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Anorectoplasty: Complications and final results
Anorectoplasty: Complications and Final Results .~VILLIAM A. MCMAHON, M.D., HE purpose of this paper is to present the
T incidence of complications and final results obtained in a series of 853 patients on whom an amputative type of anorcctoplasty was performed. This series was taken from my own practice over a period of five years. Institutional cases and those t h a t were not followed up in nay own office are not included. Dissatisfaction with results obtained by the established clamp and ligature procedurcs, along with nay owff acceptance of the essential part that structures in the crypt-bearlng area play in the pathogcnesis of anorcctal disease, was responsible for a change to "m amputative operation with ablation of the entire crypt area. T h e series to be presented comprises 853 patients on whom surgery was performed for the basic problem of hemorrhoids. In an analysis of thcse cases, other anorectal disorders were found in 94.3 per cent. (Table L) T h e operative procedure employed had as its objective the removal of hemorrhoids and all diseascd portions of the anus and rectum. T o accomplish this aim, an amputative anorcctoplasty was performcd in which the entire hemorrhoklal area was dissected free, including skin tags, external henmrrholds, anal crypts and papillae, areas of scar associated with fissure, internal henmrrhoids, and rcdundant mucosa of the anal canal and lower rectal ampulla. T h e disscction was carricd upward to a point where normal mucosa could be brought down and anastomoscd to the skin after anaputation of the diseased tissues. This anastomosis was made without tension and was fixed at the normal level of the pcctinate line on the medial aspcct of tile internal sphincter. Tile primary aim in the postoperative period was to obtain a normal-formed stool in ordcr to accomplish daily physiologic dilation of the
Seattle, Washington
anal canal and sphincter elements. No manual dilation was believed to be necessary aside from gentle exploration of the anal canal with a small cotton applicator. TABLE I )12rent~ge
Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cryptitls . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pectenosis or stenosis . . . . . . . . . . . . . . . . . Papillae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No.
of C~'1sos
9- I 7.8 0.7 4-l
418 " 237 176 12o
8.1
69
7-0 7.0 5 2 218
60 60 44 24
These patients were seen at intervals postoperatively until such time as healing was complete and the functional result was considercd normal. T h e average length of time comprising this period of observation was about thrce months. CO•IPLICATIONS
In the analysis of tile postoperative con> plications and sequelae, the occurrence of urinary retention was not consldcrcd as being relatcd to tile operative procedure employed. Postopcrative pain was not formidable and hence no special mcasnres such as local anesthesia or prolonged use of narcotics were cmployed. Table II illustrates the complications encountered in their order of frequency. Impaetion. Impaction occurred in 143 patients, or I6.8 per cent. This was found most often one week following surgery. The condition responded to simple enemas in all patients 739
American Journal of Surger],', Volume 92, IVorembtr, z9..r
McMahon except one. Here digital removal under anesthesia was necessary. Stenosis. The diagnosis of postoperative stenosis requiring surgical correction was made in nineteen patients, or 2.2 per cent. A narrowing of the stools to pencil size was commonly
complete removal of the anal crypts accomplished by this amputative procedure may be the deciding factor. Certainly the clinical course bore very little resemblance to tile usual type of anal fissure. Thrombosis. Thrombosis of external hemorrhoidal vessels was noted postoperatively in four patients, or 0.5 per cent. This can hardly be considered an operative complication but is included for completeness. It gives evidence of incomplete removal of the external hemorrhoidal vessels in these patients. Abscess. Abscess formation occurred in three patients, or o.4 per cent. These were simple abscesses having their origin at tile line of anastomosis and were not followed by fistula formation. Simple incision and drainage resulted in uneventful healing. Altered Sensation. Altered sensation occurred postoperatively in three patients, or 0.4 per cent. It was not uncommon to find that some patients had difficulty in differentiating flatus from stool during the immediate postoperative period; however, in all but these three patients normal sensation had returned at tile end of two to four Weeks. In the aforcmentioned patients some changes in perception continued for as long as six months but eventually disappeared. Postoperath'e Itemorrbage. Post operative hemorrhage occurred in three patients, or 0.4 per cent. In one of these complete avulsion of the line of anastomosis occurred on the seventh postoperative day. This patient had chronic myelogenous leukemia and surgery had been undertaken for the control of severe bleeding from large prolapsing hemorrhoidal masses. Healing was delayed, but eventually was complete. Ectropion. This condition occurred in two patients, or o.2 per cent. It resulted from fixation of the anastomosis between skin and mucous membrane at too low a leveI. While in both instances only a segment of the circumference was involved, the defects were productive of symptoms and were corrected by subsequent surgery.
