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Postoperative Anorectal Hemorrhage
Postoperative Anorectal Hemorrhage GEORGE L. WALKER, M.D., F.A.C.S.* NORMAN D. NIGRO, M.D., F.A.C.S.**
POSTOPERATIVE wounds following anorectal surgery differ from other surgical wounds in several respects. First, the subepithelial tissues are highly vascular. Second, because of potential infection, the wounds are often left open to heal by second intention. Even when sutured, they frequently disrupt and become open wounds after a few days. Third, anal wounds cannot be immobilized for long, but must remain functional. The fact that these wounds are open, are in a vascular area and are subject to early trauma makes it inevitable that there be a small amount of bleeding during the postoperative period. The blood is usually noted following the passage of stool, but is nearly always slight in amount, and patients ar'f) advised to expect this. In contrast to such minor bleeding, massive hemorrhage causing alarming systemic signs and symptoms may also occur. Fortunately, the incidence of such severe bleeding is low-less than 1 per cent of all anorectal operations (GabrieI4 ). PREVENTION OF HEMORRHAGE AT OPERATION
The treatment of rectal hemorrhage is both prophylactic and active. Preventive measures at the time of operation include transfixion of all ligatures wherein the vessel may retract or cannot be accurately seen. If there is any doubt, the internal hemorrhoidal pedicle should be re-ligated before hemorrhoidectomy is completed, and we often do this as a prophylactic measure. At the completion of the operation, a petrolatum gauze wick or a Penrose drain is placed in the anal canal and an outside pressure dressing is applied (Fig. 453). The outside dressing consists of three gauze rolls, each 1 inch in diameter, placed on the anus in wedgeshaped fashion, covered by a large perineal pad and held in place by adhesive strapping of the buttocks. Additional support is obtained by
* Associate Surgeon, Harper Hospital; Clinical Assistant Professor of Surgery, Wayne State University, College of Medicine, Detroit, Michigan. ** Chief, Division of Proctology, Harper Hospital; Clinical Assistant Professor of Surgery, Wayne State University, College of Medicine, Detroit, Michigan. 1655
George L. Walker, Norman D. Nigro
1656
.~ ....... ~ .......•........•..•...... ;...•.•.•..•............,.:-' ,
\(,' ____.,.{jj~i:.';~, -,:'
Fig. 453. External pressure dressing for anorectal surgery. Three gauze rolls are applied to the anus, covered by a perineal pad and T-binder.
the application of a snug T-binder which applies pressure on the perineal or anterior portion of the dressing where the adhesive pressure is inadequate. The pressure dressing and the anal drain are removed the day after operation. Although adequate hemostasis during the surgical procedure is obtainable by ligature in most cases, there are at least two exceptions. One is the patient with the hyperemia which accompanies marked inflammation in the anal canal. Such wounds often bleed excessively. The other is the patient with a bleeding tendency which makes control by ligature incomplete. In these patients, we obtain as much hemostasis as possible by suturing of the wound and supplement these measures by application of pressure. The latter is obtained by the contraction of the sphincter muscle on an opened gauze square wrapped in the petrolatum gauze wick described above. As in the case of the anal drain, this simple pack is removed the day after operation. POSTOPERATIVE HEMORRHAGE OF ANORECTAL ORIGIN CLASSIFICATION
A. Immediate-1st, 2nd postoperative day 1. External 2. Internal or concealed B. Delayed-5th postoperative day up to two weeks 1. Internal or concealed
Immediate Hemorrhage
1. External in Origin. This type of bleeding is the most common form of postoperative anal hemorrhage and occurs on the first or second postoperative day. The source is an unligated vessel in the external skin wound. Such a vessel may have been ligated at operation and the ligature slipped off, or it may not have been noted at operation because of retraction applied to the wound, or because of a temporary state of hypotension. In either case, bleeding is noted soon after operation. Usually the
Postoperative Anorectal Hemorrhage
1657
