Complications and management in Colon and Rectal surgery
FAZL Q PARRAY
Department of Surgery
Sher-I-Kashmir Institute of Medical Sciences,
Soura, Srinagar-190011,J &K, INDIA
All Surgeons are Human beings.
Humans are prone to mistakes right
from Adams time.
Complication –unintentional harm
done to a patient .
It leads to lot of morbidity and even
Remember even the best surgeons get
U can decrease the complications to zero if u
Surgeon, however, should aim at minimizing his
Knowing ,assisting and learning the craft
Scientific management of the complications
• Anastomotic leakage occurs in 5 - 15%
after colorectal surgery
• Leads to substantial morbidity and
• Many factors determine AL
Surgery (treatment) related
Soeters/de Zoete /Dejong/Williams/Baeten
Dig Surg 2002;19;150-155
Risk factors for AL
• Male sex increased risk of AL; 13 fold in LAR
• Lower than 10 cm anastamosis (3.5 fold
increase compare with higher than 10 cm)
• ASA group 4 (2.5 fold increase risk of AL to
compare with ASA 1-3
D.Pavalkis, Medicina, 2001, 39:421-425
Obesity and AL
• 584 elective colorectal surgery for cancer
• 158 (27%) were obese (BMI>27)
Hemicolectomies – no difference
• AR resulted in AL in 16% of obese and 6% of non-obese patients
• For obese patients in AR group diabetes mellitus and ASA status were
significant risk factors for AL
St.Benoist & all, Am J Surg, 2000, 179, 275-281
Age and AL
• . Prospective multicentric study, 75 German
hospitals, 3756 patients <65; 65-79; >80
• Left sided cancers 76.2%, 76.7%, 54.8%
• AL requiring surgery 4.2%, 3.1%, 1.5% (p>0.05)
• AL not requiring surgery 1.5%, 2.3%, 1.2%
F.Marusch at all, Int J Colorectal Dis, 2002, 17:177-184
Preoperative Albumin level <3.5 g/dl
Intraoperative blood loss of >200ml
Operative time >200 mts
Intraoperative transfusion requirement
Margin involvement in disease process
Proximal diversion should be considered for patients with 3
intraoperative risk factors
Telem DA et al Arch Surg. 2010;145(4):371-376
• Proximal diverting Stoma reduces the severe
consequences of AL but not the incidence of
• Suggested, that all anastamosis at 6 cm or less
from anal verge should be protected.
N.D. Karanjia etal, Br. J. Surg. 1991; 78:196-198
Protective stoma not recommended for all routinely.
Male gender, low anastamosis, coronary artery
disease, preoperative radiotherapy, and smoking
are the major risk factors of anastamotic leakage.
Mozafar M etal.Iranian Journal of cancer
prevention. Vol 2, No 1 (2009)
• Avoids anastamotic leakage following ISR for
ultra-low rectal cancer
• Alleviates the anal incontinence in the early
• Conducive to the restoration of anal function.
Zuo ZG etalZhonghua Wai Ke Za Zhi. 2010 Oct 1;48(19):1479-83
• Anastamotic leakage is a serious early
complication following surgery for rectal cancer.
• The height of the anastamosis and neoadjuvant
therapy are the main predictors of an increased
• A diverting stoma diminishes the consequences
of risk and reduces the need for emergency reoperation.
Moran BJ,Acta Chir Iugosl. 2010;57(3):47-50
• Use is controversial.
• RCT and meta analysis failed to
establish any benefit.
• In the absence of data
suggesting any harm we prefer
to use drains in Colorectal
655 patients; 39 AL (6%)
Fever>38O C on day 2
Absence of bowel action on day 4
Diarrhea before day 7
Drainage more than 400 ml 0-3 day
Renal failure on day 3
Leukocytosis after day 7
Alves A & all, J AM Coll Surg, 1999, 189:554-9
• Pelvic abscess, localised collections (transanal USG,
• Controlled leaks with distal patency-Conservative
• Broad Spectrum Antibiotics; TPN?
• Increasing leaks; Defunction with stoma
• Peritonitis-Emergency surgery
Stoma; Take down anastamosis; Hartmans; Paul
• Try to preserve a low anastamosis.
