Healing the hidden wound: treating a chronic presacral sinus after low anterior resection by transanal endoscopic operation (TEO) approach: a case report

Introduction

Colorectal anastomoses are an intrinsic part of colorectal surgery with a high success rate, although there are potential complications that can arise postoperatively. Among the most frequent of such complications are anastomotic leaks that can, in turn, develop into a chronic sinus, a condition that is rare and poorly documented but can cause discomfort and affect a patient’s quality of life (1-3). Treatment can be challenging, and many approaches have been proposed, from a conservative approach with broad-spectrum antibiotics to minimally invasive or more aggressive surgeries, with a combined approach being the most frequently used (1,4).

In this article, we present a case report of a patient who developed a chronic sinus after a low anterior resection of the rectum with a colorectal anastomosis and propose a safe and reproducible treatment for chronic sinus. We present this article in accordance with the CARE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-1/rc).

Case presentation

A 63-year-old woman presented to our clinic at Parc Taulí University Hospital (Sabadell, Spain) with a complaint of persistent perianal discomfort and intermittent purulent discharge for six months following a low anterior resection for stage II rectal cancer, without neoadjuvant therapy. The initial surgery had been performed successfully without immediate complications with the anastomosis at approximately 7 cm from the anal verge. No diverting ileostomy was performed.

On examination, there were no external findings in the perianal region. On rectal exam, a small, discharging sinus was noted near the surgical site. The patient did not exhibit signs of systemic infection, such as fever or elevated white blood cell count.

A contrast-enhanced computed tomography (CT) scan of the pelvis revealed a sinus tract extending posteriorly from the rectal anastomosis site, which was consistent with a chronic presacral sinus. A colonoscopy to identify the sinus location and rule out malignancy recurrence was performed, along with a gastrografin enema that revealed the sinus tract in the lower rectum (Figure 1).

Figure 1 Gastrografin enema revealing the chronic sinus (arrow).

Given the clinical and radiological findings, a multidisciplinary approach was adopted to treat the sinus and the associated infection:

• The patient was started on a 10-day course of broad-spectrum antibiotics to control the local infection.
• After a period of antibiotic therapy, a surgical procedure was planned to address the chronic presacral sinus. The surgery was performed by a transanal endoscopic operation (TEO) (5) approach. The intervention was divided into 3 steps:
  • First, identification and widening of the entrance of the fistulous tract with the harmonic scalpel (Figure 2).
  • Next, open the cavity with an endostapler (Figure 3). An opening of around 2–3 cm is sufficient in most cases. In this case, an ECHELON™ Stapler (blue staple reload), with a jaw length of 45 mm, was used.
  • Finally, a curettage and purging (Figure 4), usually performed with a cautery hook, of the cavity to promote tissue healing and closing of the sinus.

Figure 2 Identification and widening of the entrance of the fistulous tract.

Figure 3 Open the cavity.

Figure 4 Curettage and purging.

The patient’s postoperative recovery was uneventful. Serial examinations and imaging studies confirmed the resolution of the chronic presacral sinus (Figure 5). At six months follow-up, the patient reported no discomfort, discharge, or signs of recurrence.

Figure 5 Gastrografin enema 6 months after surgery.

Ethical consideration

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

A presacral sinus following a dehisced low anterior resection can be particularly challenging to heal, especially when radiation therapy has preceded it. Attempting to revise such an anastomosis is often not advisable, primarily due to the fibrosis that typically occurs in the pelvis following radiation and chronic sepsis. Fortunately, many sinus cases do eventually heal or develop a wide neck that becomes non-problematic when the diverting stoma is closed. However, in some instances, chronic sepsis can persist due to the entrapment of stool within the sinus, leading to symptoms such as pus discharge from the anus with the subsequent impact on patients’ quality of life.

The procedure described in this case report by TEO can be safely and easily performed and can lead to sinus healing and resolution of patients’ symptoms. TEO allows treatment of lesions in the whole length of the rectum [transanal minimally invasive surgery (TAMIS), on the other hand, might have a more limited range], even though higher lesions can be trickier to treat. Therefore, sinuses could be treated at any location in the rectum, but we believe that those located in the middle rectum could be easier to treat than low or high rectum sinuses.

Whitlow et al. (6) addressed a presacral sinus with a different approach, using laparoscopic cautery scissors. Alsanea et al. (1) published a case series of patients with presacral sinus treated with a similar technique to the one shown in this article. Recently, endoluminal vacuum therapy has emerged as a potential treatment for anastomotic leaks after rectal surgery. However, it has shown limited success in patients who have previously undergone radiation therapy (7). Thus, it is essential to consider alternative options, such as the procedure described in this report, especially for patients with branching sinus tracts.

Conclusions

This case report highlights the successful management of a chronic presacral sinus in a 63-year-old woman following low anterior resection for rectal cancer. A comprehensive approach involving clinical examination, radiological evaluation, and surgical intervention by TEO can lead to the successful resolution of this complication.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-1/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-1/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-1/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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