Post Hemorrhoidectomy Can They Fall Down Again
Clin Colon Rectal Surg. 2016 Mar; 29(1): 14–21.
Complications Following Anorectal Surgery
Hiroko Kunitake
1Boston Medical Middle, Boston Academy School of Medicine, Boston, Massachusetts
Vitaliy Poylin
2Beth Israel Deaconess Medical Middle, Harvard Medical School, Boston, Massachusetts
Abstruse
Anorectal surgery is well tolerated. Rates of minor complications are relatively high, merely major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avert meaning patient morbidity. The most mutual acute complications include haemorrhage, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and fifty-fifty mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.
Keywords: anorectal surgery, complications, hemorrhage, urinary retention, pelvic sepsis
Anorectal pathology is prevalent throughout the world, with most anorectal complaints being transient and without the demand for formal medical evaluation. For those that do require surgical intervention for their anorectal pathology, the surgery can usually be done safely in the outpatient setting with minimal morbidity. However, no intervention is without risk, and complications frequently ascend after anorectal surgery, with rates upwardly of l% in some studies.i The purpose of this chapter is to review the short- and long-term complications that can ascend after anorectal surgery, including the diagnostic arroyo, interventions, and prevention strategies for these complications.
Short-Term/Acute Complications
Postoperative Hemorrhage
Minor bleeding after anorectal surgery is mutual. Since nosotros expect patients to proceed with normal bowel function, the already disturbed anorectal mucosal becomes further irritated with activity and bowel movements. Since some bloody discharge is normal, the patient should exist accordingly counseled on what to expect so every bit to avert unnecessary anxiety and phone calls. It may as well be helpful to remove/wash out clots from the rectum while still in the operating room to minimize confusion later on surgery. Yet, major haemorrhage can too occur, admitting rarely, and may crave farther intervention. While the presentation of major bleeding is non uniform, patients often written report frequent passing of small to moderate amounts of clot and vivid reddish blood starting after the first bowel movement.
Hemorrhoid surgery involves the vascular cushions of the anus, so not surprisingly, hemorrhoidectomy is associated with higher rates of bleeding when compared with other anorectal procedures.1 2 3 Haemorrhage subsequently other anorectal procedures such as procedures for anal fistula or fissure is very low (0.4–1.2%).iv five
Rates of clinically significant bleeding afterward hemorrhoid surgery vary based on type of the procedure. For conventional hemorrhoidectomy (Milligan–Morgan and Ferguson) and bipolar energy device hemorrhoidectomy (Ligasure), rates of clinically significant hemorrhage has been reported in the range of 0.iii to 6%, with an average of effectually 2%.one 2 3 6 seven There does not seem to be a pregnant difference in rates of bleeding between conventional hemorrhoidectomy and bipolar energy device assisted procedures.
The timing of bleeding after hemorrhoidectomy varies, and can be by and large divided into immediate and delayed.5 Firsthand bleeding occurs within 24 to 48 hours of a procedure and is likely related to loss of control of the vascular pedicle. Delayed bleeding is divers as haemorrhage reported up to 2 weeks postprocedure, and is more often related to infection or local trauma.4 5 Delayed haemorrhage may exist influenced by postal service-operative hurting medications. Hemorrhoidectomy is associated with significant postoperative pain, and multimodality direction is routinely employed to help alleviate discomfort. NSAIDS are an integral role of this hurting direction and can increase the incidence of bleeding.viii
Thankfully, most bleeding will resolve spontaneously. For bleeding that does not resolve, the treatment depends on the location of the bleeding and the caste of blood loss. If the bleeding is more than external in nature, holding force per unit area with gauze, cauterization, or suture ligation at the bedside are all acceptable interventions with loftier rates of success. Injection of local anesthetic with epinephrine can also exist performed in dispensary or on the ward; nonetheless, this can exist uncomfortable and there are no data available on the success of this arroyo. For bleeding that is located within or above the anal culvert, bedside intervention is more difficult, and the commencement arroyo is typically to tamponade the bleed with a finger or a slice of Vaseline gauze. Oft, the patient's own sphincter tone acts every bit a tamponade on bleeding vessels within the anal canal, which can explain the episodic nature of postoperative bleeding. In more than severe cases, tamponade with a Foley balloon catheter can be employed, peradventure in conjunction with Vaseline gauze and Surgicel.four 5 Tamponade tin can exist quite uncomfortable for the patient, and is often used equally a temporizing measure while a more definitive program is being activated.