• Whenever in doubt; go for a stoma
• Our parents decided not to teach us Chinese.
It was an era when they felt we would be
better off if we didn't have that complication.
The urogenital tract is most at risk of injury
during surgery for locally invasive
Advanced inflammatory bowel conditions
Previous history of pelvic irradiation
Presence of fibrosis or adhesions
Previous pelvic surgery
Radical pelvic lymphadenectomy
4 specific points:
Ist-High ligation of IMA-Junction of
upper third and middle third ureter
2nd-Mobilization of upper mesorectum
near Sacral Promontory.
3rd-Anterolateral dissection between
lower rectum, pelvic side wall, bladder
4th-Cephalhead part of perineal phase at
• The Golden Rule is Early recognition
• Time of diagnosis is most important independent
factor determining outcome
• Best prognosis in those diagnosed intra-op and
• Only 30-45% of iatrogenic ureteral injuries
early diagnosis 2.4%
late diagnosis 18.4%
• Surgical exploration of retro peritoneum with
direct visualization of wall of ureter
• IV indigo carmine or methylene blue with
inspection for Ureteral dye leakage
• Ultrasound dilatation of upper urinary
• IVP delayed renal function
• Ureteric dilatation or deviation
• Extravasation of contrast
• Non-visualisation of ureter
• Contast CT dilated upper urinary system
• Retrograde most sensitive radiographic
study; allows stent placement
• Aspirate from drain or wound for Cr and
• Uretero-ureterostomy (end to end)
• Boari flap
• Psoas hitch
Total loss of ureter
• Ileal interposition
• Uretero-ureterostomy (end-to-end
• Ureteral end should be debrided and
• The end are spatulated.
• Internal JJ stent.
• Closure interrupted 4-0 Polyglactin.
• Bladder catheter – 2 days.
• Stent – 6 weeks.
Amputation of the lower pole of kidney
Ureter end debrided, spatulated
Interrupted 4-0 polyglactin
Catheter: 2 days
Stent – 6 weeks
• Upper part of effected
ureter transposed across
• 1.5 cm ureterotomy,
medical aspect of
contralateral Ureter .
• Stent, watertight
• Catheter: 2 days.
• Stent – 6 weeks.
Mobilization of the bladder flap
Anti-reflux implantation through
• Extreme complication is contrary to art.
• Frequent in adherant
• Recognized usually on
• Repair in 2 layers with a
catheter in for 7-10 days.
• Late presentations present
as pneumaturia, fecaluria,
or urine in abdomen.
• Urinary/Fecal diversion
followed by reparative
• In APR –Perineal dissection
• Injury in membranous or
• Visualization of Foley catheter.
Small injuries - repair with 50
suture with catheter in for 2-4
Large injuries - Suprapubic
diversion with delayed repair
with gracilis urethral
Sympathetic roots form
Plexus (B) at level of Aortic
• Hypogastric nerves (C) lateral
to ureter and internal iliac
• Pelvic autonomic plexus (D) at
lateral pelvic wall
• Parasympathetic fibres run
along nervi erigentes to reach
inferior hypogastric plexus (E)
located anterior and lateral to
1. Hypogastric plexus (aortic bifurcation) during
high ligation of IMA.
2. Injury to the pelvic plexus during lateral
3. Cavernous nerves/ Nervi erigenti during
anterior mobilization of the rectum where
the anterior rectal wall is only separated from
prostate and seminal vesicles by fascia of
Nerve sparing resection
Improves Q OL in Rectal
Nerve sparing resection
AP resection 15-92%
surgery – better
potency rates 14-73%
plexus(sympathetic)-High ligation of IMA
• Hypogastric nerves at Sacral
promontory-Mobilization of upper
Retrograde Ejaculation-Commonest S D
Usually resolves in 6-12 months.
• Damage to Pelvic nerves-in lateral
• Nervi erigentes or Cavernous nerves –
Anterior dissection-erectile dysfunction
• Best treatment is Prevention
• Highest risk of Para sympathetic
injury is in the plane anterior to
Denonviller’s fascia and flush with
the posterior aspect of seminal
vesicles and prostate.