T A B L E II
Complication
Impactlon ........................... Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atony of sphincter (temporary, s p o n d e d to exercise) . . . . . . . . . . . . . . .
[o.
Per-
i:e L s
centage
~3 9
z6.8 2.2
re-
Fistul.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fissure. . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . Altered sensation (temporary). . . . . . . . Postoperative hemorrhage (one patlenl had leukemia). . . . . . . . . . . . . . . . . . . . Ectropion (partial). . . . . . . . . . . . . . . . . . i
t.5 I.I
0".6 0.5 0.4 0-4
0-4 0.2
noted in the first month postoperatively. During this period the first digital examination was done to explore tile line of anastomosis, still relying on tile formed stools and physiologic softening of the scar to accomplish restoration of tile caliber of the bowel to normal. In the nineteen patients in whom contraction of the outlet persisted and showed no sign of improvement, simple sphincterotomy was performed. Ato~w. Atony of the sphincter was noted in thirteen patients, or i. 5 per cent. This was a temporary condition and in most patients it followed the correction of conditions involving more than the ustml degree of prolapse. The Condition responded quickly to sphincter exercise in all cases. Fistula. Postoperative fistula occurrcd in ten patients, or I.l per cent. In five of the ten patients there was a pre-existing fistula, two of which were of the rectovaginal type. The other five postoperative fistulas occurred independently of previous fistula formation. Fissure. Postoperative fissure occurred in five patients, or 0.6 per cent. Two of these patients had anal fissure as an associated diagnosis at the time of surgery. The shortest duration of these fissures was two weeks and the longest eleven months, but all healed spontaneously. This is significant since the
SUMMARY
An analysis of the complications encountered after an amputatlvc type of anorcctoplasty have been presented. In thc scrics of 853 cases complications occurrcd in 24.I per cent. This seems to bc an extremely high rate 740
Anorectoplasty of complications until it is further qualified by noting t h a t fully two-thirds come under the heading of postoperative impactions. Since this series was compiled, the routine use of aerosol 0. T. by mouth in the postoperative period has reduced the incidence of impactions to a minimum, certainly under I per cent. In reviewing this series, the complications encountered do not seem to w a r r a n t the intense criticism which has been directed toward all Whitehead t y p e a m p u t a t i v e procedurcs. A consideration of the final results of the corrcctive surgical procedure used on this group of patients reveals t h a t they have normal function and are free from anorectal disease at the present writing. I t can be estimated t h a t fllture anorcctal disease is not liable to dcvclop since no recurrences have been encountered. I t is m y hope t h a t a s t u d y will be carried out on a comparable series of patients undergoing the more conventional clamp and ligature procedures so t l m t further comparisons m a y be made of these two widely divergent approaches to the correction of anorectal disorders. DISCUSSION
I{OI~ERTE. Po.~mlmEx" (Dayton, Ohio): 1 cannot share Dr. McMahon's enthusiasm for the use of an amputatlve type Of hemorrhoidectomy as a routine procedure. Thcre can be no doubt that such an extensive procedure results in more postoperative morbidity in terms of patient discomfort and disability. It would therefore secm desirable to reserve the amputative type of hemorrhoidectomy for the more severe cases involving the entire anorectal ring. The statistics presented by Dr. McMahon indicate a good response to the procedure when viewed in the light of his explanatory notes. However, several of the complications such as postoperative impactlon, stenosls and fistula seem much more frequent than would be anticipated if more conservative surgery were practiced. My own experience with the amputatlve method has not been as trouble-free as Dr. McMahon has indicated, especially in regard to altered sensation, stenosis and ectropion. There seems to be a great difference in patient response to any given procedure and it is not always possible to regulate the bowel movements to the propcr consistency, nor is it possible to predict how a patient will progress following an opcration. Any deviation from the normal in the postoperative course of the patient is verb" likely to result in a complication if the amputative method has been used. The importance of the crypt-bearlng area cannot be denied and is recognized by all proctologists as a 74I
