*Małgorzata Kołodziejczak1, 2
How to avoid misqualification for colorectal surgeries – 7 key questions
Jak uniknąć błędu w kwalifikacji do operacji proktologicznej ? 7 kluczowych pytań
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital in Warsaw
2Department of General Surgery, District Hospital in Ostrów Mazowiecka, Poland
Streszczenie
W artykule omówiono problem właściwej kwalifikacji do zabiegu proktologicznego. Biorąc pod uwagę realia pracy chirurga i często zbyt mało czasu na wywiad z pacjentem, zdarza się, że kwalifikacja do operacji jest zbyt pochopna. Cele chirurga nie zawsze są też tożsame z oczekiwaniami, które wiąże pacjent z planowanym zabiegiem. Żeby uniknąć błędnej kwalifikacji do zabiegu i w konsekwencji związanych z tym kłopotów, autorka sformułowała 7 następujących pytań, jakie powinien zadać chirurg pacjentowi, a także i sobie samemu, przed zakwalifikowaniem pacjenta do zabiegu proktologicznego: 1. Czy w ogóle operować pacjenta i czy wykorzystano wszystkie metody nieinwazyjnego leczenia choroby? 2. Jakie najbardziej uciążliwe dolegliwości zgłasza pacjent i czy operacja może je zlikwidować? 3. Jakie są oczekiwania pacjenta dotyczące przeprowadzonego zabiegu? 4. Czy pacjent dobrze trzyma gazy i stolec? 5. Czy nie współistnieją inne choroby (np. zapalne jelit, internistyczne, psychiczne), które mogą pogorszyć przebieg gojenia? 6. Czy moje umiejętności i możliwości ośrodka, w którym zamierzam wykonać operację, są odpowiednie dla danego pacjenta (stan ogólny pacjenta, rozległość zabiegu, wymagany czas hospitalizacji)? 7. Czy kontakt (porozumienie) między mną (lekarzem-operatorem) a pacjentem jest dobry?
W artykule omówiono przykładowo kilka proktologicznych jednostek chorobowych i związanych z nimi pułapek w kwalifikacji do zabiegu operacyjnego. Właściwa kwalifikacja do operacji proktologicznej, a czasem odstąpienie od zabiegu, jest elementem decydującym o wyleczeniu pacjenta, a także w dużej części pozwala uniknąć pooperacyjnych komplikacji.
Summary
This paper discusses the issue of proper qualification for colorectal surgery. Given the reality of a surgeon’s work and often insufficient time for collecting patient’ history, it happens that the qualification for surgery is hasty. Also, the surgeon’s objectives are not always the same as the patient’s expectations associated with the planned procedure. In order to avoid an erroneous qualification for surgery and its consequences, I have formulated the following 7 questions that surgeons should ask both their patients and themselves before qualifying these patients for colorectal surgeries: 1. Is surgical treatment necessary and have all non-invasive options been exhausted? 2. What are the most bothersome symptoms reported by the patient and can they be eliminated surgically? 3. What are the patient’s expectations of the surgery performed? 4. What is the patient’s (gas and stool) continence status? 5. Are there any comorbidities (e.g. inflammatory bowel disease, internal diseases, psychiatric conditions) that may impair healing? 6. Are my skills and the capacity of the centre where I intend to perform the surgery appropriate for the patient (patient’s general condition, extent of surgery, required length of hospital stay)? 7. Is the contact (understanding) between the operating doctor (me) and the patient good? This paper discusses several examples of colorectal disorders and the associated pitfalls in the preoperative qualification process. Correct qualification for colorectal surgery, which may sometimes mean abandonment of the procedure itself, plays a key role in the patient’s recovery and often helps avoid postoperative complications.
Introduction
Given the reality of the Polish surgeon’s work and often insufficient time for collecting patient’s history, the process of qualifying for colorectal surgery may be too hasty. Colorectal procedures are performed within or around the anal sphincter and therefore involve the risk of incontinence. The surgeon’s objectives are also not always consistent with patient’s expectations of the planned intervention. In order to avoid an erroneous qualification for surgery and its consequences, I have formulated the following 7 questions that surgeons should ask both their patients and themselves before qualifying these patients for colorectal surgeries:
1. Is surgical treatment necessary and have all non-invasive options been exhausted?
2. What are the most bothersome symptoms reported by the patient and can they be eliminated surgically?
3. What are the patient’s expectations of the surgery performed?
4. What is the patient’s (gas and stool) continence status?
5. Are there any comorbidities (e.g. inflammatory bowel disease, internal diseases, psychiatric conditions) that may impair healing?
6. Are my skills and the capacity of the centre where I intend to perform the surgery appropriate for the patient (patient’s general condition, extent of surgery, required length of hospital stay)?
7. Is the contact (understanding) between the operating doctor (me) and the patient good?
As an example, the practical application of these questions in several colorectal disorders is presented.
Haemorrhoidal disease
Question 1. Is surgical treatment necessary and have all non-invasive options been exhausted?
Conservative treatment in the form of an anti-constipation diet, as well as general and topical agents should always be used in the early stages of haemorrhoidal disease (HD). Alternative, minimally invasive interventions (rubber band ligation, obliteration) are also used in grade II and III haemorrhoids. Therefore, in the case of HD patients, the answer to the question on whether to perform a surgery is most often NO. According to the literature, only about 5-10% of HD patients require surgery (1).
As for minimally invasive techniques, patients nowadays most often ask about the laser technique, which is used for grade II and III haemorrhoids, but may not meet the expectations of grade IV patients. There is a belief among patients that the haemorrhoid laser procedure (HeLP) ensures rapid full recovery with no pain or oedema. Each patient qualified for HeLP should be informed that this treatment modality is in fact “a surgery” that may be accompanied by pain and oedema and that anal discharge usually persists for several weeks.