On an average, 15 to 33% of patients with haemorrhage subsequently hemorrhoidectomy will require a render to the operating room for control of the hemorrhage.iii ix Interestingly, nigh will not have an identifiable source of haemorrhage by the time they are examined in the operating room. Nevertheless, these bleeding episodes can exist significant and a return to the operating room for the second await may be justified.
Bleeding subsequently stapled hemorrhoidectomy (procedure for prolapse and hemorrhoids, PPH) is slightly more common than for excisional hemorrhoidectomy, with rates equally high as 9.6%.1 2 three At the same fourth dimension, rates of reintervention for bleeding are lower for PPH compared with conventional hemorrhoidectomy.3 Bleeding after Doppler-guided hemorrhoidal de-arterialization has been reported to be depression (4.three%); nevertheless, this needs to be counterbalanced with the take a chance of long-term recurrence.10
Special consideration should be given to patients with an increased take chances for bleeding after anorectal surgery. Patients on hemodialysis have reported rates of postoperative bleeding as high as eleven.1% after conventional hemorrhoidectomy.11 For patients on systemic anticoagulation, there are limited published information on postoperative bleeding. A study by Nelson et al focused on condom band ligation for patients on antithrombotic prophylaxis, and reported minimal adventure of bleeding for patients on aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS) or coumadin.12 However, this group establish that clopidogrel carried a higher take a chance of bleeding (eight.6%), even if information technology was held prior to the banding and restarted in a delayed mode. Data on newer antithrombotic medications and hemorrhoid procedures are not available.
There is significant controversy regarding whether or not antithrombotic therapy should exist stopped prior to the surgical treatment of hemorrhoids. Most would consider aspirin and NSAIDS more often than not are prophylactic to keep through the perioperative catamenia. Coumadin at low doses seems to exist safe every bit well, although several surgeons would recommend stopping it prior to surgery and restarting when chance of bleeding afterward the process decreases. The risk of bleeding while on other antiplatelet therapy such as clopidogrel is significant, and these medications should be stopped, or the procedure should be delayed until it can be stopped if at all possible.
Infection
Infectious complications afterwards anorectal surgery are thankfully uncommon, merely tin can be significant when they do occur. Since painful drainage (including more than fibrinous material) and swelling is expected afterward most anorectal procedures, the diagnosis of an infection may exist difficult and is ofttimes delayed. Fever, worsening pain after initial improvement in symptoms, and the development of delayed urinary retention are iii very important alert signs. Patients exhibiting these three symptoms should exist examined promptly to avoid worsening complications. Imaging, including computerized tomography or magnetic resonance imaging may be considered especially if a deeper abscess or pelvic sepsis is suspected. When an infection following anorectal surgery has been diagnosed, the surgeon should take low threshold for a quick return to the operating room for command of infection and debridement of any devitalized tissue.
Transient bacteremia later on hemorrhoidectomy is mutual, and has been reported in up to 8% of cases,13 but clinically pregnant infections are extremely uncommon. Given the location, information technology is expected that all wounds will get colonized past leaner shortly after surgery. The exact rate of infectious complications later on anorectal surgery is difficult to interpret. The development of severe pelvic sepsis (Fournier'due south gangrene) following anorectal surgery has only been described as individual example reports, with 24 published cases between 1978 and 2004.14 15 There are a few reports of development of liver abscess and septic emboli after anorectal surgery.14 Rates of abscess germination after hemorrhoidectomy take been reported between 0.v and 4%1 3 4 16 17 with most studies reporting a charge per unit of 1%. Patients who are immunosuppressed seem to be at higher risk.18 nineteen There does not seem to be a significant difference between open and closed hemorrhoidectomy or between traditional hemorrhoidectomy and PPH.one 15 Several studies also report wound complications (drainage, nonhealing, etc.), but it is possible that these were acquired/resulted from infection that was not clinically evident.
