Bowel and Rectal / Anal Surgery Complications.
Disease and Injury pathology surrounding rectal and anal structures are commonplace with large numbers of relatively minor complaints being no more than inconvenient for the sufferers. Rarely do such disorders require anything other than a primary medical examination and most not even that, almost none of these problems require surgery. When Surgery is required it is generally for one of the following procedures (note that this is far from an exhaustive list);
A colectomy, or often referred to as a colon resection, is a procedure aimed at removing all or part of the body’s large intestine.
Sectional: an incision is made in the mid-abdominal area, above the diseased section of bowel. The section of bowel containing the disease is then removed. If the excision is made because of the invasion of a cancerous tumour, an effort is made to remove a wider area of the bowel to include any lymph nodes. The ends of the bowel that are healthy and unaffected are then joined (anastomosis) to be water-tight and permit healing.
Total Colectomy: Sometimes the disease is so rampant or so widespread that it requires removal of the entire colon with anastomosis of the end of the small bowel to the rectum. Familial polyposis or ulcerative colitis often require removal of the colon and rectum. A new pouch (neorectum) is created with the small bowel folded and stapled back on itself; this pouch is joined down to the anus.
Polypectomy: A surgeon may remove a cancerous polyp or polyps from the colon or rectum using a colonoscope. The colonoscope is inserted into the rectum and a sharp wire loop is passed through the instrument to surround and surgical incise the offending polyp. The wire loop is usually subject to a high degree of localised heat or current which can quarterise the wound and prevent further bleeding.
A colostomy is typically a laparoscopic technique (keyhole surgery) where s one end of the colon is accessed through a small incision on the abdominal wall. A Pouch can then be inserted or other operative procedures can be performed. Surgeons perform colostomy procedures to treat several colon and rectal conditions. It is now among the most common operations performed on the bowel.
The area where the new opening sits is called a stoma. This is where waste matter will exit your body. After your colostomy, you will need a colostomy bag, which collects the waste from your body. The bag lies outside of your body. Before you are discharged, a trained ostomy nurse will teach you how to care for your stoma and manage the bag.
Temporary colostomies are performed for specific conditions that allow for the reattachment of the colon later. The colostomy allows the affected area to heal because the stool is not passing through the area. Once the affected area has healed, you undergo a colostomy reversal procedure. Permanent colostomies are used in cases such as Crohn’s disease. There is no realistic prospect of reversing this surgery.
Endoscopic surgery is performed using a flexible metallic tube with a camera and light at the tip. This permits visualisation of the colon and obviates the need for the performance of an incision in order to perform minor operations, although, it is fair to observe that currently endoscopic procedures are typically used only for diagnosis.
First line treatment for haemorrhoids, as detailed very thoroughly elsewhere on this blog includes lifestyle changes and various medication. Surgery is not commonplace. For haemorrhoids such surgery is known as haemorrhoidectomy. During a haemorrhoidectomy, various incisions around your anus are made to remove the swollen sections of the haemorrhoids this allows them to be almost “sectioned out” of the vascular apparatus that is present. Haemorrhoidectomy provides the most efficient long-term results for haemorrhoids in those who have suffered chronic conditions.
The Procedure for prolapse and haemorrhoids (PPH), is a minimally invasive procedure to treat haemorrhoids and anal prolapse. A circular stapling device is used to reposition the hemorrhoidal tissue back to its original position in the anus and trim the excess tissue that is causing irritation and localised inflammation. PPH permanently reduces the blood flow to the haemorrhoids, causing them to shrink. PPH is an effective procedure however, it is one fraught with technical difficulty. It is worth noting that ligation, where a rubber band is placed around the haemorrhoid to cut off its blood supply and destroy the tissue, may be used as a pre-operative procedure to PPH.
Ileal Pouch Anal Anastomosis (J-Pouch)
Ileal pouch anal anastomosis (IPAA), also known as a J-pouch procedure, is a procedure to create a pouch from the end of your small intestine and attach the pouch to the anus. If you need to have your large intestine (colon) removed, IPAA restores your stool function. The advantage of the J-pouch is that it eliminates the need for the permanent opening (stoma) and waste bag. The procedure preserves the anus, and the internal pouch serves as the storage place for stool. This allows you to maintain bowel control and eliminate waste through the anus. It is fair to indicate that J pouch is probably the most popular option (particularly in young women) for small intestine colorectal surgery as it has a high degree of success and allows the patient greater control of their bowel function without the necessity for portal issues (including infection) or issues surrounding appearance and personal image.
