Year 2019 Vol. 27 No 4




Kazan State Medical University 1,
Republican Clinical Cancer Center 2, Kazan,
The Russian Federation

Total mesorectumectomy is a risk factor of development and formulation of pathological presacral sinuses. In the result of the rectum resection with total mesorectumectomy, the volumetric cavity is formed in the pelvisbounded by thebone structures. In case of accumulation of the liquid and blood in it, the risk of infection and the formation of presacral abscesses increases. If the pathological cavity does not heal during 12 months, such sinus is considered to be chronic. The chronic presacral sinus is formed in 5-9.5% of patients, those who underwent total mesorectumectomy. The main causes of development are neoadjuvantchemotherapy, high intraoperative bleeding, tumors of large size. The diagnostics includes the following instrumental methods: rectoscopy, proctography, magnetic resonance imaging of the pelvic organs. The basic methods of treatment in small sinuses are the application of fibrin glue and the EndoVac system. Fibringluecloses defects mechanically, stimulates proliferation of fibroblasts and provides matrix for the synthesis of collagen and for the processes of the wound healing. Fibrin glue is most often used as the final stage of the EndoVac system therapy, when a sponge, corresponding to the defect sizes, is placed in the abscess cavity, and is replaced every 48-72 hours. Treatment effectiveness is 66-100%. In the case of a large sinus, drained through a small defect in anastomosis or inefficiency of the EndoVac system, the method of endoscopic marsupialization is appropriate to be used. The given method allows saving the colorectal anastomosis. In patients with symptomatic presacral sinus in whom stoma reversionis impossible, transversal proctectomy with the cavity tamponade by greater omentum is advisable.

Keywords: total mesorectumectomy, colorectal anastomosis, anastomosis leak, anterior rectal resection, rectal cancer, chronic pelvis sinus
p. 435-442 of the original issue
  1. van Groningen JT, van Hagen P, Tollenaar RAEM, Tuynman JB, Marang-van de Mheen PJ, Doornebosch PG, Tanis PJ, de Graaf EJR. Evaluation of a completion total mesorectal excision in patients after local excision of rectal cancer: a word of caution. J Natl Compr Canc Netw. 2018 Jul;16(7):822-28. doi: 10.6004/jnccn.2018.7026
  2. Baik SH, Kim NK, Lim DR, Hur H, Min BS, Lee KY. Oncologic outcomes and perioperative clinicopathologic results after robot-assisted tumor-specific mesorectal excision for rectal cancer. Ann Surg Oncol. 2013 Aug;20(8):2625-32. doi: 10.1245/s10434-013-2895-8
  3. Lee L, de Lacy B, Gomez Ruiz M, Liberman AS, Albert MR, Monson JRT, Lacy A, Kim SH, Atallah SB. A multicenter matched comparison of transanal and robotic total mesorectal excision for mid and low-rectal adenocarcinoma. Ann Surg. 2018 Jun 18. doi: 10.1097/SLA.0000000000002862 [Epub ahead of print]
  4. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgerythe clue to pelvic recurrence? Br J Surg. 1982 Oct;69(10):613-16. doi: 10.1002/bjs.1800691019
  5. Muratore A, Mellano A, Marsanic P, De Simone M. Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results. Eur J Surg Oncol. 2015 Apr;41(4):478-83. doi: 10.1016/j.ejso.2015.01.009
  6. Zarnescu EC, (Vasiliu), Zarnescu NO, Costea R, Neagu S. Review of risk factors for anastomotic leakage in colorectal surgery. Chirurgia (Bucur). 2015 Jul-Aug;110(4):319-26.
  7. Liu L, Wang T, Zhang G, Dai R, Liang H, Tang L. Risk factors for early complications after laparoscopic total mesorectal excision for locally advanced rectal cancer: A single center experience. J Cancer Res Ther. 2016 Jan-Mar;12(1):350-54. doi: 10.4103/0973-1482.139273
  8. Tortorelli AP, Alfieri S, Sanchez AM, Rosa F, Papa V, Di Miceli D, Bellantone C, Doglietto GB. Anastomotic leakage after anterior resection for rectal cancer with mesorectal excision: incidence, risk factors, and management. Am Surg. 2015 Jan;81(1):41-47.
  9. Whitlow CB, Opelka FG, Gathright JB Jr, Beck DE. Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum. 1997 Jul;40(7):760-63.
  10. Enker WE, Merchant N, Cohen AM, Lanouette NM, Swallow C, Guillem J, Paty P, Minsky B, Weyrauch K, Quan SH. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg. 1999 Oct;230(4):544-52; discussion 552-54.
