Turnbull–Cutait abdominoperineal pull-through: a safe approach for recurrent sacrococcygeal teratoma complicated by rectovaginal fistula

Abstract

Sacrococcygeal teratomas are rarely seen and are classified as type I germ cell tumors. While surgery is the main treatment option, poor postoperative urological and anal functional outcomes and recurrence are major concerns [1]. An extensive resection with proctectomy is one of theoptions offering a curative treatment for recurrent sacrococcygeal teratomas. Maintenance of intestinal continuity is another component of a comprehensive therapeutic approach and should be considered for the sake of the patient’s quality of life after surgery. We hereby present the Turnbull–Cutait abdominoperineal pull-through anastomosis (T–C) technique in a patient with recurrent sacrococcygeal teratoma complicated by a rectovaginal fistula. A 41-year-old female had undergone surgery for a benign sacrococcygeal teratoma 24 years ago and had no complaints until last year. After she sought help for tailbone pain at an outside hospital, a recurrent presacral mass was discovered with a computer tomography scan. Fine-needle biopsy performed at an outside hospital confirmed the diagnosis of a recurrent sacrococcygeal teratoma. The initial operation which was performed to excise the recurrent lesion failed, and a rectovaginal fistula developed on postoperative day 20. A diverting ileostomy was then created to control pelvic sepsis, and the patient was eventually referred to our institution. At presentation, a baseline pelvic magnetic resonance imaging scan was requested, which revealed the recurrent sacrococcygeal teratoma with operative changes related to prior surgery (Fig. 1a). A stricture at 7 cm from the anal verge was found where pus drainage was observed in rectal examination which was performed under general anesthesia. The patient had type 1 diabetes, a body mass index of 21.9 kg/m and an American Society of Anesthesiologists (ASA) score of 3. Her surgical history included cholecystectomy and total abdominal hysterectomy in addition to prior surgical intervention for sacrococcygeal teratoma. It was determined that a total mesorectal excision was necessary in order to achieve total removal of the neoplastic lesion. The patient was consented preoperatively for colovaginal fistula takedown and colorectal anastomosis plus possible abdominoperineal resection. During the operation, after resection of the rectum, stapled anastomosis was deemed inappropriate due to poor tissue quality and the decision was made to proceed with our traditional two-staged T–C technique [2]. The operation was completed uneventfully. The perineal colonic segment was resected on postoperative day 5, and hand-sewn coloanal anastomosis was performed (Fig. 1b). Postoperatively, the patient had persistent pelvic pain and developed a pelvic abscess which was diagnosed on postoperative day 12 and was drained percutaneously. Intravenous antibiotic therapy was started, and the patient was discharged on postoperative day 20 after pain control was achieved. A T–C pull-through with delayed coloanal anastomosis, T–C, was first described by Turnbull and Cutait for the treatment of rectal cancer, Hirschsprung’s disease and megacolon in Chagas disease [3, 4]. Basic steps of the Turnbull–Cutait abdominoperineal pull-through anastomosis were shown in the Fig. 1c–f. T–C is not typically preferred for low pelvic anastomoses, since advanced stapler technology is now used effectively. However, we believe that T–C has its place in low coloanal anastomoses, The study was supported by the Ed and Joey Story Endowed Chair in Colorectal Surgery.