There does not seem to be an clan between performing a perianal cake with local anesthetic and postoperative infection.xiv Rates of infection afterwards procedures for anal fistula seem to be similarly depression, but even harder to translate since localized infection is an indication for surgery and these data are often combined with recurrence/reoperation.11 12 There has been no convincing testify to suggest that either preoperative or postoperative antibiotics decrease rates of infectious complications for anorectal surgery.20 Exceptions to this are discussed in article "Perioperative Management of the Ambulatory Anorectal Surgery Patient" on pp. seven–13.
Urinary Retention
Urinary retention is the most common complexity after anorectal surgery, with rates varying between three and 50%21 22 23 24 25 26 with virtually studies reporting a rate effectually fifteen%.22 23 24 25 Postsurgical urinary memory is multifactorial with contributions from irritation/blockade of pelvic nerves and pain evoked reflexes.24 27 The multifactorial nature of urinary retention makes it a difficult problem to deal with afterwards anorectal surgery. Pain is a major issue and hurting treatment strategies can exacerbate the problem. For example, local anesthetic tin significantly improve postoperative pain and nerve irritation; withal, it can too lead to decreased sensation of the urge to micturate leading to bladder distention.27
Several adventure factors have been identified over the years that increase the likelihood of retention. Some of these factors are non modifiable, including historic period, male sexual activity, and type of surgery.23 24 25 26 27 Other factors are modifiable and lead to changes in practices associated with anorectal surgery. In general, epidural and spinal anesthesia have been associated with higher rates of urinary retention25 26 27 compared with monitored anesthesia care. Opioids, oftentimes needed after anorectal surgery, can as well contribute to the problem.
Excess intravenous fluid has also been shown to significantly increase the risk of urinary retentivity, and strategies for intravenous fluid restriction are typically employed.22 25 A more detailed word of fluid brake tin can exist found in the affiliate on convalescent anorectal surgery. Of note, several medications take been employed in attempts to reduce urinary retentivity, but the data are mixed and for the about office disappointing. Although well-designed, the previous studies on this topic suffered from small numbers and the employ of older medications. Urecholine and prazosin have both been shown to be very effective in treating established urinary memory, but not in preventing it in anorectal surgery.22 24
Typical symptoms of urinary memory include pain, pressure, discomfort, an unproductive urge to urinate, and frequent, small volume micturition with persistent feeling of incomplete evacuation. In patients with practiced pelvic nerve blockade and decreased sensation, abdominal pressure may be the only early symptoms. Urinary memory can atomic number 82 to urinary tract infections. If non addressed in the timely mode, retentivity can result in over distention of the bladder that tin farther exacerbate the problem and in some cases lead to astute renal injury from postrenal obstruction.27 Clinical symptoms also as noninvasive float scanners are very constructive in diagnosing this problem.
Thankfully, well-nigh issues with urinary retention are self-limited, and will resolve without major intervention. Since inflammation and swelling seem to contribute to the problem, patients with mild retention are ofttimes counseled to sit in a bath of very warm water, filled above the waist, to see if this can alleviate swelling and facilitate urination. When this is unsuccessful, patients may require float catheterization. This may involve intermittent straight catheterization or a temporary indwelling catheter, which can typically be removed after a few days without further testing. α1 antagonists such equally tamsulosin can be helpful, and attempts to minimize opioid intake is likewise worthwhile.27 While these measures alone will aid most patients, a referral to a urologist for further studies is indicated if prolonged urinary retention occurs.
Other Astute Complications
Thrombosed hemorrhoids and fissures following anorectal surgery have been described by several papersane 2 3 four 5 18 19 and are probable related to local tissue trauma, injection of local anesthetic with epinephrine, and constipation. Incidences of these complications in all the studies reviewed are very low (although maybe underreported), and then information technology is hard to make meaningful conclusions well-nigh truthful risks and preventive strategies. In full general, sitz baths and abstention of constipation can be helpful in fugitive fissures and thrombosed hemorrhoids, likewise as in the treatment of these conditions when they develop.
