The realm of colorectal surgery has seen significant advancements over the years, with an increasing shift towards laparoscopic procedures for various conditions like adenocarcinoma, rectal endometriosis, and diverticular disease. Despite its benefits, one challenge that continues to plague postoperative care is anastomotic bleeding from the staple line—a potentially fatal complication if not managed promptly and effectively. A recent case study series, published in “Chirurgia (Bucharest, Romania : 1990)” journal, sheds light on the successful endoscopic treatment for this complication.
DOI: 10.21614/chirurgia.114.2.295
The study, focusing on three distinct cases, accentuates the efficacy and safety of early endoscopy in achieving hemostasis following major rectal bleeding within the first 24 hours after laparoscopic high anterior resection. Each of the patients underwent surgery that incorporated a transanal anastomosis according to the Knight-Griffen technique using circular staplers—a method typically associated with reduced pain and faster recovery compared to traditional surgeries. Unexpected bleeding from the stapled anastomotic line, however, posed a significant risk to their recovery.
Patient 1, who was operated on for adenocarcinoma, had significant rectal bleeding that was promptly addressed endoscopically before the end of the surgical procedure. The endoscopic intervention entailed washout and removal of clots alongside direct infiltration of epinephrine (Adrenaline) 1:10000 at a volume of 2 ml at the hemorrhaging sites along the stapled line, successfully achieving hemostasis. The use of epinephrine, a vasoconstrictor agent, played a pivotal role in halting the hemorrhage effectively.
The other two cases, including a female patient with rectal endometriosis and a male patient with diverticular disease, also presented with significant bleeding within a day following their procedures. Similarly, they underwent endoscopic washouts and clot removals, accompanied by the administration of epinephrine directly at the bleeding sites. These interventions not only halted further bleeding but also prevented the need for additional surgical procedures that could have increased morbidity and extended hospital stays.
The case series conclusion emphasizes early endoscopic treatment as a safe and efficient method of managing colorectal anastomotic bleeding. Compared to conservative management or the need for reoperation, endoscopic approaches provide a minimally invasive way to correct this complication, which can improve patient outcomes and reduce healthcare resource utilization.
Incorporating this study into a larger context, it’s important to note that while laparoscopic colorectal surgery has provided several benefits over open surgery—including smaller incisions, reduced pain, and shorter recovery times—potential postoperative complications like anastomotic bleeding remain a concern. The successful management of such complications through endoscopy offers valuable insights into improving patient outcomes while adhering to minimally invasive principles.
References
1. Mari Giulio, Costanzi Andrea, Crippa Jacopo, Berardi Valter, Santurro Letizia, Gerosa Martino, Maggioni Dario. (2019). Endoscopic Treatment of Anastomotic Bleeding in Laparoscopic Colorectal Surgery. Chirurgia (Bucharest, Romania: 1990), 114(2), 295-299. DOI: 10.21614/chirurgia.114.2.295
2. Vignali A, et al. (2010). A prospective randomized trial of different laparoscopic colorectal anastomosis techniques influencing the postoperative outcome in 202 patients. Surgery, 147(4), 542–547. DOI: 10.1016/j.surg.2009.10.053
3. van der Pas MH, et al. (2013). Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncology, 14(3), 210–218. DOI: 10.1016/S1470-2045(13)70016-0
4. MacRae HM, et al. (2011). Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis. Diseases of the Colon & Rectum, 54(4), 484-488. DOI: 10.1007/DCR.0b013e3182098a83
5. Arezzo A, et al. (2017). The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report. Surgical Endoscopy, 27(9), 3073-3084. DOI: 10.1007/s00464-013-2852-2
Keywords
1. Laparoscopic Colorectal Surgery
2. Endoscopic Treatment
3. Anastomotic Bleeding
4. Staple Line Hemorrhage
5. Early Endoscopy Efficacy
In conclusion, this case study series offers valuable insights into a pressing concern in laparoscopic colorectal surgery—postoperative anastomotic bleeding from the staple line. The early application of endoscopic techniques coupled with epinephrine infiltration presents a promising approach for effective management. The insights provided by this study could serve as a foundation for improved postoperative care and establish a new standard practice that prioritizes patient safety and surgical efficiency.