Sepsis

Sepsis can be defined early or late. The incidence of such complications varies in 5-25% of cases after RPs [4, 5], and approximately half of these are responsible for the failure of the surgical operation. The majority of the cases depend on the anastomot-ic complications regarding the pouch anal or regarding the proximal ileum to the pouch. After modification via mucosectomy's technique, which is used preliminarily to remove all disease (prone mucosa), the sepsis rate is remarkably reduced. The experience of the surgeon in transanal surgery is the factor that can meaningfully influence any complications [3, 6, 7].

Early sepsis manifests itself as fever, tenesmus and loss of pus through the anus. In a certain number of cases, antibiotic therapy can resolve the infection. In others, however, TC-guided transanal or transabdominal drainage is necessary. In some cases, it is sufficient to open the pouch-anal anastomosis in order to guarantee adequate transanal drainage. In severe sepsis, laparotomic access is mandatory; it is in these cases that the removal of the pouch from its natural site is frequently carried out, whereas the closing of the ileostomy is done infrequently.

In the experience of Heuschen [8] with 131 patients with sepsis, approximately 16% of these could be treated conservatively. Failure was in relation to the procedure carried out. In fact, it occurred in 6% of the cases after minimal surgery and in 47% of the cases after major surgery. Consequently, it is obvious that premature sepsis represents an important risk factor regarding the success or failure of the procedure.

Late sepsis generally manifests itself with the appearance of abdominal or pelvic abscesses and/or with formation of fistulas. In the case of circumscribed sepsis, surgical or TC-guided drainage can resolve the inflammatory process, otherwise pouch salvage surgery, with the removal of the pouch from the pelvis and the positioning of it under the abdominal wall along with the creation of a mucosal fistula, can represent an adequate therapeutic choice. This procedure was successful in five patients of eight in the study of Keighley [9] and in two of four in the study of the Mayo Clinic Group [10].

In Fazio's study [11] of 35 patients with sepsis, of which 29 had leakage of the ileo-anal anastomosis, the patients were treated via abdominal surgery. The rescue of the pouch was achieved in 21 out of 22 patients with ulcerative colitis, preserving transanal evacuation to the detriment of the bowel function, which was characterised by an evacuative frequency of 9 motions within 24 h, (ranging between 4 and 35 motions). The quality of life (QoL) was good in 17 patients and bad in 13.

Cohen [12] performed salvage surgery on 24 patients and obtained acceptable results for 20. In 18 of these, the medium frequency of elimination was 5 evacuations/day and 1.5 nocturnally, with good continence in 13 of the patients. Galandiuk [13] operated for intra-abdominal sepsis on 29 patients and reported 17 failures, which emphasises that the possibility for failure increases with time.

Heuschen [8] reports 131 patients with sepsis on 706 PR. In the experience of the author, early sepsis involves a greater risk of failure that increases with time at a rate of 20% at 3 years and 40% at 10 years. The site of the fistula is proximal to the pouch in 13% of cases, at the level of the neorectal cuff in 31% and at the level of the ileo-anal anastomosis in 50% of cases. Treatment has been conservative in 18% of cases, with transanal surgery in 25% of cases and abdominal in 56% of cases. The difference in the failure is higher after major surgery (45%) than minor surgery (5%). The failure was also correlated to the dehiscence of the pouch-anal anastomosis and to the presence of a pouch-vaginal fistula. Experiences up to now demonstrate a great variability of results in relation to the severity of sepsis, the site regarding the pouch-anal anastomosis and to the duration of the follow-up.

Gorfine [14] of Mount Sinai in New York reports on 1 185 RPs: 51 patients with sepsis from leakage of the pouch-anal anastomosis in which 85 surgical procedures were carried out including 48 transanal surgeries in patients without ileostomy, 37 transanal surgeries in patients with ileostomy and 4 abdominal and perineal operations in patients with ileostomy. In 40% of patients he obtained a good result at a medium follow-up of 65 months. Comparing patients with and without ileostomy who received a surgical transanal procedure, the author did not see any evidence of differences in results. Moreover, he reports on the failure in all patients who had abdominal surgery. The author concludes, that in order to obtain good results, more surgical procedures are necessary, so that there are no differences between patients with and without ileostomy, which emphasises the failure of abdominal procedures used in the attempt to rescue the pouch.

Dehni [15] reported on the experience acquired from 54 patients who underwent salvage surgery, of which 47 had sepsis. In 19 patients with cases of abscess, he utilised a transanal approach preceded by surgical or radiological transanastomotic or perineal drainage. In the remaining cases he preferred an abdominoperineal approach. Altogether, 27 of the 40 patients evaluated after abdominoperineal surgery and 13 of the 18 after transanal surgery, obtained satisfactory results. Of the patients operated on for sepsis, 44 at a medium follow-up of 30 months obtained good results. Crohn's disease was subsequently diagnosed in three patients out of four who had pouch failure after salvage surgery.

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