Endoscopic management of postoperative stapled colorectal anastomosis hemorrhage

Abstract

Rectal bleeding following colorectal anastomosis is common but usually self-limited. Continuous hemorrhage is rare, and when it occurs, often requires further treatment. The most frequently used strategies for treatment of stapled anastomotic hemorrhage are clinical observation with or without blood transfusion, rectal packing, angiographic identification of the bleeding site with vasopressin infusion or embolization, and endoscopic eletrocoagulation. We report the case of a 49-year-old man with uncomplicated diverticular disease who was treated by laparoscopic sigmoidectomy, with double-stapled colorectal anastomosis. Six hours later, the patient presented intense rectal bleeding and was taken to the operation room for urgent colonoscopic examination. After complete removal of blood clots inside the rectum, a bleed localized at the anastomotic site was identified and submucosal peri-anastomotic injection of 10 ml adrenaline (1:200 000) in saline was performed with immediate bleeding control.

Staple line haemorrhage following laparoscopic left-sided colorectal resections may be more common when the inferior mesenteric artery is preserved

“…This may be explained by the difference in operative technique for laparoscopic left-sided colorectal surgery, the major differ-291 Tech Coloproctol (2008) 12:289-293 Table 2). Perez et al [14] reported the immediate control of a bleed that occurred 6 hours after laparoscopic sigmoidectomy with a double-stapled colorectal anastomosis by submucosal perianastomotic injection of 10 ml adrenaline (1:200,000) in saline. Cirocco and Golub [12] described successful colonoscopic electrocoagulation of oozing granulation tissue along the full length of a side-to-side (functional end-to-end) stapled anastomosis using linear stapling instruments in two patients 6 and 8 days after surgery.…”

Complicações pós-operatórias das anastomoses colorretais

“…Na maioria das vezes, cessam espontaneamente, às vezes exigem reposição volêmica ou até procedimentos locais pela via endoscópica com cauterização, uso de clipe ou injeção local de vasoconstritores [57][58][59][60] . Raramente necessitam de uma intervenção maior, como a relaparotomia 58 .…”

Bringt die dritte Klammernahtreihe eines neuen Endostaplers einen medizinischen Vorteil?

“…Obwohl die Entwicklung chirurgischer Staplerinstrumente schon auf das frühe 20. Jahrhundert zurückgeht, hat es bis in die 50er-Jahre gedauert, bis zunächst in Russland Instrumentenserien für vaskuläre und gastrointestinale Anastomosen produziert wurden [21]. In den folgenden Jahrzehnten fanden diese Instrumente eine weltweite Verbreitung und zogen in fast alle Kliniken industrialisierter Nationen ein.…”

“…Sich manifestierende Hämor-rhagien im Bereich einer Anastomose sind häufig selbst limitierend und bestehen selten kontinuierlich fort. Persistieren die Blutungen jedoch, so sind endoskopische oder operative Interventionen indiziert [21]. …”

“…Insbesondere der mechanisch belastenden rektalen Tamponade stehen wir kritisch gegenüber. Perez et al berichteten über eine erfolgreiche Intervention mit endoskopischer submukosaler Adrenalininjektion zur Blutungskontrolle[21]. Die häufigste Ursache von Anastomosenblutungen sehen Murray und Schoetz[19] in der Interposition mesenterialen Fettgewebes in der Klammernahtreihe und plädieren daher für eine adäquate Präparation der zu verbindenden Darmenden sowie für die regelhafte intraoperative Blutungskontrolle nach Anastomosierung der Strukturen.…”