Despite development of improved surgical techniques,
advances in perioperative and critical care and introduction of
broad-spectrum antibiotics, colorectal surgery continues to present
us with a great challenge, particularly in elderly and poor-risk
patients with coexistent cardio-respiratory, renal and hepatic
disorders. Postoperative complications are common, occurring in
18–57% of patients after elective surgery and in 39.3–72% after
emergency colorectal surgery 
All postoperative complications can be divided into two
groups: systemic complications, requiring mainly a conservative
treatment and surgical abdominal complications. Another
classification includes division of complications into non-septic and
- a) cardiovascular (in 3.5–7 % of electively and in 12
% of urgently operated on patients),
- b) respiratory (in 7–17 % of electively and in 24 %
urgently operated on patients),
- c) urinary (in 2.5–14 % of patients),
- d) cerebral,
- e) thromboembolic.
Postoperative surgical complications after colorectal
surgery include: ileus, anastomotic leak, intraabdominal abscess,
fistula, splenic injury, presacral and anastomotic hemorrhage,
bladder dysfunction, sexual dysfunction, fecal incontinence, femoral
and peroneal neuropathies, wound infection.
Ileus occurring within 30 postoperative days is observed
in 2.5–9.5 % of cases. In the majority of patients ileus is treated
conservatively, but if there is no improvement in bowel function by 3
weeks, surgical exploration should be considered. Actual surgical
intervention is required in 13–20% of patients. Postoperative
intraabdominal bleeding/hemorrhagia occurs in 5–7.4% of patients
and always requires surgery. Complications of peptic ulcer, such as
bleeding or perforation, occur in less than 1% of cases. Thus, in
patients with peptic ulcer history a prophylactic use of proton pump
blockers should be consi-dered. An intraoperative spleen injury is
observed in 0.8–3% of patients. Spleen preservation management is
recommended. Ureteral injuries during colorectal surgery affect
0.3–10 % of operated on patients. Left ureter is injured more
frequently and injuries are most often asso-ciated with ligation of
inferior mesenteric artery, division of lateral rectal stalks,
surgery within cul-de-sac or promontorium region and also at the time
As the consequence of colorectal surgery, especially
after rectal excision, in 20–30% of patients a urinary bladder
dysfunction is being observed. In 15–60 % of surgical patients a
sexual dysfunction becomes a late complication of colorectal surgery.
The most dangerous intraoperative complication during
colorectal surgery is presacral hemorrhage. In order to stop bleeding
several procedures are recommended: direct suture, local application
of beewax, direct cautery, cautery through a gauze or a piece of
muscle, occlusion by finger, baloon tamponade, application of
thumbtacts through the sacrum, local application of orthopedic bone
cement and finally, as the last resort, packing.
Septic complications following elective and emergency
colorectal surgery occur in 7–24% and 23.6–34.2%, respectively
[2, 3, 4]. Septic complications may be divided into systemic
(respiratory and urinary tract infection) treated conservatively and
abdominal surgical complications. Abdominal complications such as
wound infection, wound dehiscence, anastomotic leakage,
intraperitoneal abscess, peritonitis or septicaemia frequently
require reoperation. Abdominal septic complications occur in 15–22%
of patients [5, 6].
Respiratory tact infections occur in 7–17% of
patients, urinary tract infections in 2.5–11% of patients and
surgical site infections in 5–17.5% of electively and in 33% of
urgently operated patients has been observed . In large series of
studies intraperitoneal anastomotic leakage rates range from 1% to
5%, while in pelvic colorectal anastomoses leakage occurs in 5–30%
. Postoperative intraabdominal abscesses are mainly due to a
failure in surgical technique. Intraoperative spillage of colonic
contents, especially when haematoma or necrotic tissue is present in
intraperitoneal cavity, can result in an abscess formation.
Ultrasound and CT-scan are the most precise methods to diagnose and
treat an abscess by transcutaneous drainage. Fecal fistula may be the
presentation of an abscess, radiation, inflammatory bowel diseases or
anastomotic leak. Antibiotics and parenteral nutrition are essential
elements of the treatment. Most fistulas resolve under conservative
treatment, however, some of them require surgery. There is no
possibility to completely reduce the risk of anastomotic leak.
Leakage can be prevented by proper anastomosis applied with no
tension, good hemostasis, adequate blood supply in the region of
anastomosis, adequate lumen of anastomosis and appropriate suturing
technique. The closer the anastomosis to the anal verge, the higher
the probability of leakage. Consequences of an anastomotic leak are
the following: fistula, abscess, stercoral diffuse peritonitis and an
early cancer recurrence. Leakage should be diagnosed as soon as
possible. Early diagnosis is crucial for patient’s survival.
Treatment of anastomotic leak includes early surgery with taking down
of the leaking anastomosis (Hartmann procedure), broad-spectrum
antibiotics, peritoneal lavage, open abdomen technique, TPN and
treatment in ITU.
Risk factors for surgical site infections include: age,
poor ASA, coexistent diseases, malnutrition, malignancy, high BMI,
chemo-, radio-, steroidotherapy.
Bad surgery, bad disease, bad patient, duration of
operation longer than 2 hours and a long hospital stay before surgery
are the most relevant risk factors in colorectal surgery. In order to
reduce the number of complications we recommend the following
measures: patient preparation, good surgery (atraumatic, bloodless,
possibly shortest), postoperative fast tract in surgery.
During a 10-year period between 1988 and 2007 1513
patients have been operated on. Within this group there were 922
patients with malignant colorectal tumors and 591 patients with a
benign disease. Perioperative and postoperative complications
occurred in 475 patients (31.4% of total number). Septic
complications were observed in 331 patients (21.9% of the total).
Most common complications included surgical site infections in 11.2%,
anastomotic leak in 7.8%, cardiovascular complications in 5.3%,
urinary infections in 3.6%, sepsis in 3%, respiratory infections in
2.2%, bleeding/hemorrhage in 1.3% and cerebral complications in 0.2%.
Based on our own experience and data from literature the
following conclusions can be drawn:
- Postoperative complications occur in about 32 % of
patients after colorectal surgery.
- Septic complications occur more frequently in
patients operated on due to a non-malignant disease of the large
bowel in comparison to those undergoing surgery due to colorectal
cancer (24.7% vs 19%, p < 0.05). On the other hand, rectal cancer
is a surgical burden with higher risk of septic complications
comparing to colonic cancer surgery (23.5% vs 15.5%, p < 0.01)
- Anastomotic leakage was the most serious abdominal
septic complication bearing risk of systemic sepsis and bearing risk
of high mortality. In the group of 888 patients with primary
anastomosis anastomotic leak occurred in 69 patients accounting for
- The mortality rate in the cancer group was 7.6%,
including elective and emergency surgery and 8.7% in the benign
diseases group, including elective and emergency surgery.
- Emergency surgery resulted in higher morbidity and
mortality; 16.1% in colorectal cancer surgery and 25.6% in benign
dr. hab. med. Krzysztof Bielecki
of General and Gastrointestinal Surgery
Center for Postgraduate Medicine
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