nurse reports that there is excessive external bleeding, requiring repeated reinforcement or changing of the dressings. The diagnosis is made by a careful inspection of the external skin wounds which reveals the actively bleeding vessel. Treatment is simple and immediately effective. The bleeding vessel is isolated and ligated under local anesthesia with the patient in the left lateral position. This is done either in the operating room or in the patient's room. 2. Internal in Origin. Concealed or internal hemorrhage occurring soon after operation is much less common than the external type and is due to an unligated vessel within the anal canal. It is potentially more dangerous because it is usually more severe and it may occur for several hours without detection. The blood accumulates in the lower rectum, but is held back by the sphincter and nothing is visible on the external dressings. As the accumulation proceeds, the patient feels the urgency for a movement which is usually the first symptom of a concealed hemorrhage. The pressure may become so great that the blood is expelled along with the drain and dressings involuntarily in bed. At other times, the patient faints in the bathroom following passage of the bloody stool. As in all hemorrhage, clinical shock depends upon the rate and amount of blood loss. Obviously, the amount of blood loss in these patients may be considerable before it is detected. Once hemorrhage has occurred in the immediate postoperative phase, treatment must be prompt and usually is operative. Blood volume depletions sufficient to be clinically detectable are replaced by transfusions. The patient is returned to the operating room and, under adequate anesthesia, the rectum is inspected and the bleeding vessel found and religated, following which the usual postoperative rectal pressure dressing is applied. DELA YED HEMORRHAGE, INTERNAL IN ORIGIN
We have not seen delayed bleeding from external anal wounds, but severe hemorrhage from internal anal wounds occurring from five to 14 days following operation is second only to excessive bleeding from outside wounds immediately after operation. It is most common on the seventh and eighth postoperative days. The bleeding in delayed hemorrhage is due to disruption of the clot in unligated vessels or, more commonly, to a slough of tissue which exposes a large vessel. The symptomatology is quite characteristic in that the patient passes a normal stool and, shortly thereafter, the urge to stool returns. The patient then passes a watery stool which is mostly blood. He mayor may not faint but usually becomes understandably alarmed. With the continued passage of blood, the patient will go into shock. Delayed internal hemorrhage may occur after the patient has left the
1658
George L . Walker, Norman D . Nigro
Fig. 454. Internal anorectal pack (Burrows and Buie). Black silk passes through anal canal and is tied around an external gauze roll. Pack is removed by cutting black silk and pulling white ligature.
hospital, in which event he should be rehospitalized. Treatment should be vigorous and prompt. The bleeding is usually controlled by the application of a simple pack. The patient is given a hypodermic of morphine, and an anoscope is inserted with the patient on the left side in bed in his room. After the evacuation of blood and clots, a 4 by 4 inch gauze square is opened lengthwise and placed through the scope into the anal canal. The scope is removed while holding the distal end of the gauze with a forceps so that the end protrudes slightly from the anus. An external pressure dressing similar to that used following hemorrhoidectomy completes the dressing. Supportive treatment in the form of whole blood transfusions is given as required. Complete bed rest, fluid diet and adequate sedation complete the treatment. Oftentimes, this pack can be left in place for 24 hours. However, it will not permit the patient to expel gas and this may become quite intolerable. Then, either the pack is replaced as necessary or a soft rubber catheter is inserted alongside the gauze dressing to provide a vent for accumulating gas. If this simple pack is inadequate, the patient will experience an irresistible urge to defecate, and he will expel the pack along with more blood. Under these circumstances, he should be taken to the operating room and given a suitable anesthetic. Inspection of the granulating wounds often fails to reveal any active bleeding. If a bleeding area is found, the tissue is so friable that it is difficult to ligate even with a suture ligature. In this situation, we believe it best to apply an occlusive pack such as
Postoperative Anorectal Hemorrhage
1659
described by Burrows2 and Buie.1 This consists of a 4 by 4 piece of surgical gauze (Fig. 454) through which is threaded a piece of silk suture. Mter the insertion of the gauze in the lower rectum, the silk suture is pulled up. This collapses the gauze into a tamponade which is held firmly against the lowermost rectum by passing the silk suture through the anal canal and tying it over an external gauze roll placed on the anus. The pack completely occludes the anal canal and effectively stops bleeding; however, it also obstructs the rectal outlet so that it has to be removed in 24 hours. This is done quite simply by cutting the silk suture and pulling the cotton (white) ligature. We have found this pack to be the most efficient hemostatic dressing available for the anorectal area. However, it is quite painful and