Severe constipation is common afterwards anorectal surgery, with rates between 15 and thirty%.1 2 iii Hemorrhoidectomy has the highest rates reported. A fear of bowel movements and the associated pain can atomic number 82 to functional constipation. Opioid consumption likewise plays a major role. While fecal impaction tin can develop, this is less mutual, and disimpaction is rarely required, with nearly cases treated on an outpatient basis. A solution to postoperative constipation is the combination of a strict bowel regimen with a multimodality hurting regimen that limits opioid consumption. Information technology is important to note that several patients have pre-existing constipation as a cause of their underlying anorectal disease, and vigilance is needed to avert exacerbating this problem subsequently surgery.16
Anal fistulas accept also been reported later anorectal procedures. In cases where fistula-in-ano was not a master problem, it is either the effect of infection, trauma to the anal canal, or abnormal healing. The treatment of these fistulas varies significantly based on the degree of sphincter muscle involvement. Rectovaginal and ano-vaginal fistulas have also been reported with college prevalence in PPH procedures. This can occur when the rectovaginal septum incurs harm, and then information technology is more mutual in surgeries that involve the anterior anal culvert and rectum, including hemorrhoidectomies and full-thickness trans-anal excisions.3 For this reason, careful autopsy and postprocedure examination of the rectovaginal septum is warranted to avoid fistula.
Long-Term Complications
Complications subsequently anorectal surgery are not always immediate, and can instead take months or years to fully develop. In general, these complications are more severe and more hard to treat than those that occur in the acute postoperative period. We will discuss the most mutual and most feared long-term complications below.
Anal Stricture/Stenosis
If excluding coloanal anastomoses, anal stricture and stenosis are nearly unremarkably seen later on hemorrhoidectomy, but tin occur after any surgery within the anal canal. Stenosis tin complicate a stapled or radical amputative hemorrhoidectomy in 1 to 7.5% of cases.x 27 28 29 In these patients, the normal pliable anoderm is replaced by cicatrized tissue due to excessive removal of the anoderm and distal rectal mucosa. The patient may also endure from injury to the underlying anal sphincter muscle, leading to severe and progressive stenosis. Patients with anal stenosis oft study straining to have a bowel motion, smaller caliber stools, and hurting with defecation. Anal stenosis may also lead to fecal impaction and overflow incontinence.
A review of the patient'due south previous operative reports forth with a detailed anorectal test can ostend the diagnosis. Office evaluation with a digital exam, anoscopy, and proctoscopy are usually adequate, only patients with severe stenosis or pain may require an exam under anesthesia. An test nether anesthesia may besides 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 anesthesia while anatomic stricturing volition not change. If the etiology of the stenosis is unclear, biopsies of the area are advisable to exclude neoplastic or inflammatory etiologies.
Anal stenosis may be classified past the severity of the stricture too equally the level of involvement of the anal canal (Table 1).30 The management of anal stenosis is determined by the degree of symptoms rather than the degree of stenosis, and an asymptomatic patient does non necessarily crave intervention, given that a malignant cause of the stenosis has been excluded.
Table one
Classification of anal strictures
| Severity of stricture | |
| Mild | Tight anal canal can be examined past a well-lubricated alphabetize finger or a medium Hill–Ferguson retractor |
| Moderate | Forceful dilation is required to insert the alphabetize finger or a medium Hill–Ferguson retractor |
| Severe | Neither the little finger nor the small Hill–Ferguson retractor can be inserted without forceful dilation |
| Level of stricture | |
| Low | At least 0.v cm below the dentate line |
| Centre | 0.5 cm proximal or distal to the dentate line |
| High | More than 0.v cm proximal to the dentate line |
Balmy strictures can often be treated with dietary modifications, stool softeners, or fiber supplements. The regular passage of stool provides the most "natural" stretching possible. Digital dilatation or the use of anal dilators tin can be part of the treatment plan if medical management is non sufficient. The initial dilation should be performed under anesthesia and patients should go along daily dilations using a digit or a plastic dilator at dwelling house. The author recommends the use of the plastic insert from a disposable anoscope with lidocaine jelly every bit an constructive dilator for home use. If patients remain symptomatic with these measures, it is important to ensure that the symptoms are not due other causes, such as an anal fissure.
