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Complications of anorectal surgery
COMPLICATIONS OF ANORECTAL SURGERY LYMAN
R. PEARSON,
Indianapolis,
T
HE common comphcations of anorecta1 surgery have received IittIe attention in textbooks and other pubIications. Some surgeons are reIuctant to admit the minor compIications which can be so distressing to the patient as we11as to the proctologist. The most common compIications are: (I) postoperative pain, (2) immediate hemorrhage, (3) deIayed hemorrhage, (4) edematous ana tags, (3) deIayed heaIing of wounds in the ana cana and (6) ana stenosis. A certain amount of pain cannot be avoided, but excessive pain may be modified in severa different ways. The sphincter muscIe, the deep Iayer as we11as the superficia1 Iayer which is adherent to the skin, must be gentIy handIed. Hemostats shouId not be pIaced on any of these muscIe fibers. AImost a11bIeeding vesseIs in the muscIe wiI1 retract with pressure in a short time. Ties shouId be used sparingIy and delinitely not put on fibers of the muscIe. CIamps put on any bIeeders during the operation shouId be removed at the finish when few vesseIs wiI1 be found stiI1 bleeding. A tie may be used on a very smaI1 amount of tissue if bleeding is persistent. In most of my operations I use none. In our experience we have had IittIe success with oiI-soIubIe anesthetics injected into the muscIe. Perhaps our technic was not proper, but we found these patients needing just as many postoperative hypodermics as those in whom we did not use oi1. SpinaI anesthesia using nupercaine, * 2.5 mg. in 5 per cent dextrose soIution, with the addition of three to four drops of adrenaIin wiI1 provide proIonged saddIe anesthesia when given with the patient in a sitting position. This anesthetic has been used to date in over 150 cases with no compIications. No headaches resuIted which needed specia1 medication. The anesthesia has been satisfactory even when surgery has Iasted Ionger than one hour. The patients have been abIe to move around in bed on return from surgery but have had no pain sense for from four to tweIve hours after injection. This enabIes the patient to fee1 better and to eat soIid food two to three hours * Ciba PharmaceuticaI Products, Inc., Summit, N. J. January,
I 95 I
M.D.
Indiana after surgery. It aIso reduces the need for narcotics. Our patients receive an average of two hypodermics of morphine sulfate, s/4gr., during the first twenty-four hours foIIowing operations. Few ever use more and many have none or one. A patient seIdom compIains of sphincter spasm as a resuIt of the aforementioned procedures. The subcutaneous portion of the externa sphincter is divided one-haIf way through routineIy in a11 cases of fissure and spastic sphincter. This of course shouId not be done in patients with hypotonic sphincters or with recta1 proIapse or procidentia. After the first postoperative dressing I use hot sitz baths and surfacaine ointment* freeIy; these greatIy increase the comfort of the patient. Hemorrhage may occur in the first twentyfour hours foIIowing operation due to the sIipping of a tie on one of the hemorrhoida veins or the breaking Ioose of a cIot in an untied artery or vein where the packing does not create adequate pressure. This is usuaIIy initiated by vomiting, coughing or too rapid movements of the patient. The bIeeding may be profuse, without warning. The patient may be found Iying in a poo1 of bIood or the hemorrhage may manifest itseIf by an intense desire to defecate in which the patient expeIs packing, drain and aI1. When such a hemorrhage occurs, a11dressings shouId be removed, the raw areas cIeansed we11 with peroxide and a carefu1 externa1 examination made. If the bIeeding vesse1 is superficia1, a cIamp can be put on for a few minutes and the bIeeding stopped. With oxyce1 gauze used as packing, these superficia1 bIeeders are rare. If no bIeeders are seen externaIIy, the patient shouId be returned to surgery immediateIy, given an intravenous anesthetic and the bIeeder found and Iigated. There shouId be no deIay whiIe attempting to use antihemorrhagic drugs to contro1 bIeeding. BIood transfusions may be needed after the bIeeder is tied. Late hemorrhage is more diffrcuIt to contro1. This usuaIIy occurs seven to fourteen days foI* Eli Lilly & Co., IndianapoIis, Ind.
