Case series of postoperative intraluminal bleeding in left
Jimena Alaniz, Diego A. Ramisch, Romina Bianchi, Gabriel Gondolesi,
General Surgery, Coloproctology and Multiorgan Transplantation Service.
Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina
Colorectal surgery, like any surgical procedure, is not exempt from complications, the incidence of which depends on the surgical approach. The most frequent are wound infection (superficial infection of the surgical site), ventral hernia, postoperative ileus, anastomosic dehiscence, fistula, and postoperative bleeding, according to different series.
Bleeding complications are classified into two large groups: those of the gastrointestinal tract, evidenced by intraluminal postoperative bleeding (InPB) and those involving the abdominal cavity and abdominal wall, constituting extraluminal postoperative bleeding.1 The incidence of reoperation for postoperative bleeding complications is approximately 1%.2
InPB has an incidence of up to 5.4%2 and its presentation does not differ from lower gastrointestinal bleeding (LGB) of another etiology.
The most frequent presentation is self-limited hematochezia with the first stool, without clinical impact, nor a decrease in hematocrit or hemoglobin. However, in 0.7 to 3%, bleeding is severe and requires different management, which includes aggressive resuscitation with expansion and transfusion of blood products, endoscopic treatment, angiographic embolization and/or even surgical resolution.3 The diagnostic and therapeutic algorithm does not differ from that used for the rest of LGB.
The objective of this study is to analyze patients with InPB as an anastomotic complication of colorectal surgery who required some type of treatment in our department and to carry out a bibliographic review on the subject.
MATERIAL AND METHODS
This is a retrospective study of colorectal resections with primary anastomosis complicated with anastomotic intraluminal postoperative bleeding (AInPB) performed in our center between January 2017 and December 2021. This complication was defined by the presence of direct (hematochezia) or indirect (laboratory parameters) signs of LGB, added to one or more of the following criteria: need for transfusion of blood products, hemodynamic instability or shock (systolic BP < 90 mmHg or lack of response to fluid and electrolyte replacement), need for interventional management with endoscopy and/or emergency surgery within the first 30 postoperative days, without evidence of another bleeding site.
The following variables were analyzed: age, gender, cancer history, anticoagulation and its indication, hemoglobin descent, surgery (type and indication), surgical approach, anastomosis (handsewn or stapled), electiveness of surgery, complications, length of stay and therapeutic management.
Complications DC > III of the Dindo-Clavien (DC) classification were considered clinically relevant.
Data were processed with the SPSS® program, V 20.
During the study period, 180 colorectal resections were performed, 134 (74.4%) with primary anastomoses. The decision to perform or not a primary anastomosis with or without protection is governed by a checklist protocol carried out by the surgeon according to the risk of the procedure and the patient's.
In 20% (36) of the patients there was some postoperative complication, clinically relevant only in 13.9% (25). The incidence of InPB was 3% (4), in all cases after an elective left colectomy. The patients had the same gender distribution and the mean age was 72 (range 54-87) years.
Two patients were anticoagulated with hematological monitoring and another had discontinued anticoagulation due to repeated episodes of diverticular bleeding (Table 1). A patient receiving treatment with dicoumarins due to a high risk of venous thromboembolic disease was prescribed prophylaxis with low molecular weight heparin during the 24 hours prior to surgery. Both anticoagulated patients discontinued anticoagulant therapy 5 and 4 days before surgery as recommended.
Table 1. Demographic data, cancer history and anticoagulation.
Intermittent pneumatic compression was used in all cases during surgery and for 24 hours afterward.
The surgical indication was for adenocarcinoma in 2 cases and benign conditions in another 2 (1 Hartmann´s reconstruction with resection of a dysfunctional colonic segment and 1 diverticular disease with multiple bleeding episodes). In 3 cases the approach was laparoscopic and in 1 open. In all cases, the anastomosis was performed end-to-end with circular staplers, 3 of 29 mm and 1 of 31 mm (Table 2).
Table 2. Indication for left colectomy, surgical approach, clinical presentation and treatment of postoperative anastomotic bleeding.
Postop BM: Postoperative bowel movement. RBCs: Red blood cells. O: Open. L: Laparoscopic. HQ: Hematoquezia.
HI: Hemodynamic instability. RS: Rigid sigmoidoscopy. MT: ;edical treatment.
In the 4 patients the clinical presentation was hematochezia, in 2 with hemodynamic instability. The first bowell movement in all cases occurred before 24 hours postoperatively (range 1:30-20 h). The maximum decrease in hemoglobin was 3.4 g/dL and the minimum was 1.8 g/dL (Table 2).