patients require considerable medication to keep them comfortable. Fortunately, this occlusive pack does not often have to be used. Patients with hemorrhagic disease present several problems both diagnostic and therapeutic. It has been emphasized that routine determinations of bleeding and clotting time are inadequate. Diamond3 notes that false-positive reactions occur under which circumstances surgical treatment might be denied a patient who would otherwise benefit. Mild forms of hemorrhagic disease occur which are detectable only by special tests such as prothrombin consumption or thromboplastin generation. Also, he presents eight patients who bled during and after operation and yet had no demonstrable coagulation defect. For these patients, a history of excessive bruising and post-traumatic bleeding is the best clue to the presence of a bleeding tendency. The management of these patients is definitive where specific defects are detected such as deficiencies in platelets, a condition often responding to steroids preoperatively. Certain types of hemophilia or Christmas disease respond to an infusion of whole blood, plasma or serum. Platelet transfusions are available but are of only temporary therapeutic benefit. Fibrinogen deficiencies are temporarily affected by fibrinogen transfusions. Calcium and high doses of ascorbic acid are helpful where such deficiencies exist. Capillary fragility may be treated with carbazochrome salicylate. To these measures are added the standard therapeutic measures of application of pressure dressings and administration of whole blood as needed. SUMMARY
Severe postoperative anorectal bleeding is rare. It may be immediate or delayed and the source is either external or internal. Most common is immediate external hemorrhage which requires simple ligature. Internal hemorrhage is usually delayed and often requires the application of pressure by various types of packs as well as control by suture. Shock can be a complication of internal bleeding and is treated accordingly.
1660
George L. Walker, Norman D. Nigro REFERENCES
1. Buie, L. A.: Practical Proctology. Philadelphia, W. B. Saunders, 1938, p. 93.
2. Burrows, W. F. and Burrows, E. C.: Rectal Packing. J.A.M.A. 78: 1293-1294, 1922. 3. Diamond, L. K. and Porter, F. S.: Inadequacies of Routine Bleeding and Clotting Times. New England J. Med. 259: 1025-1027, 1958. 4. Gabriel, W. B.: Principles and Practice of Rectal Surgery. Springfield, Ill., Charles C Thomas, 1948, p. 95. 10 Peterboro Street Detroit I, Michigan
POSTOPERATIVE wounds following anorectal surgery differ from other surgical wounds in several respects. First, the subepithelial tissues are highly vascular. Second, because of potential infection, the wounds are often left open to heal by second intention. Even when sutured, they frequently disrupt and become open wounds after a few days. Third, anal wounds cannot be immobilized for long, but must remain functional. The fact that these wounds are open, are in a vascular area and are subject to early trauma makes it inevitable that there be a small amount of bleeding during the postoperative period. The blood is usually noted following the passage of stool, but is nearly always slight in amount, and patients ar'f) advised to expect this. In contrast to such minor bleeding, massive hemorrhage causing alarming systemic signs and symptoms may also occur. Fortunately, the incidence of such severe bleeding is low-less than 1 per cent of all anorectal operations (GabrieI4 ). PREVENTION OF HEMORRHAGE AT OPERATION
The treatment of rectal hemorrhage is both prophylactic and active. Preventive measures at the time of operation include transfixion of all ligatures wherein the vessel may retract or cannot be accurately seen. If there is any doubt, the internal hemorrhoidal pedicle should be re-ligated before hemorrhoidectomy is completed, and we often do this as a prophylactic measure. At the completion of the operation, a petrolatum gauze wick or a Penrose drain is placed in the anal canal and an outside pressure dressing is applied (Fig. 453). The outside dressing consists of three gauze rolls, each 1 inch in diameter, placed on the anus in wedgeshaped fashion, covered by a large perineal pad and held in place by adhesive strapping of the buttocks. Additional support is obtained by
* Associate Surgeon, Harper Hospital; Clinical Assistant Professor of Surgery, Wayne State University, College of Medicine, Detroit, Michigan. ** Chief, Division of Proctology, Harper Hospital; Clinical Assistant Professor of Surgery, Wayne State University, College of Medicine, Detroit, Michigan. 1655
George L. Walker, Norman D. Nigro
1656
.~ ....... ~ .......•........•..•...... ;...•.•.•..•............,.:-' ,
\(,' ____.,.{jj~i:.';~, -,:'
Fig. 453. External pressure dressing for anorectal surgery. Three gauze rolls are applied to the anus, covered by a perineal pad and T-binder.