Inflammatory Bowel Disease (IBD) Surgery
Inflammatory bowel disease (IBD), which is an umbrella term for conditions such as ulcerative colitis and Crohn’s disease, causes flare-ups of intense intestinal pain, cramping and both constipation and explosive diarrhea that may require extensive medication with steroids or even hospitalisation for fluid balance and infection control. Great strides have been made using biological agents for Crohns and UC including the trade name Infliximab which in the UK is now widely circulated in NHS Trusts as a front-line treatment for chronic UC and Crohns sufferers.
Surgeons perform surgery to remove the colon (colectomy) to treat ulcerative colitis and Crohn’s disease. The surgery is usually effective against ulcerative colitis (assuming a correct diagnosis), possibly curing the problem and removing the risk of colon cancer. For Crohn’s disease, the surgery can provide long-term relief from flare-ups. Unfortunately, there is no cure for Crohn’s disease.
Surgeons typically perform an internal sphincterotomy to deal with anal fissures (small tears in the mucous lining of the rectum) that are not resolving spontaneously with conservative treatment. The procedure of internal sphincterotomy is one of stretching the internal sphincter to weaken the muscle temporarily, allowing it to heal. It is an operation, of course, with some appreciable risk for failure. The degree of recovery and he extent of post-operative problems with incontinence is hard to predict with high certainty.
Rectopexy is a high success rate surgical procedure to treat rectal prolapse. This procedure repositions the internal structures and secures them in place with minimal damage it is not suitable for serious cases of prolapse but may have value in those cases where conservative treatment has assisted but not cured the issue. During rectopexy, your surgeon will make an incision along your abdomen, then after accessing the abdominal cavity will lift the rectum and suture it to the sacrum. There is then likely to be an anterior resection where part of your large intestine is surgically removed.
See colostomy above –
Abdominoperineal Resection: Generally referred to as “Rectal Resection”. This surgery is performed to treat anal cancer. The anus, rectum and part of the sigmoid colon are removed to include the attending vessels and lymph nodes. A colostomy is then performed.
Small Bowel Resection: This surgery is aimed usually at conditions such as Crohn's disease, cancer, ulcers, and asymptomatic polyps. There is a removal of the diseased parts of the small intestine and rejoinder of the healthy intestine. If necessary, an opening to the outside of the body called an ostomy is created.
Low Anterior Resection: In this operation, part of the rectum is removed, but it is re-joined (anastomosed). Entailed in this operation is dissection deep into the pelvis. Anastomoses at this deep level are at increased risk to leak, so often, an ostomy is created above to stop the pressure of bowel movements. The problem which is typical in all such deep pelvic incisions is the potential for injury to nerves that serve the bladder and sex organs.
Laparoscopic Colon Resection: The laparoscope is a lighted tubular instrument used to examine abdominal organs when passed through a small abdominal incision. Laparoscopic colon resection uses this approach for removing cancerous tissue.
Looking at the scope of this list it can be said that generally, anal and rectal surgery is successful and its techniques well established. Post operatively whilst some problems are known to exist, they are generally very minor complications that are easily corrected.
Large scale operative problems are very rare. What is an identified stumbling block for clinicians is the identification of complications at an early stage. To a certain extent this is understandable. The area is not without sensitivity and inevitably any surgical intervention is likely to result in soreness and inflammation and in many cases, these can mask ongoing symptoms. Typically, post-operative symptoms that may lead to a diagnosis of error can be bleeding, signs of infection (heat, localised tenderness, inflammation, smell etc), urinary retention, both faecal and urinary incontinence, anal stenosis (narrowing of the anal canal) and pain.
Minor bleeding post-surgery is common. Patients are expected to continue with normal bowel function and frequently this means that the already disturbed anorectal mucosal becomes further irritated with activity and bowel movements. Therefore, it is not unusual to suffer some post-operative bleeds. Major bleeding is not usual.