One unit of red blood cells was transfused to a single patient during surgery (case 3). All received transfusions in the first 24 postoperative hours and 3 even required transfusions in the following days.
The therapeutic management was conservative, only transfusion of blood products and follow-up, in the 2 patients with hemodynamic stability. The other 2 patients with hemodynamic instability, after receiving electrolyte resuscitation and red blood cell transfusions required interventional treatment in the first 24 hours (Table 2). In case 1, hybrid treatment with rigid endoscopy and laparotomy was performed, withouth finding evidence of active bleeding. In case 4, colonoscopy revealed active bleeding from the anastomosis that stopped with the placement of 2 clips (Fig. 1).
Median hospitalization was 9 (range 5-47) days. Hospitalization lasted more than 10 days in only one of the patients due to severe acute pancreatitis that caused death (case 4). This patient was the only one who presented a second clinically significant complication (DC=5). The 3 patients who survived did not present anastomotic dehiscence.
Figure 1. A. Colonoscopy showing active arterial bleeding at the colonic anastomosis.
B. Resolution with clip placement.
Anastomotic bleeding from the small intestine and colon is a rare clinical problem, occurring in 1% and 5.4% of cases, respectively.2 Following colonic resections, patients frequently present with mild accompanying hematochezia at the first bowel movement. AInPB must be differentiated from that caused by hemorrhoidal disease, intestinal ischemia and/or anastomotic dehiscence, which require another type of management.
There is no evidence of the influence of comorbidities on the risk of anastomotic bleeding, even some series such as the one by Martínez Serrano et al.3 report 7 patients with bleeding and no comorbidities.
The number of anticoagulated patients has increased significantly in recent years and their perioperative management at the time of major surgery is a factor of great importance. The decision to withdraw or maintain anticoagulation will be given by a balance between the thrombotic and the hemorrhagic risks. The main determinant for deciding whether to suspend is the metabolism and route of elimination of the anticoagulant. Dicoumarins or vitamin K inhibitors (acenocoumarol and warfarin) should be discontinued 3 and 5 days before surgery, respectively.4 This applies as long as patients are within the therapeutic range (INR 2-3).4 In the case of direct-acting anticoagulants (dabigatran, rivaroxaban), the timing of suspension depends on renal function, so management is adjusted to each patient.
Two of our InPB patients were anticoagulated, one on warfarin and the other on dabigatran. Both suspended the medication 5 and 4 days prior to surgery, in accordance with our institutional protocol.
Thromboembolic risk due to the condition that led to anticoagulation (mechanical heart valve, AF, and venous thromboembolism) is classified as high, medium and low based on the probability of an annual arterial or venous thromboembolic event (>10, 5-10, and <5%, respectively).4 Vivas et al.4 only recommend the use of bridging therapy in high-risk cases. Coincidentally, one of our patients with a mechanical aortic valve and coronary artery disease was prescribed low molecular weight heparin.
The Cochrane Group conducted a comparison between stapled and handsewn anastomoses in 662 patients, looking at several items, including the rate of anastomotic bleeding.5 This risk was 2.7%, higher for stapled anastomoses, although the authors concluded that there was no scientific evidence demonstrating an increase in bleeding with one technique or another.5 Currently, the use of stapled anastomosis seems to have increased compared to those handsewn, so the potential risk of bleeding should be re-examined.
In our series, and others,6 the first clinical manifestation of bleeding was between 1:30 and 20 hours after completion of surgery, that is, in 100% of cases it occurred within 24 postoperative hours, according to the literature, in agreement with the literature.
Also coinciding with the literature,6 in our patients we observed that the first clinical manifestation of bleeding was between 1:30 and 20 hours after completion of surgery, that is, in 100% of cases it occurred within 24 postoperative hours.
Regarding treatment, since self-limited hematochezia is the most frequent, the most accepted approach is conservative/medical management, which achieves a satisfactory response in 90% of cases. It consists of the restoration of the hydroelectrolytic imbalance, correction of the coagulopathy and strict clinical control. In a smaller percentage bleeding is not self-limited and requires, in addition to transfusions of blood products, endoscopic management, embolization by radiological intervention, and even surgery.