25
26
Pearson-AnorectaI
Iowing operation . Since my patients are usuaIIy sent home in six to seven days, this occurs usually at home. It is more common in very eIderIy persons or those who are anemic or debiIitated. Late hemorrhage is caused either by absorption of the ligature on a vein or the puIIing off of the Iigature by a hard feca1 mass where the vein has not formed a soIid cIot with cIosure of the Iumen. Packing these areas is not satisfactory. The patient shouId be returned to the hospitaI, taken to surgery and the bIeeder found and tied. I have used a11 types of sutures from No. oo pIain catgut to chromic No. 2 and find that the suture makes IittIe difference. I routineIy use chromic No. I, singIe and have never had a patient return with a second hemorrhage. In these cases, aIso, a bIood transfusion usuaIIy aids in convaIescence and improves the moraIe of the patient and his famiIy. In 200 consecutive hemorrhoidectomies I have had three superficial hemorrhages which necessitated removal of the oxyce1 gauze, thorough cleansing with hydrogen peroxide, repacking with oxyce1 gauze and application of a firm pressure dressing. In a11 of these there was no subsequent excessive bIeeding. In the same group there were four patients with recta1 hemorrhages. One occurred eight hours after surgery expeIIing a11 packing and drain. One occurred on the seventh postoperative day, one on the tweIfth and one on the sixteenth. These four patients were a11 returned to the operating room where the bleeding vesseIs were Iigated. Edematous ana tags form usuaIIy five to ten days foIIowing operation. They are caused by inadequate drainage of the ana wounds which aIIows coIIection of exudate under the skin bridges and produces edema. The bridges become swoIIen, from 3 to IO mm. in size, and are red, hard and painfu1. The patient wiI1 notice the tender tag on sitting and also whiIe cIeansing himself. These tags may be prevented by not undercutting skin bridges so compIeteIy. However, it is more important to undercut these bridges and excise the entire pIexus of externa1 hemorrhoida veins even at the cost of a few tags than to Ieave these veins as sites for possibIe future thrombosis. By carefuIly saucerizing the skin edges and pointing the end of the wound, sufficient drainage may be obtained to minimize the incidence of postoperative tags. Since these usuaIIy occur after the patient Ieaves the hospita1, they are excised in the
Surgery off&e on his first or second check-up. Thrs can easiIy be done under IocaI anesthesia. If aIIowed to remain they wiI1 graduaIIy subside but wiI1 aIways remain as foIds or tags which might initiate a future pruritus ani. During the remova1 of these tags a large enough area must be excised to obtain adequate drainage or the same condition may recur. SIow heaIing of the anoderm high in the ana cana is seen frequentIy in the postoperative period and is practicaIIy aIways due to inadequate skin drainage. It occurs most commonIy in very obese individuaIs. Many patients have been seen two to three years after surgery with high ana uIcers or Iow recta1 uIcers due to improper postoperative care. In my own cases the skin areas often hea beautifuIIy but the modified skin of the ana canal remains open. If not given proper care they never wiI1 heal. During the postoperative care the anoderm should not be aIIowed to heaI before the mucosa1 surfaces. I treat the dista1 margins of the raw areas in the skin weekIy, with IO per cent nitric acid in order to retard healing. At the same time I treat the proxima1 raw areas with I0 per cent siIver nitrate to stimulate granuIation tissue. If in spite of this the skin heaIs first, I excise an area of skin aImost as Iarge as the origina wound under IocaI anesthesia in order to get proper drainage. This procedure is most important in order to get compIete heaIing. OccasionaIIy, overIooked smaI1 ana papiIIae wiI1 enIarge during the earIy postoperative period. Sometimes the area of Iigation of the hemorrhoida vein wiI1 deveIop a poIypoid growth. The edges of the mucosa1 wounds may sometimes become edematous and swoIIen. Before dismissa the patient shouId be given a thorough examination both with finger and proctoscope. If any of these Iesions is found, it shouId be corrected under IocaI anesthesia. AnaI stenosis is perhaps the most common complication of anorectal surgery. The technic of surgery and postoperative care is planned with the thought or fear of future stenosis. The avoidance of this condition begins with surgery. Leaving an adequate amount of anoderm, Ieaving as wide skin bridges as possibIe and incising the externa1 sphincter muscIe a11 heIp. By the fourth postoperative day I begin recta1 diIations, continuing them every three to seven days depending on the tightness of the canal unti1 the heaIing is complete. I do not aIIow American