  11. McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg. 2015 Apr;102(5):462-79. doi: 10.1002/bjs.9697
  12. Kawada K, Takahashi R, Hida K, Sakai Y. Impact of transanal drainage tube on anastomotic leakage after laparoscopic low anterior resection. Int J Colorectal Dis. 2018 Mar;33(3):337-40. doi: 10.1007/s00384-017-2952-z
  13. Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg. 2004 Aug;240(2):260-68. doi: 10.1097/01.sla.0000133185.23514.32
  14. Hoshino N, Hida K, Sakai Y, Osada S, Idani H, Sato T, Takii Y, Bando H, Shiomi A, Saito N. Nomogram for predicting anastomotic leakage after low anterior resection for rectal cancer. Int J Colorectal Dis. 2018 Apr;33(4):411-18. doi: 10.1007/s00384-018-2970-5
  15. Matsuda K, Yokoyama S, Hotta T, Watanabe T, Tamura K, Iwamoto H, Mizumoto Y, Yamaue H. Pelvic drain after laparoscopic low anterior resection for rectal cancer in patients with diverting stoma. Surg Laparosc Endosc Percutan Tech. 2018 Apr;28(2):82-85. doi: 10.1097/SLE.0000000000000517
  16. Brehant O, Hanes A, Fuks D, Sabbagh C, Blanpain S, Brazier F, Regimbeau JM. Stapled marsupialisation of chronic low rectal anastomotic sinuses. Int J Colorectal Dis. 2009 Oct;24(10):1233-37. doi: 10.1007/s00384-009-0780-5
  17. van Koperen PJ, van der Zaag ES, Omloo JM, Slors JF, Bemelman WA. The persisting presacral sinus after anastomotic leakage following anterior resection or restorative proctocolectomy. Colorectal Dis. 2011 Jan;13(1):26-29. doi: 10.1111/j.1463-1318.2010.02377.x
  18. Arumainayagam N, Chadwick M, Roe A. The fate of anastomotic sinuses after total mesorectal excision for rectal cancer. Colorectal Dis. 2009 Mar;11(3):288-90. doi: 10.1111/j.1463-1318.2008.01585.x
  19. Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ. Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg. 2017 Nov;266(5):870-77. doi: 10.1097/SLA.0000000000002429
  20. Patsouras D, Schizas A, George ML. Novel application of anal fistula plug for the treatment of chronic anastomotic sinus. Int J Colorectal Dis. 2015 Dec;30(12):1735-36. doi: 10.1007/s00384-015-2142-9
  21. Sloothaak DA, Buskens CJ, Bemelman WA, Tanis PJ. Treatment of chronic presacral sinus after low anterior resection. Colorectal Dis. 2013 Jun;15(6):727-32. doi: 10.1111/codi.12094
  22. Musters GD, Borstlap WA, Bemelman WA, Buskens CJ, Tanis PJ. Intersphincteric completion proctectomy with omentoplasty for chronic presacral sinus after low anterior resection for rectal cancer. Colorectal Dis. 2016 Feb;18(2):147-54. doi: 10.1111/codi.13086
  23. Ming LI, Wei CUI, Teng MA, Weijun KOU, Liang ZHOU, Mingwen KOU, Wenbo ZHANG. Value of CRP and MMP-9 detection for diagnosis of anastomotic leakage after rectal cancer anterior resection. Chongqing Medicine. 2017;46(25):3506-8,3511.
  24. Daams F, Wu Z, Lahaye MJ, Jeekel J, Lange JF. Prediction and diagnosis of colorectal anastomotic leakage: a systematic review of literature. World J Gastrointest Surg. 2014 Feb 27;6(2):14-26. doi: 10.4240/wjgs.v6.i2.14
  25. Gessler B, Eriksson O. Angenete E. Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis. 2017; 32(4):549-56. doi: 10.1007/s00384-016-2744-x
  26. Vermeer TA, Orsini RG, Daams F, Nieuwenhuijzen GA, Rutten HJ. Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment. Eur J Surg Oncol. 2014 Nov;40(11):1502-9. doi: 10.1016/j.ejso.2014.03.019
  27. Veenhof AA, Brosens R, Engel AF, van der Peet DL, Cuesta MA. Risk factors and management of presacral abscess following total mesorectal excision for rectal cancer. Dig Surg. 2009;26(4):317-21. doi: 10.1159/000231882
  28. Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc. 2008 Aug;22(8):1818-25. doi: 10.1007/s00464-007-9706-x
  29. DHondt M, De Hondt G, Malisse P, Vanden Boer J, Knol J. Chronic pelvic abscedation after completion proctectomy in an irradiated pelvis: another indication for ENDO-sponge treatment? Tech Coloproctol. 2009 Dec;13(4):311-14. doi: 10.1007/s10151-009-0505-3
  30. Prasad LM, deSouza AL, Blumetti J, Marecik SJ, Park JJ. Endoscopic-assisted closure of a chronic colocutaneous fistula. Gastrointest Endosc. 2010 Sep;72(3):662-64. doi: 10.1016/j.gie.2009.12.028
