Stapled Trans-Anal Procedures: Complications Management

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

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

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: 1666-75. Boccasanta P et al. Am J Surg 2001; 182:64-8 Ganio et al. Br J Surg 2001; 88: 669-74. Wilson MS et al. Dis Colon Rectum 2002; 45: 1437-44. Krska Z et al Colorectal Dis 2003; 5: 573-6. Hetzer F et al. Arch Surg 2002; 137: 337-40- Ortiz H et al. Br J Surg 2002; 89: 1376-81 Kairaluoma M. Dis Colon Rectum 2003; 46: 93-9.

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.

Annals of Surgery Volume 264, Number 5, November 2016

The Dark Side

www.thelancet.com Published online October 7, 2016 http://dx.doi.org/10.1016/s0140-6736(16)31803-7

www.thelancet.com Published online October 7, 2016 http://dx.doi.org/10.1016/s0140-6736(16)31803-7 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

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.

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 0.2 25%

Rassegna delle Complicanze

Sanguinamento intraoperatorio

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.

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.

Emorragia post-operatoria Precoce (prime 24-48 h) Postdimissione (anche >10 gg)

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

Emorragia endoluminale Day post surgery N Day 1-7 4 (29%) Day 8-22 10 (71%) Overall 14/513 (2.7%) Table 3: Bleeding by postop. day ASCRS, Seattle 2006

Emorragia endoluminale 22

Emorragia endoluminale

Emostasi endoscopica

Ematoma retrorettale

Ematoma retrorettale 26

Ematoma retroperitoneale

Deiscenza anastomotica 1

Fistola retrorettale

Drenaggio endoscopico di ascesso pararettale 39

Drenaggio endoscopico di ascesso pararettale 40

Drenaggio endoscopico di ascesso pararettale

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

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

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

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, 822 830 2010 45

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