Patients with moderate or severe strictures who have failed conservative management require surgical intervention. To determine the proper surgical procedure, the differential involvement of the anoderm compared with the underlying anal sphincter complex must be determined. A patient with a healthy anoderm and underlying fibrotic internal sphincter may merely demand a unilateral or bilateral sphincterotomy.31 32 Treatment of a fibrotic anal sphincter with sphincterotomy alone is nigh successful if the stricture is mild and low in the anal canal. Results of sphincterotomy alone for anal stenosis are limited but good results have been reported in up to 67% of patients.30
Patients with stenosis of the anoderm crave the introduction of salubrious tissue into the anal canal, replacing lost or diseased nonpliable anoderm with elastic and compliant neoanoderm.32 33 Several advancement flaps are described below. Patients with scarring of the anal sphincter musculus as well as stenosis of the anoderm should undergo a flap procedure combined with an internal sphincterotomy. Simple release of a stricture may provide temporary relief of symptoms but generally should be avoided because of the loftier charge per unit of recurrent stricture.
There are multiple types of flaps for anal stenosis, which are generally classified as advancement, rotational, or adjacent tissue transfer flaps.32 The choice of flap is influenced past the location of the stricture. Mid and upper anal canal stenoses are optimally treated with mucosal advancement flaps. For stenoses below the dentate line, a dermal advancement flap anoplasty is recommended. The 5–Y advocacy flap is used for strictures at the dentate line. Longer stenoses are best treated with diamond or house flap. Very large defects may require multiple house flaps or an S-plasty.31 32
Mucosal Advancement Flap
Mucosal advocacy flaps are all-time suited for treating midlevel and upper anal canal stenosis. The scar tissue is excised and a unilateral or bilateral internal sphincterotomy is performed if the underlying anal sphincter complex is also scarred and stenotic. A flap of healthy proximal rectal and anal mucosa with the underlying muscle is then undermined for two to 5 cm and advanced over the defect. Advancing the flap too far and suturing it to the anal verge may result in ectropion, leading to difficulty with incontinence and fungus belch. Studies demonstrate success rates of upward to 90% with the chief complications being abscess, fecal leakage, and restenosis.34
Anoplasty
Several options for flap configuration be, of which the about common flaps will be described below (Figs. ane and 2). In general, the operative techniques include acceptable mobilization to avert tension and the maintenance of a healthy claret supply to the flap. The pedicled flap should typically retain a wide base, with care taken not to cone in when dissecting deep to the anoderm.
Anoplasty (A: house flap, B: Y–V flap, C: diamond flap).
Anoplasty. (Epitome courtesy of W. Brian Sweeney, Physician.)
The Y–V advancement flap is performed by making a Y-shaped incision with the vertical limb of the Y extending into the surface area of stenosis and the two artillery of the Y extending widely out onto the perianal pare to form the Five. The 5 flap is mobilized, generally down to the underlying fascia to maintain its subdermal vascular plexus. This is then sutured into the vertical limb of the Y incision. If the proximal portion of the flap is too narrow, the patient may take insignificant widening of the stenosis.
V–Y advocacy flap is performed by making the Five-shaped incision with the broad base oriented toward the dentate line. Once again, the flap is mobilized ensuring that the subdermal vascular plexus is preserved. The donor site is closed primarily, creating the vertical limb of the Y. The flap is then secured proximally to replace the area of excised scar.
To create a diamond flap, the scar tissue is incised and a diamond-shaped flap is created on the perianal skin at the distal terminate of the incision. Again, the flap is advanced over the surface area of incised scar and the donor site is closed primarily. Like to the diamond-shaped flap, the U-shaped flap is created on the perianal skin after the anal stenosis scar tissue is incised and the flap is advanced over the surface area of incised scar. The donor site is left open to heal.35
The house flap anoplasty is used for anal stenosis when a 5–Y advocacy flap may non provide adequate tissue coverage. It has the advantage of a larger, flat proximal segment without a corner that can be susceptible to ischemia. A longitudinal incision is made from the dentate line to the terminate of the stenosis. The flap is created in the shape of an inverted firm with the base oriented proximally and is avant-garde into the anal canal and secured in place. It is of paramount importance that the flap be created with an acceptable length and width to embrace the defect. The donor site can be left open or closed primarily. Bilateral house flaps can exist used for severe stenosis or ectropion.36 37 38
Rotational S Flap
The rotational S-plasty flap is well suited for coverage of large areas but it does non work as well to open strictures as an advocacy flap. Rotational S-plasty flaps are full-thickness flaps with the length of the base of operations equivalent to its length. After the scar at the anal canal is excised, the flaps are rotated such that the apex is sutured to the opposite side of the anal culvert and the side of the flap is sutured to the lateral wall.