the application of a snug T-binder which applies pressure on the perineal or anterior portion of the dressing where the adhesive pressure is inadequate. The pressure dressing and the anal drain are removed the day after operation. Although adequate hemostasis during the surgical procedure is obtainable by ligature in most cases, there are at least two exceptions. One is the patient with the hyperemia which accompanies marked inflammation in the anal canal. Such wounds often bleed excessively. The other is the patient with a bleeding tendency which makes control by ligature incomplete. In these patients, we obtain as much hemostasis as possible by suturing of the wound and supplement these measures by application of pressure. The latter is obtained by the contraction of the sphincter muscle on an opened gauze square wrapped in the petrolatum gauze wick described above. As in the case of the anal drain, this simple pack is removed the day after operation. POSTOPERATIVE HEMORRHAGE OF ANORECTAL ORIGIN CLASSIFICATION
A. Immediate-1st, 2nd postoperative day 1. External 2. Internal or concealed B. Delayed-5th postoperative day up to two weeks 1. Internal or concealed
Immediate Hemorrhage
1. External in Origin. This type of bleeding is the most common form of postoperative anal hemorrhage and occurs on the first or second postoperative day. The source is an unligated vessel in the external skin wound. Such a vessel may have been ligated at operation and the ligature slipped off, or it may not have been noted at operation because of retraction applied to the wound, or because of a temporary state of hypotension. In either case, bleeding is noted soon after operation. Usually the
Postoperative Anorectal Hemorrhage
1657
nurse reports that there is excessive external bleeding, requiring repeated reinforcement or changing of the dressings. The diagnosis is made by a careful inspection of the external skin wounds which reveals the actively bleeding vessel. Treatment is simple and immediately effective. The bleeding vessel is isolated and ligated under local anesthesia with the patient in the left lateral position. This is done either in the operating room or in the patient's room. 2. Internal in Origin. Concealed or internal hemorrhage occurring soon after operation is much less common than the external type and is due to an unligated vessel within the anal canal. It is potentially more dangerous because it is usually more severe and it may occur for several hours without detection. The blood accumulates in the lower rectum, but is held back by the sphincter and nothing is visible on the external dressings. As the accumulation proceeds, the patient feels the urgency for a movement which is usually the first symptom of a concealed hemorrhage. The pressure may become so great that the blood is expelled along with the drain and dressings involuntarily in bed. At other times, the patient faints in the bathroom following passage of the bloody stool. As in all hemorrhage, clinical shock depends upon the rate and amount of blood loss. Obviously, the amount of blood loss in these patients may be considerable before it is detected. Once hemorrhage has occurred in the immediate postoperative phase, treatment must be prompt and usually is operative. Blood volume depletions sufficient to be clinically detectable are replaced by transfusions. The patient is returned to the operating room and, under adequate anesthesia, the rectum is inspected and the bleeding vessel found and religated, following which the usual postoperative rectal pressure dressing is applied. DELA YED HEMORRHAGE, INTERNAL IN ORIGIN
We have not seen delayed bleeding from external anal wounds, but severe hemorrhage from internal anal wounds occurring from five to 14 days following operation is second only to excessive bleeding from outside wounds immediately after operation. It is most common on the seventh and eighth postoperative days. The bleeding in delayed hemorrhage is due to disruption of the clot in unligated vessels or, more commonly, to a slough of tissue which exposes a large vessel. The symptomatology is quite characteristic in that the patient passes a normal stool and, shortly thereafter, the urge to stool returns. The patient then passes a watery stool which is mostly blood. He mayor may not faint but usually becomes understandably alarmed. With the continued passage of blood, the patient will go into shock. Delayed internal hemorrhage may occur after the patient has left the
1658
George L . Walker, Norman D . Nigro
Fig. 454. Internal anorectal pack (Burrows and Buie). Black silk passes through anal canal and is tied around an external gauze roll. Pack is removed by cutting black silk and pulling white ligature.