potential source of disease. Nonetheless, I would not advocate sacrificing so much tissue if it means an appreciable increased morbidity any more than 1 would advocate hysterectomy because a fibroid might later develop in the uterus. RtCIIARO A. I lovvlr~c (East Orange, N. J.): I would llke to mention one glaring omission in Dr. McMahon's list of complications. Very often tags in the perianal skin occur following this type of procedure, and I am wondering if he discounts these as a complication. EMIL GRANET (New York, N. Y.): Although I have not compiled my own series in detail, I can report on approximately 500 anorectoplasties probably similar in technic to the type that Dr. McMahon performs. I also find that the most frequent complication in the immediate postoperative period is impaction. Whether the type of impactlon that my patients experience can really be called a specific complication of anorectoplasty is questionable. I find that in patients who have had a simple ligature type of operation, impactions occur in about the same proportion. Stricture occurred infrequently in my patients, much less than the 2.2 per cent reported by Dr. McMahon. This was so perhaps because of my use of partial posterior myotomy in all patients who presented a fibrotlc anal canal (pecten band) when examined digitally following induction of anesthesia. In patients with chronic anal fissure (ulcer), inflammatory fibrosis below the ulcer often extends deeply into the internal sphincter muscle so that a good portion of that muscle must be sacrificed in order to attain cure. Some of my patients, perhaps 5 per cent, do complain of incontinence to very soft stools and to flatus in the immediate postoperative period. Partial incontinence often persists until the wound is healing well and the patient is not afraid to contract the sphincter muscles, a period of two to three weeks. A point of great importance which I would like to emphasize is that the functional and anatomic end result in any type of anorectoplasty requires the lapse of a prolonged period of time in order for physiologic changes to take place in the wound. Scar tissue docs soften in the anorcctal region provided nature is given time to accomplish this. Dr. McMahon has emphasized the importance of dilatation by the natural movement of the bowels through the anal canal. I agree with him that manual dilatation is not necessary. I believe it to be harmful in most patients following anorectal surgery, because with dilatation trauma is produced, thereby increasing the proliferation of fibrotic tissue. Eventually more stricture is present than if the wound had merely been explored with the little finger.
McMahon WILLIAM A. McMallo.~ (closing): In regard to Dr. Pumphrey's question about tile difficulty of controlling the patient's bowel habits, 1 would call attention to tire fact that a complete appraisal of each individual is, of course, of the greatest importance, particularly regarding the bowel habits of the past. Those patients with any semblance of an irritable bowd or any combination of symptoms which suggcst the condition arc treated during tile postoperative period by dietarb~ measures, antispasmodics and mild sedation as might be required.
In answer to Dr. Hopplng's question, I can sincerely state that there are no tags with this type of procedure. I might mention one more thing about tile reduction of impactions. Aerosal 0. T. performs amazingly. I have been using it for about six months. As you know, it is simply a wetting agent and has no action whatsocvcr on the bowel, but does prevent dehydration of the stool. I have given patients straight aerosol O. T. ! % in doses of I gm. twice a day for the past six months and have noted no impactlons.
@
742
T incidence of complications and final results obtained in a series of 853 patients on whom an amputative type of anorcctoplasty was performed. This series was taken from my own practice over a period of five years. Institutional cases and those t h a t were not followed up in nay own office are not included. Dissatisfaction with results obtained by the established clamp and ligature procedurcs, along with nay owff acceptance of the essential part that structures in the crypt-bearlng area play in the pathogcnesis of anorcctal disease, was responsible for a change to "m amputative operation with ablation of the entire crypt area. T h e series to be presented comprises 853 patients on whom surgery was performed for the basic problem of hemorrhoids. In an analysis of thcse cases, other anorectal disorders were found in 94.3 per cent. (Table L) T h e operative procedure employed had as its objective the removal of hemorrhoids and all diseascd portions of the anus and rectum. T o accomplish this aim, an amputative anorcctoplasty was performcd in which the entire hemorrhoklal area was dissected free, including skin tags, external henmrrholds, anal crypts and papillae, areas of scar associated with fissure, internal henmrrhoids, and rcdundant mucosa of the anal canal and lower rectal ampulla. T h e disscction was carricd upward to a point where normal mucosa could be brought down and anastomoscd to the skin after anaputation of the diseased tissues. This anastomosis was made without tension and was fixed at the normal level of the pcctinate line on the medial aspcct of tile internal sphincter. Tile primary aim in the postoperative period was to obtain a normal-formed stool in ordcr to accomplish daily physiologic dilation of the
Seattle, Washington
anal canal and sphincter elements. No manual dilation was believed to be necessary aside from gentle exploration of the anal canal with a small cotton applicator. TABLE I )12rent~ge
Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cryptitls . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pectenosis or stenosis . . . . . . . . . . . . . . . . . Papillae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No.