Farid et al compared 63 consecutive patients with anal stenosis past utilizing the house flap, rhomboid flap, and Five–Y anoplasty. A total of 90% of patients with a house flap had clinical improvement at 1 yr compared with lx% of patients with a rhomboid flap and thirty% of patients with Y–5 anoplasty. The incidence of complications was everyman in the house flap cohort and included ischemia of the flap in i patient, delayed healing in one patient, and sepsis in one patient. Patient satisfaction was significantly higher among patients with a business firm flap compared with a rhomboid flap or Y–Five anoplasty.37
Fecal Incontinence
Fecal incontinence following anorectal surgery can result from several problems. In cases such equally fistulotomy, sphincter muscle may have been intentionally divided with an underestimation of the functional consequence. At other times, damage to the anal sphincter or associated fretfulness occurs unintentionally. This can be due to direct mechanical or thermal trauma, or due to subsequent infection. Meticulous surgical technique is paramount in avoiding unintentional impairment to the anal sphincter. It is also essential that the gamble of fecal incontinence be included in the informed consent prior to surgery. Incontinence related to specific anorectal procedures, equally well every bit the arroyo to diagnosis and treatment of incontinence, is included below.
To prevent fecal incontinence after fistula surgery, the integrity of the anal sphincters prior to surgery must be kept in mind, as many patients undergo multiple surgeries to care for their anal fistula. It is extremely important to document an objective assessment of the patient's preoperative fecal incontinence, as this may assist in your surgical determination making, and also allows a more accurate assessment of postoperative disturbances in continence.
In select cases, it may also be beneficial to obtain preoperative imaging of the sphincter complex prior to fistula surgery. In a prospective report of 120 patients undergoing preoperative endorectal ultrasound, 37 (thirty.eight%) patients had an internal anal sphincter defect and 17 (15.9%) had an external anal sphincter defect at baseline. Of the 83 patients with no preoperative internal anal sphincter defect, 47 (56.5%) had an internal defect after surgery. Of 103 patients with no previous external defect, xx (19.4%) were constitute to accept a postoperative external defect.39
Some degree of new-onset fecal incontinence has been reported in eight% of patients post-obit a fistulotomy for a uncomplicated fistula, 24% of patients following a fistulotomy for a complex fistula, 25% of patients after a fistulectomy and sphincter repair, and 52% of patients afterward fistulectomy and advancement flap.39 40 41 Fistula characteristics, the number of abscesses incised, the number of fistulotomies performed, and the number of sphincter-sparing procedures are associated with the presence of fecal incontinence during follow-up. Every bit expected, patients treated for a subcutaneous fistula tract have a lower risk of fecal incontinence than those with more than circuitous fistulas.xl 41
Although endorectal advancement flap is considered a sphincter preserving technique, the sphincter complex can be injured past stretch during the operation, the proximal internal sphincter could be disrupted by the raising of the flap, and an ectropion acquired by advancing the flap beyond the internal fistula opening at the dentate line can cause moisture and fecal leakage. In 1 study, fecal incontinence after endorectal advancement flap for cryptoglandular fistulas was 13.2% and for Crohn fistulas it was 12% at an boilerplate follow-up of 28.nine months.42
Incontinence later hemorrhoidectomy is associated with a high incidence of partial or full-thickness internal anal sphincter injury and occasionally external sphincter defects.43 44 45 Incontinence has also been seen with intact sphincters, as the hemorrhoidal cushions are known to provide 15% of the patient's resting anal tone, and removal tin unmask bug with incontinence that were being aided by these cushions. Excision of hemorrhoids with secondary healing may too crusade decreased sensitivity and reduced capacity for rectoanal discrimination.46
Fecal incontinence can also occur after PPH, and is ordinarily related to a low-placed staple line or past injury to the internal sphincter due to the large diameter of the round stapler. In a prospective, randomized trial of 134 patients, de novo fecal incontinence at 1 year was reported in 2.v% of patients undergoing a stapled hemorrhoidopexy compared with vii.5% of patients who underwent a Milligan–Morgan hemorrhoidectomy.47 In another study of 257 patients undergoing stapled hemorrhoidopexy with a mean duration of follow-upwardly of 6.iii ± 1.2 years, 11 patients (4.nine%) reported newly developed fecal incontinence.48
Fecal incontinence is seen in 1.5 to eight% of patients afterward lateral internal sphincterotomy.49 fifty In a study of 31 women who underwent lateral internal sphincterotomy (LIS) for a chronic anal fissure, continence scores were significantly correlated with the extent of sectionalization of the internal anal sphincter muscle. Division of less than 25% of the internal anal sphincter (IAS) was correlated with a minimal risk of incontinence.51
The evaluation of patients with fecal incontinence should outset with a thorough history and concrete exam. Further studies including anorectal manometry, endorectal ultrasound, and pudendal nerve testing can assist in determining the cause of fecal incontinence. Anorectal manometry is a useful objective measure of the power of the internal sphincter and the external sphincter during voluntary contraction. Endoanal ultrasound is useful for the identification and detection of defects in the anal sphincter muscles. Magnetic resonance imaging of the anal sphincter complex is an alternative to ultrasound with equivalent accuracy, but it is significantly more expensive than ultrasound, and should be reserved for select cases.