Journal
of Surgery
Pearson-Anorectal my patients to do their own diIations, nor do I use mechanica dilators. After the first five to six days I reduce or discontinue a11 Iaxatives in order that the patient may have firm bowel movements. I do not use muciIaginous drugs to retain fluid in the intestinaI cana1. I want my patient to have soIid stools even though he may have to strain to deIiver them. I warn my patient to expect to strain and to have pain and even some bIeeding with his movements if heaIing is to progress in the normal way. In this way he gets his own daiIy diIations on which I improve with my own examination every few days. DiIation may be painfu1 to the patient. I use 5 per cent metycaine in the ana cana previous to my examinations. When the patient understands the importance of the diIation, he is usuaIIy very cooperative. Once in a Iong whiIe a short band of scar tissue may form in the Iow recta1 mucosa which I do not hesitate to incise earIy. A simiIar circu-
January,
I 95 I
Surgery
27
Iar band of scar tissue may form at the intersphincteric line which shouId aIso be incised. AIIowed to remaip, these wiI1 narrow the Iumen of the cana considerabIy. Urinary retention, rectal impaction and other minor compIications are not considered in this paper. These are usuaIIy easily controIIed. By putting my patients on a reguIar diet and aIIowing them to be up as much as they wish on the first postoperative day I seIdom have diffIcuIty with these conditions. EarIy activity and fuII diet aid in obtaining earIy bowe1 eIimination and aIso speed the patient’s reIease from the hospita1. SUMMARY
The prophyIaxis and treatment of six frequent and important compIications of anorecta1 surgery are discussed. IncIuded in this discushemorrhage, sion are postoperative pain, edematous ana tags, deIayed heaIing and anal stenosis.
R. PEARSON,
Indianapolis,
T
HE common comphcations of anorecta1 surgery have received IittIe attention in textbooks and other pubIications. Some surgeons are reIuctant to admit the minor compIications which can be so distressing to the patient as we11as to the proctologist. The most common compIications are: (I) postoperative pain, (2) immediate hemorrhage, (3) deIayed hemorrhage, (4) edematous ana tags, (3) deIayed heaIing of wounds in the ana cana and (6) ana stenosis. A certain amount of pain cannot be avoided, but excessive pain may be modified in severa different ways. The sphincter muscIe, the deep Iayer as we11as the superficia1 Iayer which is adherent to the skin, must be gentIy handIed. Hemostats shouId not be pIaced on any of these muscIe fibers. AImost a11bIeeding vesseIs in the muscIe wiI1 retract with pressure in a short time. Ties shouId be used sparingIy and delinitely not put on fibers of the muscIe. CIamps put on any bIeeders during the operation shouId be removed at the finish when few vesseIs wiI1 be found stiI1 bleeding. A tie may be used on a very smaI1 amount of tissue if bleeding is persistent. In most of my operations I use none. In our experience we have had IittIe success with oiI-soIubIe anesthetics injected into the muscIe. Perhaps our technic was not proper, but we found these patients needing just as many postoperative hypodermics as those in whom we did not use oi1. SpinaI anesthesia using nupercaine, * 2.5 mg. in 5 per cent dextrose soIution, with the addition of three to four drops of adrenaIin wiI1 provide proIonged saddIe anesthesia when given with the patient in a sitting position. This anesthetic has been used to date in over 150 cases with no compIications. No headaches resuIted which needed specia1 medication. The anesthesia has been satisfactory even when surgery has Iasted Ionger than one hour. The patients have been abIe to move around in bed on return from surgery but have had no pain sense for from four to tweIve hours after injection. This enabIes the patient to fee1 better and to eat soIid food two to three hours * Ciba PharmaceuticaI Products, Inc., Summit, N. J. January,
I 95 I
M.D.