of C~'1sos
9- I 7.8 0.7 4-l
418 " 237 176 12o
8.1
69
7-0 7.0 5 2 218
60 60 44 24
These patients were seen at intervals postoperatively until such time as healing was complete and the functional result was considercd normal. T h e average length of time comprising this period of observation was about thrce months. CO•IPLICATIONS
In the analysis of tile postoperative con> plications and sequelae, the occurrence of urinary retention was not consldcrcd as being relatcd to tile operative procedure employed. Postopcrative pain was not formidable and hence no special mcasnres such as local anesthesia or prolonged use of narcotics were cmployed. Table II illustrates the complications encountered in their order of frequency. Impaetion. Impaction occurred in 143 patients, or I6.8 per cent. This was found most often one week following surgery. The condition responded to simple enemas in all patients 739
American Journal of Surger],', Volume 92, IVorembtr, z9..r
McMahon except one. Here digital removal under anesthesia was necessary. Stenosis. The diagnosis of postoperative stenosis requiring surgical correction was made in nineteen patients, or 2.2 per cent. A narrowing of the stools to pencil size was commonly
complete removal of the anal crypts accomplished by this amputative procedure may be the deciding factor. Certainly the clinical course bore very little resemblance to tile usual type of anal fissure. Thrombosis. Thrombosis of external hemorrhoidal vessels was noted postoperatively in four patients, or 0.5 per cent. This can hardly be considered an operative complication but is included for completeness. It gives evidence of incomplete removal of the external hemorrhoidal vessels in these patients. Abscess. Abscess formation occurred in three patients, or o.4 per cent. These were simple abscesses having their origin at tile line of anastomosis and were not followed by fistula formation. Simple incision and drainage resulted in uneventful healing. Altered Sensation. Altered sensation occurred postoperatively in three patients, or 0.4 per cent. It was not uncommon to find that some patients had difficulty in differentiating flatus from stool during the immediate postoperative period; however, in all but these three patients normal sensation had returned at tile end of two to four Weeks. In the aforcmentioned patients some changes in perception continued for as long as six months but eventually disappeared. Postoperath'e Itemorrbage. Post operative hemorrhage occurred in three patients, or 0.4 per cent. In one of these complete avulsion of the line of anastomosis occurred on the seventh postoperative day. This patient had chronic myelogenous leukemia and surgery had been undertaken for the control of severe bleeding from large prolapsing hemorrhoidal masses. Healing was delayed, but eventually was complete. Ectropion. This condition occurred in two patients, or o.2 per cent. It resulted from fixation of the anastomosis between skin and mucous membrane at too low a leveI. While in both instances only a segment of the circumference was involved, the defects were productive of symptoms and were corrected by subsequent surgery.
T A B L E II
Complication
Impactlon ........................... Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atony of sphincter (temporary, s p o n d e d to exercise) . . . . . . . . . . . . . . .
[o.
Per-
i:e L s
centage
~3 9
z6.8 2.2
re-
Fistul.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fissure. . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . Altered sensation (temporary). . . . . . . . Postoperative hemorrhage (one patlenl had leukemia). . . . . . . . . . . . . . . . . . . . Ectropion (partial). . . . . . . . . . . . . . . . . . i
t.5 I.I
0".6 0.5 0.4 0-4
0-4 0.2
noted in the first month postoperatively. During this period the first digital examination was done to explore tile line of anastomosis, still relying on tile formed stools and physiologic softening of the scar to accomplish restoration of tile caliber of the bowel to normal. In the nineteen patients in whom contraction of the outlet persisted and showed no sign of improvement, simple sphincterotomy was performed. Ato~w. Atony of the sphincter was noted in thirteen patients, or i. 5 per cent. This was a temporary condition and in most patients it followed the correction of conditions involving more than the ustml degree of prolapse. The Condition responded quickly to sphincter exercise in all cases. Fistula. Postoperative fistula occurrcd in ten patients, or I.l per cent. In five of the ten patients there was a pre-existing fistula, two of which were of the rectovaginal type. The other five postoperative fistulas occurred independently of previous fistula formation. Fissure. Postoperative fissure occurred in five patients, or 0.6 per cent. Two of these patients had anal fissure as an associated diagnosis at the time of surgery. The shortest duration of these fissures was two weeks and the longest eleven months, but all healed spontaneously. This is significant since the
SUMMARY
An analysis of the complications encountered after an amputatlvc type of anorcctoplasty have been presented. In thc scrics of 853 cases complications occurrcd in 24.I per cent. This seems to bc an extremely high rate 740