  31. Nagell CF, Holte K. Treatment of anastomotic leakage after rectal resection with transrectal vacuum-assisted drainage (VAC). A method for rapid control of pelvic sepsis and healing. Int J Colorectal Dis. 2006 Oct;21(7):657-60. doi: 10.1007/s00384-005-0083-4
  32. Riss S, Stift A, Meier M, Haiden E, Grünberger T, Bergmann M. Endo-sponge assisted treatment of anastomotic leakage following colorectal surgery. Colorectal Dis. 2010 Jul;12(7 Online):e104-8. doi: 10.1111/j.1463-1318.2009.01885.x
  33. Swain BT, Ellis CN. Fibrin glue treatment of low rectal and pouch-anal anastomotic sinuses. Dis Colon Rectum. 2004 Feb;47(2):253-55. doi: 10.1007/s10350-003-0040-7
  34. Abild N, Bulut O, Nielsen CB. Endoscopic stapled marsupialisation of chronic presacral sinus following low anterior resection: a simple option in selected cases. Scand J Surg. 2012;101(4):307-10. doi: 10.1177/145749691210100416
  35. Hammond TM, Grahn MF, Lunniss PJ. Fibrin glue in the management of anal fistulae. Colorectal Dis. 2004 Sep;6(5):308-19. doi: 10.1111/j.1463-1318.2004.00676.x
  36. López V, Abrisqueta J, LujÁn J, Serrano A, Parrilla P. Endoscopic treatment with biologic glue of chronic presacral sinus after low anterior resection. Cirugía Española. 2015 Mar;93(3):133-10. doi: 10.1016/j.cireng.2014.09.004
  37. Lippert E, Klebl FH, Schweller F, Ott C, Gelbmann CM, Schölmerich J, Endlicher E, Kullmann F. Fibrin glue in the endoscopic treatment of fistulae and anastomotic leakages of the gastrointestinal tract. Int J Colorectal Dis. 2011 Mar;26(3):303-11. doi: 10.1007/s00384-010-1104-5
  38. Mees ST, Palmes D, Mennigen R, Senninger N, Haier J, Bruewer M. Endo-vacuum assisted closure treatment for rectal anastomotic insufficiency. Dis Colon Rectum. 2008 Apr;51(4):404-10. doi: 10.1007/s10350-007-9141-z
  39. Verlaan T, Bartels SA, van Berge Henegouwen MI, Tanis PJ, Fockens P, Bemelman WA. Early, minimally invasive closure of anastomotic leaks: a new concept. Colorectal Dis. 2011 Nov;13 Suppl 7:18-22. doi: 10.1111/j.1463-1318.2011.02775.x
  40. Arezzo A, Verra M, Passera R, Bullano A, Rapetti L, Morino M. Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis. 2015 Apr;47(4):342-45. doi: 10.1016/j.dld.2014.12.003
  41. Strangio G, Zullo A, Ferrara EC, Anderloni A, Carlino A, Jovani M, Ciscato C, Hassan C, Repici A. Endo-sponge therapy for management of anastomotic leakages after colorectal surgery: a case series and review of literature. Dig Liver Dis. 2015 Jun;47(6):465-69. doi: 10.1016/j.dld.2015.02.007
  42. Goldsmith HS, Griffith AL, Kupferman A, Catsimpoolas N. Lipid angiogenic factor from omentum. JAMA. 1984 Oct 19;252(15):2034-36. doi: 10.1001/jama.1984.03350150034017
  43. Konturek SJ, Brzozowski T, Majka I, Pawlik W, Stachura J. Omentum and basic fibroblast growth factor in healing of chronic gastric ulcerations in rats. Dig Dis Sci. 1994 May;39(5):1064-71. doi: 10.1007/BF02087559
  44. Walker FC, Rogers AW. The greater omentum as a site of antibody synthesis. Br J Exp Pathol. 1961 Jun; 42(3):222-31.
  45. Gultekin FA, Bakkal BH, Tayfun S, Babuccu O, Comertet M. Chronic pelvic abscedation after completion proctectomy in a rectal stump insufficiency; treatment with gracilis muscle flap following vacuum assisted closure therapy. Ann Coloproctol. 2013 Aug;29(4):172-76. doi: 10.3393/ac.2013.29.4.172
Address for correspondence:
420000, The Russian Federation,
Kazan, Baturin Str., 49,
Kazan State Medical University,
Department of Oncology, X-ray Diagnostics and Radiotherapy,
Tel. +79274299671,
Vasiliy I. Egorov
Information about the authors:
Akhmetzyanov Foat Sh., MD, Professor, Head of the Department of Oncology, X-ray Diagnostics and Radiotherapy, Kazan State Medical University, Head of the Surgery Clinic, Republican Clinical Cancer Center, Kazan, Russian Federation.
Egorov Vasiliy I., PhD, Assistant of the Department of Oncology, X-ray Diagnostics and Radiotherapy, Kazan State Medical University, Oncologist, Republican Clinical Cancer Center, Kazan, Russian Federation.
Contacts | ©Vitebsk State Medical University, 2007-2023