Thankfully, most bleeding will resolve spontaneously. For bleeding that does not resolve, the treatment depends on the location of the bleeding and the degree of blood loss. Interestingly a high degree of patients will require a return to the operating room for bleeding control. Bleeding after stapled haemorrhoidectomy (procedure for prolapse and haemorrhoids, PPH) is slightly more common than for excisional haemorrhoidectomy.
Infectious complications post colorectal surgery are uncommon, however they can be significant. Since painful drainage is usual after most procedures, the diagnosis of an infection may be difficult and is often considerably delayed.
Fever, pain after initial improvement in symptoms, and the development of delayed urinary retention are three very important warning signs. Patients exhibiting these three symptoms should be examined promptly. Imaging may be considered especially if an abscess or pelvic sepsis is suspected.
Anal stricture and stenosis are most commonly seen after haemorrhoidectomy but can occur after any surgery within the anal canal. Patients with anal stenosis often report straining to have a bowel movement, smaller calibre stools, and pain with defecation. Anal stenosis may also lead to faecal impaction and overflow incontinence. An examination under anaesthesia may also be helpful in determining how much of the stricture is from anatomic distortion versus a functional problem leading to muscle hypertonicity. With functional stenosis, the anus will relax under anaesthesia while anatomic stricturing will not change.
Mild strictures can often be treated with dietary modifications, stool softeners, or fibre supplements. The regular passage of stool provides the most “natural” stretching possible. Digital dilatation or the use of anal dilators can be part of the treatment plan if medical management doesn’t succeed. It may be that surgery is the only treatment that has lasting long term remedial value.
Faecal incontinence following colorectal surgery can result from several issues but typically involve damage to the anal sphincter or associated nerves. This can be due to direct mechanical trauma, or due to subsequent infection. Meticulous surgical technique is paramount in avoiding unintentional damage to the anal sphincter.
Incontinence after haemorrhoidectomy is associated with a high incidence of partial or full-thickness internal anal sphincter injury and occasionally external sphincter defects. Faecal incontinence can also occur after PPH and is usually related to a low-placed staple line or by injury to the internal sphincter due to the large diameter of the circular stapler.
The evaluation of patients with faecal incontinence should start with a thorough history and physical examination following which medical management is the best treatment for most patients with faecal incontinence after colorectal surgery.
To some degree, anal pain is common following surgery, particularly after haemorrhoidectomy, but this generally resolves completely within 3 to 4 weeks. This pain can be related to residual underlying pathology, new or ongoing fissures and/or thrombosed haemorrhoid, or subtle anal infections. If postoperative pain persists beyond what is expected, the patient should undergo a detailed evaluation focused on the above-mentioned causes, with special attention paid to the possibility of an infection or a nonhealing wound.
Thankfully, many patients with pain will slowly improve over time. Overall, chronic pain after anorectal surgery can be quite difficult to manage, which reinforces the importance of proper knowledge of the anatomy and use of meticulous surgical technique.
What is the Legal Position for Patients?
Ultimately colorectal and anal surgery is not without risk. This is usually recognised in the consent. The issue with such complications is always one of proof. Ultimately the potential claimant must be able to show that the clinician has not administered treatment in a way that would be supported by a reasonable body of similarly qualified professionals.
Ultimately, no one can consent for poor treatment, so signing such a document is hardly a get out clause for bad surgery, however, it does throw an evidential burden on the patient. We must show that the surgery, was the reason behind the poor outcome and not the inevitable outcome that follows the statistical prevalence of risk.
That’s all a bit technical, however, ultimately, what counts is that we must be demonstrate error and that the error led to the symptoms and not the underlying condition or the risk involved even in a good surgical procedure. Its not easy. However, for the patient, who faces a lifetime of complications and problems associated with an essential system for living being compromised (sometimes painfully) the prospect of compensation is at least something.
The Author is Mr Graham G Balmforth, BA (Hons) LLB (Hons), DipFMS (Glasgow) M.Sc (F.Med), Solicitor Advocate and Law Society of England, specialist Clinical Panel Member