We recommend that the surgeon be cognizant of the rate of complications and the risk factors for CRS leak and maintain a high index of suspicion in at-risk patients.
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