Endoscopy as the first option in the diagnostic-therapeutic algorithm is a safe and effective method that has the advantage of precise localization of the bleeding site by direct visualization. A drawback is the risk of anastomotic dehiscence, especially if performed within the first 4-5 postoperative days when the integrity of the anastomosis depends primarily on the suture. This is the most feared complication, since it exponentially increases morbidity and mortality.3-8 However, other authors argue otherwise. Chardavoyne et al.6 consider that colonoscopy is safe even on the first postoperative day, as long as insufflation pressures below 30 mmHg are used. Techniques used for bleeding control through colonoscopy include epinephrine injection, bipolar electrocoagulation, and clipping (360 degree rotation or OVESCO clips). With epinephrine injection alone there is a risk of rebleeding, but Malik et al.7 suggest that a second attempt at endoscopic hemostasis is a safe measure before reoperation.
In 2016, Besson et al.8 published the results of 37 patients treated by this method, out of a total of 727 patients. In 24% of them the bleeding stopped spontaneously, 27% required control with endoscopic clipping, 30% with epinephrine injection and 19% with the combination of both methods. Only 5 patients underwent surgery due to the endoscopic finding of an anastomotic leak.
Bowel preparation is usually not required because bleeding speeds intestinal transit. Depending on the general clinical condition, colonoscopy can be performed in the operating room or in the endoscopy suite. Management in the operating room with the surgical team ensures better care of the complex patient.
Angiography followed by selective embolization is considered an appropriate therapeutic approach when endoscopic control of bleeding fails. In 1974, the first therapeutic angioembolization was performed by Bookstein et al.9 This group and others reported the risk of colonic ischemia after the procedure, so it cannot be considered innocuous. The latest publications report an ischemia rate of 10%, associated with a considerable increase in postoperative mortality.9-10 However, due to its high precision for bleeding control, it is still considered a current approach. It is indicated in massive or recurrent bleeding that cannot be resolved with endoscopic treatment, when the bleeding site can be identified (bleeding > 0.5 ml/min). Although this method is available at our institution, it was not used in any of the reported patients.
Surgery should be reserved for patients with hemodynamic instability and failure of other therapies. In one case of our series, a combined endoscopic-surgical treatment was chosen to facilitate rigid endoscopy, the only one available at that time, with the aim of demonstrating and/or treating a possible dehiscence.
The low frequency of AInPB impacts on the correct implementation of prevention measures and techniques in the pre and intraoperative period. Their proper use reduces the risk of anastomotic dehiscence and the need for ostomy and contributes to low morbidity and mortality.11
Anastomotic intraluminal bleeding is a rare complication of colorectal surgery that requires interventional treatment only in cases with hemodynamic instability.
In high-volume centers, all the equipment for its management must be available.
1. Pekolj J, Ardiles V, Hyon SH. Complicaciones de la cirugía abdominal: Cómo manejarlas. Clínicas Quirúrgicas del Hospital Italiano. 1a ed. Buenos Aires: delhospital ediciones, 2015.
2. Fernández de Sevilla Gómez E, Vallribera Valls F, EInPB Basany E, Valverde Lahuerta S, Pérez Lafuente M, Segarra Medrano A, et al. Hemorragia en anastomosis intestinales y cólicas. Manejo terapéutico y sus complicaciones. Cir Esp. 2014; 92:463-67.
3. Martínez-Serrano MA, Parés D, Pera M, Pascual M, Courtier R, Egea MJ, Grande L. Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis. Tech Coloproctol. 2009 ; 13:49-53.
4. Vivas D, Roldán I, Ferrandis R, Marín F, Roldán V, Tello-Montoliu A, et al. Perioperative and periprocedural management of antithrombotic therapy: consensus document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU. Rev Esp Cardiol. 2018; 71:553-64.
5. Matos D, Atallah ÁN, Castro AA, Silva Lustosa SA. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003144. DOI: 10.1002/14651858.CD003144.
6. Chardavoyne R, Stein TA, Ratner LE, Bank S, Wise L. Is colonoscopy safe in the early postcolectomy period? Am Surg. 1991; 57:734-36.
7. Malik AH, East JE, Buchanan Kennedy RH. Endoscopic haemostasis of staple-line haemorrahage following colorectal resection. Colorectal Dis. 2008; 10:616-18.
8. Besson R, Christidis C, Denet C, Bruyns L, Levard H, Gayet B, et al. Management of postoperative bleeding after laparoscopic left colectomy. Int J Colorectal Dis. 2016; 31:1431-36.
9. Bookstein JJ, Chlosta EM, Foley D, Walter JF. Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology. 1974; 113:277-85.
10. Uflacker R. Transcatheter embolization for treatment of acute lower gastrointestinal bleeding. Acta Radiol. 1987; 28:425-30.
11. Hoedema RE, Luchtfeld MA. The management of lower gastrointestinal haemorrhage. Dis Colon Rectum. 2005; 48:20-24.