hospital, in which event he should be rehospitalized. Treatment should be vigorous and prompt. The bleeding is usually controlled by the application of a simple pack. The patient is given a hypodermic of morphine, and an anoscope is inserted with the patient on the left side in bed in his room. After the evacuation of blood and clots, a 4 by 4 inch gauze square is opened lengthwise and placed through the scope into the anal canal. The scope is removed while holding the distal end of the gauze with a forceps so that the end protrudes slightly from the anus. An external pressure dressing similar to that used following hemorrhoidectomy completes the dressing. Supportive treatment in the form of whole blood transfusions is given as required. Complete bed rest, fluid diet and adequate sedation complete the treatment. Oftentimes, this pack can be left in place for 24 hours. However, it will not permit the patient to expel gas and this may become quite intolerable. Then, either the pack is replaced as necessary or a soft rubber catheter is inserted alongside the gauze dressing to provide a vent for accumulating gas. If this simple pack is inadequate, the patient will experience an irresistible urge to defecate, and he will expel the pack along with more blood. Under these circumstances, he should be taken to the operating room and given a suitable anesthetic. Inspection of the granulating wounds often fails to reveal any active bleeding. If a bleeding area is found, the tissue is so friable that it is difficult to ligate even with a suture ligature. In this situation, we believe it best to apply an occlusive pack such as
Postoperative Anorectal Hemorrhage
1659
described by Burrows2 and Buie.1 This consists of a 4 by 4 piece of surgical gauze (Fig. 454) through which is threaded a piece of silk suture. Mter the insertion of the gauze in the lower rectum, the silk suture is pulled up. This collapses the gauze into a tamponade which is held firmly against the lowermost rectum by passing the silk suture through the anal canal and tying it over an external gauze roll placed on the anus. The pack completely occludes the anal canal and effectively stops bleeding; however, it also obstructs the rectal outlet so that it has to be removed in 24 hours. This is done quite simply by cutting the silk suture and pulling the cotton (white) ligature. We have found this pack to be the most efficient hemostatic dressing available for the anorectal area. However, it is quite painful and patients require considerable medication to keep them comfortable. Fortunately, this occlusive pack does not often have to be used. Patients with hemorrhagic disease present several problems both diagnostic and therapeutic. It has been emphasized that routine determinations of bleeding and clotting time are inadequate. Diamond3 notes that false-positive reactions occur under which circumstances surgical treatment might be denied a patient who would otherwise benefit. Mild forms of hemorrhagic disease occur which are detectable only by special tests such as prothrombin consumption or thromboplastin generation. Also, he presents eight patients who bled during and after operation and yet had no demonstrable coagulation defect. For these patients, a history of excessive bruising and post-traumatic bleeding is the best clue to the presence of a bleeding tendency. The management of these patients is definitive where specific defects are detected such as deficiencies in platelets, a condition often responding to steroids preoperatively. Certain types of hemophilia or Christmas disease respond to an infusion of whole blood, plasma or serum. Platelet transfusions are available but are of only temporary therapeutic benefit. Fibrinogen deficiencies are temporarily affected by fibrinogen transfusions. Calcium and high doses of ascorbic acid are helpful where such deficiencies exist. Capillary fragility may be treated with carbazochrome salicylate. To these measures are added the standard therapeutic measures of application of pressure dressings and administration of whole blood as needed. SUMMARY
Severe postoperative anorectal bleeding is rare. It may be immediate or delayed and the source is either external or internal. Most common is immediate external hemorrhage which requires simple ligature. Internal hemorrhage is usually delayed and often requires the application of pressure by various types of packs as well as control by suture. Shock can be a complication of internal bleeding and is treated accordingly.
1660
George L. Walker, Norman D. Nigro REFERENCES
1. Buie, L. A.: Practical Proctology. Philadelphia, W. B. Saunders, 1938, p. 93.
2. Burrows, W. F. and Burrows, E. C.: Rectal Packing. J.A.M.A. 78: 1293-1294, 1922. 3. Diamond, L. K. and Porter, F. S.: Inadequacies of Routine Bleeding and Clotting Times. New England J. Med. 259: 1025-1027, 1958. 4. Gabriel, W. B.: Principles and Practice of Rectal Surgery. Springfield, Ill., Charles C Thomas, 1948, p. 95. 10 Peterboro Street Detroit I, Michigan