Medical management is the best treatment for the bulk of patients with fecal incontinence afterwards anorectal surgery. Bulking of the stool with cobweb or antidiarrheals tin can make the stool easier to control and decrease the frequency of incontinence episodes. Biofeedback and sacral neuromodulation have also been shown to decrease fecal incontinence severity and better quality of life.52 53 However, this has non been well studied in patients with iatrogenic injury to the anal sphincter circuitous. For patients with sphincter disruption, sphincteroplasty may too exist helpful,54 although this surgery is not typically associated with long-term durability.
Chronic Pain
Chronic anal pain after anorectal surgery can be disabling for the patient and difficult to treat. To some degree, acute anal pain is common following anorectal surgery, particularly after hemorrhoidectomy, but this mostly resolves completely within iii to 4 weeks. Prior to surgery, patients should exist counseled nigh the anticipated duration and intensity of postoperative pain.
The causes of chronic hurting after anorectal surgery are numerous. This pain can exist related to residual underlying pathology, new or ongoing fissures and/or thrombosed hemorrhoid, or subtle anal infections. If postoperative hurting persists beyond what is expected, the patient should undergo a detailed evaluation focused on the in a higher place-mentioned causes, with special attending paid to the possibility of an occult infection or a nonhealing wound. If a thorough test cannot be completed in dispensary, an test nether anesthesia may be helpful to determine the source of hurting.
Chronic pain syndromes later stapled hemorrhoidopexy are uncommon but well described. Patients undergoing stapled hemorrhoidopexy generally accept less immediate postoperative hurting and less chronic pain than open hemorrhoidectomy.28 55 In a prospective randomized trial at a mean follow-upwardly of 16 months, 14/50 patients undergoing an open hemorrhoidectomy and 9/50 patients undergoing stapled hemorrhoidopexy complained of occasional long-term pain.55 When chronic hurting does occur after PPH, it may exist due to smooth muscle incorporation into the staple line. It has besides been attributed to persistent hemorrhoidal affliction, sphincter spasm, anal crack, anorectal sepsis, or retained staples. Overall rates of chronic pain afterward PPH range from ane.six to 31%.56
Treatment of chronic hurting following anorectal surgery should exist targeted to the underlying source. Warm sitz baths and nonsteroidals can relieve mild pain. Antispasmodics such as diazepam or cyclobenzaprine may be added if levator spasm is noted. Anismus may be treated with botulinum toxin injection.57 Sacral neuromodulation has also been described for chronic pelvic pain after anorectal surgery.58 If retained staples after PPH are identified, an exam under anesthesia with staple removal is advisable. Thankfully, many patients with pain will slowly better over time. Overall, chronic pain subsequently anorectal surgery can exist quite difficult to manage, which reinforces the importance of proper knowledge of the anatomy and use of meticulous surgical technique.
Decision
While anorectal surgery is generally well tolerated, short- and long-term complications often occur. To boxing this, the surgeon should perform a thorough preoperative work-up of the patient's baseline disability, along with a detailed discussion of complications during the informed consent process. When complications do occur, prompt identification and elimination of the offending pathology can limit the long-term impact on the patient's quality of life.
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