Viejas herramientas para problemas de siempre. Anastomosis coloanal en 2 tiempos. Pull-Through
Abstract
OLD TOOLS FOR SIMPRE PROBLEMS. COLOANAL ANASTOMOSIS IN 2 STAGES. PULL-THROUGH
Authors: Durán F. ; Brito N. ; Domínguez F. ; Duffau A. ; Laurini M. ; Viola M.
Department of Surgery of MUCAM, Montevideo, Uruguay.
Federicoduran03@hotmail.com
fabidomoco@gmail.com
alexandrafurini@hotmail.com
ORCID:
0000-0002-0426-3284
0000-0002-1394-3994
0000-0002-1746-7091
0000-0003-2763-0734
0000-0003-2494-1756
0000-0003-2733-5276
Introduction: The treatment of low rectal cancer located less than 1 cm from the anorectal ring (type 2 of the Rullier classification) represents a challenge for surgeons. Ultra-low resection and one-stage coloanal anastomosis with detransit ileostomy is considered the standard treatment. However, the incidence of anastomotic leak and morbidity associated with ileostomy are not negligible, with pelvic complications that can affect oncological and functional outcomes. The pull through procedure is presented as an attractive alternative. This involves ultra-low resection of the rectum, with total mesorectal excision and nerve preservation, associating a perineal time where partial intersphincteric resection is performed. Instead of completing the surgery with a manual coloanal anastomosis and ileostomy, the colon is exteriorized through the anal canal. In a second stage, the coloanal anastomosis is created, thus avoiding the need for an ileostomy.
Description: The following video shows the case of a 64-year-old female patient with a diagnosis of low rectal cancer, T3N1M0, surveyed by the clinic, endoscopy and magnetic resonance imaging of the pelvis, 5 mm from the puborectalis. , with an intersphincteric space free of tumor involvement. Neoadjuvant treatment was performed with long-course radiotherapy plus Capecitabine-based chemotherapy. She was re-evaluated after 10 weeks, obtaining an incomplete clinical response, due to ulceration on rectal examination, which was confirmed by rectoscopy. Pelvic MRI shows a tumor remnant and suspicious lymphadenopathy. For this reason, it was proposed to perform an ultra-low resection of the rectum, with total excision of the laparoscopic mesorectum, plus partial intersphincteric resection and colonic exteriorization according to the pull-through technique. The video shows ultra-low resection addressing the intersphincteric space laparoscopically. This maneuver then facilitates perineal time. A week after the surgery, the second stage of the procedure was performed, which consisted of perineal resection of the exteriorized colon and the creation of a manual coloanal anastomosis. The patient progressed favorably, without complications, and was discharged 48 hours after surgery. second procedure.
Conclusions: Delayed coloanal anastomosis reduces the incidence of pelvic complications, anastomotic leak, and the need for a detransit ileostomy. From a functional point of view, the studies show similar results when compared with primary anastomosis plus ileostomy.