Indiana after surgery. It aIso reduces the need for narcotics. Our patients receive an average of two hypodermics of morphine sulfate, s/4gr., during the first twenty-four hours foIIowing operations. Few ever use more and many have none or one. A patient seIdom compIains of sphincter spasm as a resuIt of the aforementioned procedures. The subcutaneous portion of the externa sphincter is divided one-haIf way through routineIy in a11 cases of fissure and spastic sphincter. This of course shouId not be done in patients with hypotonic sphincters or with recta1 proIapse or procidentia. After the first postoperative dressing I use hot sitz baths and surfacaine ointment* freeIy; these greatIy increase the comfort of the patient. Hemorrhage may occur in the first twentyfour hours foIIowing operation due to the sIipping of a tie on one of the hemorrhoida veins or the breaking Ioose of a cIot in an untied artery or vein where the packing does not create adequate pressure. This is usuaIIy initiated by vomiting, coughing or too rapid movements of the patient. The bIeeding may be profuse, without warning. The patient may be found Iying in a poo1 of bIood or the hemorrhage may manifest itseIf by an intense desire to defecate in which the patient expeIs packing, drain and aI1. When such a hemorrhage occurs, a11dressings shouId be removed, the raw areas cIeansed we11 with peroxide and a carefu1 externa1 examination made. If the bIeeding vesse1 is superficia1, a cIamp can be put on for a few minutes and the bIeeding stopped. With oxyce1 gauze used as packing, these superficia1 bIeeders are rare. If no bIeeders are seen externaIIy, the patient shouId be returned to surgery immediateIy, given an intravenous anesthetic and the bIeeder found and Iigated. There shouId be no deIay whiIe attempting to use antihemorrhagic drugs to contro1 bIeeding. BIood transfusions may be needed after the bIeeder is tied. Late hemorrhage is more diffrcuIt to contro1. This usuaIIy occurs seven to fourteen days foI* Eli Lilly & Co., IndianapoIis, Ind.
25
26
Pearson-AnorectaI
Iowing operation . Since my patients are usuaIIy sent home in six to seven days, this occurs usually at home. It is more common in very eIderIy persons or those who are anemic or debiIitated. Late hemorrhage is caused either by absorption of the ligature on a vein or the puIIing off of the Iigature by a hard feca1 mass where the vein has not formed a soIid cIot with cIosure of the Iumen. Packing these areas is not satisfactory. The patient shouId be returned to the hospitaI, taken to surgery and the bIeeder found and tied. I have used a11 types of sutures from No. oo pIain catgut to chromic No. 2 and find that the suture makes IittIe difference. I routineIy use chromic No. I, singIe and have never had a patient return with a second hemorrhage. In these cases, aIso, a bIood transfusion usuaIIy aids in convaIescence and improves the moraIe of the patient and his famiIy. In 200 consecutive hemorrhoidectomies I have had three superficial hemorrhages which necessitated removal of the oxyce1 gauze, thorough cleansing with hydrogen peroxide, repacking with oxyce1 gauze and application of a firm pressure dressing. In a11 of these there was no subsequent excessive bIeeding. In the same group there were four patients with recta1 hemorrhages. One occurred eight hours after surgery expeIIing a11 packing and drain. One occurred on the seventh postoperative day, one on the tweIfth and one on the sixteenth. These four patients were a11 returned to the operating room where the bleeding vesseIs were Iigated. Edematous ana tags form usuaIIy five to ten days foIIowing operation. They are caused by inadequate drainage of the ana wounds which aIIows coIIection of exudate under the skin bridges and produces edema. The bridges become swoIIen, from 3 to IO mm. in size, and are red, hard and painfu1. The patient wiI1 notice the tender tag on sitting and also whiIe cIeansing himself. These tags may be prevented by not undercutting skin bridges so compIeteIy. However, it is more important to undercut these bridges and excise the entire pIexus of externa1 hemorrhoida veins even at the cost of a few tags than to Ieave these veins as sites for possibIe future thrombosis. By carefuIly saucerizing the skin edges and pointing the end of the wound, sufficient drainage may be obtained to minimize the incidence of postoperative tags. Since these usuaIIy occur after the patient Ieaves the hospita1, they are excised in the
