Stapled Trans-Anal Procedures: Complications Management

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1 Stapled Trans-Anal Procedures: Complications Management Leonardo Lenisa Surgery Unit Pelvic Floor Center Humanitas San Pio X - Milano, Italy

2 Evolving concepts in transanal stapling surgery for ano-rectal prolapse Bulky Haemorrhoids 2003 PSP for External Prolapse New Device Or New Procedure? STAPLED ANOPEXY 1994(1999) STARR w/ DPPH 1998 STARR c/ Transtar 2007 POPS/ STARR Or Lap Ventral TST STARR + And High Volume Devices Haemorrhoidal Prolapse Internal Rectal Prolapse/Rectocele/ Intussusception «Tailored Treatment» Complex Pelvic Floor Prolapse

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4 SA vs. Haemorrhoidectomy Non esiste differenza per complicanze perineali precoci (OR 1,82; p=0,52) o tardive (OR 0,69; p=0,33) Ho YH et al, Dis Colon Rectum 2000;43: Boccasanta P et al. Am J Surg 2001; 182:64-8 Ganio et al. Br J Surg 2001; 88: Wilson MS et al. Dis Colon Rectum 2002; 45: Krska Z et al Colorectal Dis 2003; 5: Hetzer F et al. Arch Surg 2002; 137: Ortiz H et al. Br J Surg 2002; 89: Kairaluoma M. Dis Colon Rectum 2003; 46: 93-9.

5 STARR Registry Complications were reported in 36.0% and included: defecatory urgency (20.0%) bleeding (5.0%) septic events (4.4%) staple line complications (3.5%) incontinence (1.8%) One case of rectal necrosis and one case of rectovaginal fistula were reported.

6 Annals of Surgery Volume 264, Number 5, November 2016

7 Annals of Surgery Volume 264, Number 5, November 2016

8 The Dark Side

9 Published online October 7,

10 Published online October 7,

11 Published online October 7,

12 Published online October 7, AE SH (7%) ES (9%) Pain 9 (2,6%) 15 (4,3%) Bleeding 6 (1,7%) 2 (0,6%) Stenosis 2 (0,6%) 0 Constipation 0 9 (2,6 %) Incontinence 0 0

13 Int Surg 2015;100:44 57 Early Complications: 2,3%- 52,5%, median 16% Early Bleeding: 0% - 68% Few complications were specific to stapled hemorrhoidopexy; however, these included failure of the stapling gun, urosepsis, and pelvic sepsis. Sepsis was documented in 16 cases, all of which required hospitalization, surgical re-intervention, and antibiotic therapy. All but 1 patient required a stoma.10 Cases of pelvic sepsis and rectal perforation were documented, along with cases of Fournier gangrene, perforation, and sepsis; rectovaginal fistula with associated sepsis; a case of perforation and sepsis with rectopneumoperitoneum, pneumo-mediastinum, and rectal stricture; a case of perineal sepsis and synergistic gangrene; and a single case of perforation, obstruction, and sepsis were documented.

14 Int Surg 2015;100:44 57 Late Complications: 2,5%- 80%, median 23,7% LateBleeding: 0,18-33% Trombosed External Haemorrhoids: 0,3-4% Stenosis: 0 15,6% Incontinence 0,1 17,8% Fecal Urgency %

15 Rassegna delle Complicanze

16 Sanguinamento intraoperatorio

17 Emorragia intraoperatoria Può essere arteriolare o nappiforme dalla rima anastomotica L emostasi con trasfissi va sempre eseguita nei punti di evidenza di sanguinamento e nel punto di incrocio delle anastomosi nella tecnica con doppia stapler Inoltre tre-quattro punti distribuiti circolarmente consolidano l effetto lifting dell anopessi e migliorano l anopessi.

18 Emorragia intraoperatoria Talvolta durante il confezionamento della borsa da tabacco possono formarsi ematomi che possono alterare la qualità del resecato, generando una asimmetria nella rima anastomotica.

19 Emorragia post-operatoria Precoce (prime h) Postdimissione (anche >10 gg)

20 Emorragia post-operatoria Dal lume rettale (1,8-5%) Ematoma retrorettale (stabile/dinam ico) Emoretroperitoneo

21 Emorragia endoluminale Day post surgery N Day (29%) Day (71%) Overall 14/513 (2.7%) Table 3: Bleeding by postop. day ASCRS, Seattle 2006

22 Emorragia endoluminale 22

23 Emorragia endoluminale

24 Emostasi endoscopica

25 Ematoma retrorettale

26 Ematoma retrorettale 26

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28 Ematoma retroperitoneale

29 Ematoma retroperitoneale

30 Ematoma retroperitoneale

31 Deiscenza anastomotica 1

32 Deiscenza anastomotica 1

33 Deiscenza anastomotica 1

34 Deiscenza anastomotica 2

35 Deiscenza anastomotica 2

36 Deiscenza anastomotica 2

37 Deiscenza anastomotica 3

38 Fistola retrorettale

39 Drenaggio endoscopico di ascesso pararettale 39

40 Drenaggio endoscopico di ascesso pararettale 40

41 Drenaggio endoscopico di ascesso pararettale

42 Fistola Retto-Vaginale Intrappolamento Diretto Durante La Procedura Esito Tardivo di Ascesso Intramurale

43 RECIDIVA La recidiva va prevenuta: Riducendo prima dell introduzione del CAD il prolasso esterno con l aiuto di una garza.

44 RECIDIVA La recidiva va prevenuta: Scegliendo l attrezzo giusto in funzione del prolasso

45 RECIDIVA In una frazione di pazienti il prolasso ha un comportamento di tipo progressivodegenerativo N. A. Wijffels, R. Collinson, C. Cunningham and I. Lindsey Pelvic Floor Service, Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK Colorectal Disease, 12,

46 HUMANITAS SAN PIO X GENERAL SURGERY UNIT

47 HUMANITAS SAN PIO X Colo-Rectal Disease and Pelvic Care Center COLO-RECTAL OUTPATIENT CLINIC URO-GYNECOLOGY OUTPATIENT CLINIC GASTROENTEROLOGY OUTPATIENT CLINIC UROLOGY OUTPATIENT CLINIC The Multi-Disciplinary Team PAIN THERAPY OUTPATIENT CLINIC BEST PRACTICE PATIENTS S MANAGEMENT REHAB OUTPATIENT CLINIC

48 Thanks for Your Attention!