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 [1]

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 septic ones.

Systemic complications include:

• 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 of reperitonealization.

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 [7]. In large series of studies intraperitoneal anastomotic leakage rates range from 1% to 5%, while in pelvic colorectal anastomoses leakage occurs in 5–30% [7]. 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.

OUR OWN EXPERIENCE

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:

1. Postoperative complications occur in about 32 % of patients after colorectal surgery.
2. 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)
3. 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 7.8%.
4. 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.
5. Emergency surgery resulted in higher morbidity and mortality; 16.1% in colorectal cancer surgery and 25.6% in benign diseases surgery.

Prof. dr. hab. med. Krzysztof Bielecki

Department of General and Gastrointestinal Surgery

Medical Center for Postgraduate Medicine

231 Czerniakowska St.

00-416 Warsaw

Poland

e-mail: prof.bielecki@gmail.com