Surgery off&e on his first or second check-up. Thrs can easiIy be done under IocaI anesthesia. If aIIowed to remain they wiI1 graduaIIy subside but wiI1 aIways remain as foIds or tags which might initiate a future pruritus ani. During the remova1 of these tags a large enough area must be excised to obtain adequate drainage or the same condition may recur. SIow heaIing of the anoderm high in the ana cana is seen frequentIy in the postoperative period and is practicaIIy aIways due to inadequate skin drainage. It occurs most commonIy in very obese individuaIs. Many patients have been seen two to three years after surgery with high ana uIcers or Iow recta1 uIcers due to improper postoperative care. In my own cases the skin areas often hea beautifuIIy but the modified skin of the ana canal remains open. If not given proper care they never wiI1 heal. During the postoperative care the anoderm should not be aIIowed to heaI before the mucosa1 surfaces. I treat the dista1 margins of the raw areas in the skin weekIy, with IO per cent nitric acid in order to retard healing. At the same time I treat the proxima1 raw areas with I0 per cent siIver nitrate to stimulate granuIation tissue. If in spite of this the skin heaIs first, I excise an area of skin aImost as Iarge as the origina wound under IocaI anesthesia in order to get proper drainage. This procedure is most important in order to get compIete heaIing. OccasionaIIy, overIooked smaI1 ana papiIIae wiI1 enIarge during the earIy postoperative period. Sometimes the area of Iigation of the hemorrhoida vein wiI1 deveIop a poIypoid growth. The edges of the mucosa1 wounds may sometimes become edematous and swoIIen. Before dismissa the patient shouId be given a thorough examination both with finger and proctoscope. If any of these Iesions is found, it shouId be corrected under IocaI anesthesia. AnaI stenosis is perhaps the most common complication of anorectal surgery. The technic of surgery and postoperative care is planned with the thought or fear of future stenosis. The avoidance of this condition begins with surgery. Leaving an adequate amount of anoderm, Ieaving as wide skin bridges as possibIe and incising the externa1 sphincter muscIe a11 heIp. By the fourth postoperative day I begin recta1 diIations, continuing them every three to seven days depending on the tightness of the canal unti1 the heaIing is complete. I do not aIIow American
Journal
of Surgery
Pearson-Anorectal my patients to do their own diIations, nor do I use mechanica dilators. After the first five to six days I reduce or discontinue a11 Iaxatives in order that the patient may have firm bowel movements. I do not use muciIaginous drugs to retain fluid in the intestinaI cana1. I want my patient to have soIid stools even though he may have to strain to deIiver them. I warn my patient to expect to strain and to have pain and even some bIeeding with his movements if heaIing is to progress in the normal way. In this way he gets his own daiIy diIations on which I improve with my own examination every few days. DiIation may be painfu1 to the patient. I use 5 per cent metycaine in the ana cana previous to my examinations. When the patient understands the importance of the diIation, he is usuaIIy very cooperative. Once in a Iong whiIe a short band of scar tissue may form in the Iow recta1 mucosa which I do not hesitate to incise earIy. A simiIar circu-
January,
I 95 I
Surgery
27
Iar band of scar tissue may form at the intersphincteric line which shouId aIso be incised. AIIowed to remaip, these wiI1 narrow the Iumen of the cana considerabIy. Urinary retention, rectal impaction and other minor compIications are not considered in this paper. These are usuaIIy easily controIIed. By putting my patients on a reguIar diet and aIIowing them to be up as much as they wish on the first postoperative day I seIdom have diffIcuIty with these conditions. EarIy activity and fuII diet aid in obtaining earIy bowe1 eIimination and aIso speed the patient’s reIease from the hospita1. SUMMARY
The prophyIaxis and treatment of six frequent and important compIications of anorecta1 surgery are discussed. IncIuded in this discushemorrhage, sion are postoperative pain, edematous ana tags, deIayed heaIing and anal stenosis.