• In women-difficult to quantify
• Dyspareunia,Inability to produce
Vaginal lubricant and achieve
• Decreased Fertility
• >50%; defined as one year of
unprotected intercourse without
• Possible explanation is pelvic
• Trapped Ovary Syndrome
• Prevention-Hitching the ovaries
and adnexa to anterior abdominal
wall outside the pelvis/Wrap with
anti adhesion barrier.
Frequent complication of operation on
the sigmoid colon and anorectum
Cause remains uncertain
Inability to pass urine in the supine
Pain inhibits micturition
Presence of concomitant BPH and
some degree of LUTS
Urethral catheter for few days;
adequate analgesia; early mobilization
• Operative injury to pelvic autonomic nerves
• Clinical manifestations vary according to location and
extent of injury
• Permanent lesions following complete transaction of
• Transient dysfunction following traction or diathermy
injury of the main nerves or complete transaction of
the peripheral branches
• Only 10% of functional urinary complications are
Autonomic nerve injury presents as:
• Bladder atony with overflow
incontinence and loss of sensation
• Urge incontinence due to overactive
• Stress incontinence secondary to
damage to sphincter innervations
• Voiding dysfunction secondary to
• Mixed picture
• Apparent successful micturation following
surgery -not always indicative of normal
bladder function (Chaudri et al 2006)
• High index of suspicion after difficult
• Ultrasound bladder for residual urine
• Urodynamic assessment ASAP in patients
who develop neurogenic bladder
• Early detection and appropriate treatment
of paramount importance.
reoperation 3-6 months.
• Colovaginal-Spontaneous closure is
rare ,Proximal Stoma
Reparative surgery 6-12 weeks with
anastamosis(Turn bull Cutait
• Chronic presacral abscess or sinus
• may be the end result of leak or
• Presents 2-12 months post surgery
• CT/PET to exclude a recurrence
• Low anastamosis managed by regular
• High anastamosis-Endoscopic
• Revision surgery /Permanent fecal
• Recognition and prevention of
Bowel Ischemia –important
• Timely intervention- worthwhile.
• Remember resolution of
complete obstruction with
expectant management is <20%.
• Early obstruction(30 days POP)Usually by intense inflammatory
response; immediate surgery has
• Infection rates are
high(1010anaerobes &10 8
aerobes/gm of stool).
• Present Usually on
• Manage by opening a part of
incision to allow drainage.
• Antibiotics given if cellulitis is
• Necrotic tissue-Debride n allow
• Large wounds-Debridefollowed by VAC closure.
• Deep infections-debridement
• Invasive wound infectionClostrid Perf,B-hemolytic .
• Atypical presentation-minimal
• Fever and severe wound pain.
• Drainage of Grey fluidnecrotizing infection.
• Result from anastamotic
leaks, enterotomies, spillage
• Fever ,leukocytosis, pelvic
pain 5-7 days.
• US/CT guided drainage
through a safe window.
• Success rate usually 65-90%.
• Major cause of morbidity after
• Reason-Dead space.
• Prevention-Re approximation of
sc tissue, suction drainage,
• Chronic perineal sinus-Closure of
Cochrane Systemic Review of RCT
• Lap resection of ca colon is associated with long
term outcome that is similar to open colectomy.
• Lap surgery for ca upper rectum is feasible but
more RCTs need to be conducted to assess long
Cancer Treatment Reviews. Oct
Lap or Open
• 4555 patients were analyzed from 10 RCTS; 2159 in the
Laparoscopic Group and 1896 in the Open Group.
• A higher total intraoperative complication rate (OR 1.37, P =
0.010) and a higher rate of bowel injury in the Laparoscopic
Group (OR 1.88, P = 0.020).
• No difference in the rate of intraoperative hemorrhage or
solid organ injury.
• Laparoscopic colorectal resection is associated with a
signiﬁcantly higher intraoperative complication rate than
equivalent open surgery
Sammour T etal. Ann Surg. 2011 Jan;253(1):35-43.
How to reduce accidents?
Lymph node yield
• Update yourse
• Don’t add to miseries by inappropriate
• High index of suspicion
• Stomas to be used liberally
• Catheters removal- after 5 days in LAR
• Proper Selection
• Complications-Scientific management and referral