Anorectoplasty of complications until it is further qualified by noting t h a t fully two-thirds come under the heading of postoperative impactions. Since this series was compiled, the routine use of aerosol 0. T. by mouth in the postoperative period has reduced the incidence of impactions to a minimum, certainly under I per cent. In reviewing this series, the complications encountered do not seem to w a r r a n t the intense criticism which has been directed toward all Whitehead t y p e a m p u t a t i v e procedurcs. A consideration of the final results of the corrcctive surgical procedure used on this group of patients reveals t h a t they have normal function and are free from anorectal disease at the present writing. I t can be estimated t h a t fllture anorcctal disease is not liable to dcvclop since no recurrences have been encountered. I t is m y hope t h a t a s t u d y will be carried out on a comparable series of patients undergoing the more conventional clamp and ligature procedures so t l m t further comparisons m a y be made of these two widely divergent approaches to the correction of anorectal disorders. DISCUSSION
I{OI~ERTE. Po.~mlmEx" (Dayton, Ohio): 1 cannot share Dr. McMahon's enthusiasm for the use of an amputatlve type Of hemorrhoidectomy as a routine procedure. Thcre can be no doubt that such an extensive procedure results in more postoperative morbidity in terms of patient discomfort and disability. It would therefore secm desirable to reserve the amputative type of hemorrhoidectomy for the more severe cases involving the entire anorectal ring. The statistics presented by Dr. McMahon indicate a good response to the procedure when viewed in the light of his explanatory notes. However, several of the complications such as postoperative impactlon, stenosls and fistula seem much more frequent than would be anticipated if more conservative surgery were practiced. My own experience with the amputatlve method has not been as trouble-free as Dr. McMahon has indicated, especially in regard to altered sensation, stenosis and ectropion. There seems to be a great difference in patient response to any given procedure and it is not always possible to regulate the bowel movements to the propcr consistency, nor is it possible to predict how a patient will progress following an opcration. Any deviation from the normal in the postoperative course of the patient is verb" likely to result in a complication if the amputative method has been used. The importance of the crypt-bearlng area cannot be denied and is recognized by all proctologists as a 74I
potential source of disease. Nonetheless, I would not advocate sacrificing so much tissue if it means an appreciable increased morbidity any more than 1 would advocate hysterectomy because a fibroid might later develop in the uterus. RtCIIARO A. I lovvlr~c (East Orange, N. J.): I would llke to mention one glaring omission in Dr. McMahon's list of complications. Very often tags in the perianal skin occur following this type of procedure, and I am wondering if he discounts these as a complication. EMIL GRANET (New York, N. Y.): Although I have not compiled my own series in detail, I can report on approximately 500 anorectoplasties probably similar in technic to the type that Dr. McMahon performs. I also find that the most frequent complication in the immediate postoperative period is impaction. Whether the type of impactlon that my patients experience can really be called a specific complication of anorectoplasty is questionable. I find that in patients who have had a simple ligature type of operation, impactions occur in about the same proportion. Stricture occurred infrequently in my patients, much less than the 2.2 per cent reported by Dr. McMahon. This was so perhaps because of my use of partial posterior myotomy in all patients who presented a fibrotlc anal canal (pecten band) when examined digitally following induction of anesthesia. In patients with chronic anal fissure (ulcer), inflammatory fibrosis below the ulcer often extends deeply into the internal sphincter muscle so that a good portion of that muscle must be sacrificed in order to attain cure. Some of my patients, perhaps 5 per cent, do complain of incontinence to very soft stools and to flatus in the immediate postoperative period. Partial incontinence often persists until the wound is healing well and the patient is not afraid to contract the sphincter muscles, a period of two to three weeks. A point of great importance which I would like to emphasize is that the functional and anatomic end result in any type of anorectoplasty requires the lapse of a prolonged period of time in order for physiologic changes to take place in the wound. Scar tissue docs soften in the anorcctal region provided nature is given time to accomplish this. Dr. McMahon has emphasized the importance of dilatation by the natural movement of the bowels through the anal canal. I agree with him that manual dilatation is not necessary. I believe it to be harmful in most patients following anorectal surgery, because with dilatation trauma is produced, thereby increasing the proliferation of fibrotic tissue. Eventually more stricture is present than if the wound had merely been explored with the little finger.
McMahon WILLIAM A. McMallo.~ (closing): In regard to Dr. Pumphrey's question about tile difficulty of controlling the patient's bowel habits, 1 would call attention to tire fact that a complete appraisal of each individual is, of course, of the greatest importance, particularly regarding the bowel habits of the past. Those patients with any semblance of an irritable bowd or any combination of symptoms which suggcst the condition arc treated during tile postoperative period by dietarb~ measures, antispasmodics and mild sedation as might be required.
In answer to Dr. Hopplng's question, I can sincerely state that there are no tags with this type of procedure. I might mention one more thing about tile reduction of impactions. Aerosal 0. T. performs amazingly. I have been using it for about six months. As you know, it is simply a wetting agent and has no action whatsocvcr on the bowel, but does prevent dehydration of the stool. I have given patients straight aerosol O. T. ! % in doses of I gm. twice a day for the past six months and have noted no impactlons.
@
742