Endoscopic treatment with biologic glue of chronic presacral sinus after low anterior resection.

Anastomotic dehiscence in rectal cancer is one of the most feared complications. In the long term, a presacral sinus can form that is difficult to manage. The advent of biological tissue adhesives for the treatment of complex fistulas can be an effective alternative for this type of complication. We present a case of anastomotic dehiscence after low anterior resection and the later formation of a chronic presacral sinus, which was resolved with the endoscopic application of a biological tissue adhesive. The patient is a 67-year-old woman with no prior medical history of interest. After finalizing treatment with neoadjuvant chemo-radiotherapy, she was treated surgically for a rectal adenocarcinoma 7 cm from the anal margin by a laparoscopic low anterior resection with mechanical end-toend anastomosis without protective ileostomy. The patient was discharged on the 4th day post-op. Three days later, she came to the emergency room with fever and abdominal pain. Abdominal CT scan showed dehiscence of the posterior side of the anastomosis. At reoperation abdominal cavity lavage with a protective ileostomy was performed. During follow-up, colonoscopy and barium enema (Fig. 1) detected the formation of a presacral sinus on the posterior side of the anastomosis. The sinus was 0.6 cm wide and extended to 4 cm from the anastomosis. One year after surgery and in spite of conservative measures, the presacral sinus remained, which impeded the closure of the ileostomy. Given this situation, we used colonoscopy to carry out curettage of the presacral sinus in conjunction with the application of a cyanoacrylate biological tissue adhesive (Glubran 2). Four weeks later, barium enema and follow-up colonoscopy confirmed the closure of the defect (Fig. 2). One month after this resolution, the ileostomy was closed without incident. The patient is currently asymptomatic, with proper intestinal function and no recurrence of the disease. Anastomotic dehiscence after resection of the rectum is a complication with an important morbidity and mortality. Its incidence varies between 5% and 30%.One treatment strategy is the defunctionalization of the anastomosis with an ileostomy, which, although it does not avoid leaks, prevents serious septic complications. The use of protective ileostomy after low anterior resection, even after having received neoadjuvant chemoradiotherapy, depends on the experience of the surgical team and the final result of the anastomosis. With this management, most leaks resolve spontaneously, although in 1%–5% of cases they may lead to the appearance of a presacral sinus. Symptomatic patients present inflammation or sepsis in the pelvic region and are usually studiedwith barium enemas and repeated colonoscopies to confirm resolution. There are risk factors, such as preoperative radiotherapy, which make resolution difficult. Complications may develop, including the formation of fistulas, periurethral fibrosis, infection of adjacent tissues and even malignant degeneration. For the treatment of this condition, Whitlow et al. described unroofing of the anastomosis by means of the division of the wall between the presacral sinus and the lumen of the adjacent bowel. In another series, however, intersphincteric resection of the rectal stump together with debridement of the sinus and omentoplasty or muscular flap is presented as the technique with the best results for healing. The Endo-SPONGE system introduced by Weidenhagen et al., based on vacuum suction through a sponge that is inserted in the presacral space, showed a high rate of success, although a later study performed to evaluate these long-term results observed up to 25% of recurring abscesses. Another study compared EndoVAC with rectal lavage and drainage,