SALVAGE OF RECURRENT ANASTOMOTIC LEAK/CUTANEOUS FISTULA FOLLOWING ROBOTIC LOW ANTERIOR RESECTION WITH COLOANAL ANASTOMOSIS FOR RECTAL CANCER AFTER NEOADJUVANT THERAPY - HOW LOW CAN YOU GO?
Banner MD Anderson Cancer Center
56 yo WM with + bipolar disorder and schizophrenia was found to have a 6 cm long distal rectal cancer with distal extent 5 cm from the anal verge. He completed long-course neoadjuvant chemoradiotherapy and 8 weeks later underwent robotic LAR with stapled coloanal anastomosis (#28 EEA). The leak test was positive and the site was oversewn with suture and omentum was placed over top and a diverting loop ileostomy constructed. Pathology revealed no residual cancer. He developed a presacral abscess 5 weeks later requiring an IR drain and 5 months later Gastrograffin enema was negative for leak and loop ileostomy was taken down. Six weeks afterwards, he developed an abscess of the left buttock at the old IR drain exit site and an incision & drainage procedure was performed in the OR. The abscess resolved, however, a draining sinus opening persisted at the old IR drain exit site consistent with a fistula. The site continued to drain pus and 9 months later he underwent resection of the colocutaneous fistula as an outpatient procedure. However, 2 days later he presented to the ED with stool pouring out of the surgical site in the left buttocks. CT once again revealed a presacral abscess along with fluid and air noted in the left gluteus. Digital examination revealed a large MLP defect of the coloanal anastomosis that admitted the tip of an index finger. The patient was consented and underwent a combined transanal and transabdominal ultra-low resection of the neorectum including the failed anastomosis with a handsewn coloanal anastomosis and temporary, diverting loop ileostomy. Pathology did not reveal residual neoplasm. He had an uneventful postoperative course and was discharged home 6 days later. The temporary, diverting loop ileostomy was taken down 6 months later. It has been 9 months since the last operation and the patient reports excellent bowel function, including stool frequency, the ability to fully evacuate and complete sphincter control.
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