Colovaginal anastomosis: A totally unacceptable surgical error

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Highlights

•

Colovaginal anastomosis is a surgical error that should not happen.
•

It could be avoided by a proper intraoperative technique.
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The main reason why it is still occurring is an unacceptable lack of knowledge of some surgeons.
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There are no excuses for such surgical errors.
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In our case, additional unacceptable errors were made during the postoperative follow-up.

Abstract

Introduction

The low anterior rectal resection and double stapling technique are well-established surgical procedures with well-known pitfalls, potential complications, and preventive measures. Colovaginal anastomosis is a surgical error which should not occur.

Presentation of case

A 39-year old woman underwent low anterior resection with double stapling technique, for rectal carcinoma in the City Hospital. On the fifth postoperative day she noticed passage of gas and two days later passage of feces from vagina. The surgeons who performed the operation explained to her that it is a normal condition for such modern procedure that is supervised by international educator engaged by the Government. The patient lived with this condition, passage of gas and feces from the vagina and nothing from anus for three months when her oncologist referred her for a second opinion at the University Clinic for Digestive Surgery. The digital examinations revealed a blind rectal stump, and feces in vagina; thus having the patient’s history in mind, we assumed that the patient had a colovaginal anastomosis. Our assumption was confirmed by two succeeding radiological examinations. Initially, water soluble contrast enema was performed to assess the colon, when a clear-cut blind rectal stump was detected. Afterwards, the vaginography revealed a copious flow of contrast material from the vagina toward the sigmoid colon. After a few days, a restorative surgery was done.

Discussion

Most of the early postoperative complications are a result of surgical errors.

Conclusion

We believe that there is no excuse for such a surgical error and postoperative follow-up.

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Most cited references 16

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Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes.

D. Mutter, Phillip T. Burch, Piet L. J. M. Leroy … (2004)

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME. We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method. Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6-96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39-7.07). Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages.

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An improved technique for low anterior resection of the rectum using the EEA stapler.

C Knight, F D Griffen (1980)

The technique using the EEA stapler for low anterior resection of the rectum has been modified to permit a low anastomosis that can be done with greater facility and safety. The method eliminates the bulky puckering of the ampullary purse string and avoids the disadvantage of joining segments of bowel of different sizes. It also decreases intraoperative contamination and minimizes chances for sepsis. Additionally, it affords an opportunity to check the integrity of the anastomosis. Success of the method seems to document the safety of stapling across a staple line. Results of this method used in a small group of patients are encouraging.

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Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature.

S. Anders, B Schicke, E Bärlehner … (2005)

There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes. Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed. The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV. Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery.

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Author and article information

Contributors

Milcho Panovski

Journal

Journal ID (nlm-ta): Int J Surg Case Rep

Journal ID (iso-abbrev): Int J Surg Case Rep

Title: International Journal of Surgery Case Reports

Publisher: Elsevier

ISSN (Electronic): 2210-2612

Publication date PMC-release: 31 December 2014

Publication date (Electronic): 31 December 2014

Publication date Collection: 2015

Volume: 7

Pages: 66-69

Affiliations

[a ]University Clinic for Digestive Surgery, University Ss. Cyril and Methodius, Skopje, Macedonia

[b ]University Clinic for Radiology, University Ss. Cyril and Methodius, Skopje, Macedonia

Author notes

[* ]Corresponding author at: Pitu Guli 16, 1000 Skopje, R. of Macedonia. Tel.: +389 70206742; fax: +389 23238834. milco@ 123456drpanovski.com.mk

Article

Publisher ID: S2210-2612(14)00468-4

DOI: 10.1016/j.ijscr.2014.12.033

PMC ID: 4336402

PubMed ID: 25590648

SO-VID: fb232ec4-6aa1-4e9a-8458-b2156321206e

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

History

Date received : 15 October 2014

Date revision received : 4 December 2014

Date accepted : 4 December 2014

Colovaginal anastomosis: A totally unacceptable surgical error

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Highlights

Abstract

Introduction

Presentation of case

Discussion

Conclusion

Related collections

ScienceOpen Clinical Case Reports Collection

Most cited references 16

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes.

An improved technique for low anterior resection of the rectum using the EEA stapler.

Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature.

Author and article information

Contributors

Journal

Affiliations

Author notes

Article

History

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