Before qualifying a HD patient for surgical treatment, the stage of the disease should be considered. For example, misqualifying a patient with prolapsed grade IV haemorrhoids and overgrown anodermal folds for laser surgery may result in their disappointment due to the unacceptable cosmetic outcome associated with the remaining folds and, most likely, treatment failure.
Question 2. What are the most bothersome symptoms reported by the patient and can they be eliminated surgically?
Bleeding and haemorrhoid prolapse are the indications for haemorrhoidectomy. If the patient does not report any of these symptoms, surgery should not be offered. For example, a 90-year-old patient with grade IV haemorrhoidal disease, to which he or she “has become accustomed”, should not be persuaded to undergo surgery due to tolerable symptoms and the risk of age-related perioperative complications.
Patients often perceive haemorrhoids as a mechanical obstruction preventing normal bowel movements. It should be explained to the patient that HD is an effect rather than the cause of constipation. Haemorrhoidectomy will not eliminate constipation or the pain that may be associated with the presence of a fissure or anal thrombosis. Pain after haemorrhoidectomy may even temporarily worsen in the first few days after surgery.
Question 3. What are the patient’s expectations of the surgery performed?
Many women have “cosmetic” expectations and perceive anodermal folds as haemorrhoids. In such cases, no haemorrhoidectomy should be performed, but only excision of the folds.
Question 4. What is the patient’s (gas and stool) continence status?
This question should be asked before any colorectal procedure, including haemorrhoidectomy, although haemorrhoid surgery does not theoretically involve the sphincter. Haemorrhoids seal the anus and cause about 30% worsening of gas continence. If the patient already suffers from incontinence before haemorrhoidectomy, then the indications for haemorrhoidectomy are very narrow and limited to patients with heavy bleeding leading to anaemia. The patient should then be informed of the possible complication of poorer postoperative gas continence. It was already many years ago that Stelzer wrote that haemorrhoidectomy is only a seemingly easy procedure, with incontinence being one of its complications (2, 3).
Question 5. Are there any comorbidities (e.g. inflammatory bowel disease, internal diseases, psychiatric conditions) that may impair healing?
Operating on a patient during the active phase of inflammatory bowel disease (IBD) can cause wound healing complications. Multicentre analyses of patients with IBD and those after haemorrhoidectomy reported postoperative complications rates of 9%, with a worse postoperative course found in patients with Crohn’s disease than those with ulcerative colitis (11 vs. 5%) (4, 5). Also, operating on a patient with, for example, severe neurosis or depression not controlled with pharmacotherapy can be challenging.
Question 6. Are my skills and the capacity of the centre where I intend to perform the surgery appropriate for the patient (patient’s general condition, extent of surgery, required length of hospital stay)?
For haemorrhoidal disease, surgery can be safely performed in any general surgery department of a public hospital. Haemorrhoidectomy is also performed in commercial units. Postoperative bleeding, which must be kept in mind when qualifying a patient for surgery in a non-public centre, is the most serious early complication after haemorrhoidectomy. The patient should be also provided with a direct telephone number and instructions to immediately contact the attending doctor if complications arise (support facilities of an operational surgical unit are essential).
Question 7. Is the contact (understanding) between the operating doctor (me) and the patient good?
The lack of a good relationship between the operator and the patient is a serious reason to refuse surgery for elective indications and possibly ask for a consultation with another surgeon.
Anal fissure
Question 1. Is surgical treatment necessary and have all non-invasive options been exhausted?
All therapeutic algorithms recommend initial conservative treatment of anal fissure, hence skipping conservative treatment and imprudent, rapid qualification for surgery may expose the doctor to patient’s legal claims if any complications related to the procedure itself should arise.
Women with postpartum anal fissure should not be qualified for surgery. The aetiopathogenesis of a postpartum fissure differs from that of a typical cryptic fissure, with postpartum patients tending to have decreased (rather than increased!) sphincter tone. Therefore, a hasty qualification for surgery may result in the development of complete gas incontinence.
Question 2. What are the most bothersome symptoms reported by the patient and can they be eliminated surgically?
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Piśmiennictwo
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2. Stelzner F: Hemorrhoidectomy ? a simple operation? Incontinence, stenosis, fistula, infection and fatalities. Chirurg 1992; 63(4): 316-326.
3. Stelzner F: Surgery without anatomy? Chirurg 2016; 87(8): 683-687.
4. Grossi U, Gallo G, Di Tanna GL et al.: Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis. J Clin Med 2022; 11: 709.
5. Salgueiro P, Caetano AC, Oliveira AM et al.: Portuguese Society of Gastroenterology Consensus on the Diagnosis and Management of Hemorrhoidal Disease. GE-Port. J Gastroenterol 2020; 27: 90-102.
6. Elsebae MM: A study of fecal incontinence in patients with chronic anal fissure: Prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg 2007; 31(10): 2052-2057.
7. Kiyak G, Korukluoğlu B, Kuşdemir A et al.: Results of lateral internal sphincterotomy with open technique for chronic anal fissure: Evaluation of complications, symptom relief, and incontinence with long-term follow-up. Dig Dis Sci 2009; 54(10): 2220-2224.
8. Hananel N, Gordon PH: Lateral internal sphincterotomy for fissure-in-ano-revisited. Dis Colon Rectum 1997; 40(5): 597-602.
9. Liratzopoulos N, Efremidou EI, Papageorgiou MS et al.: Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: Our experience in 246 patients. J Gastrointest Liver Dis 2006; 15(2): 143-147.
10. Bielecki K, Kolodziejczak M: A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis 2003; 5(3): 256-257.
11. Garg P: Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study. Int J Surg 2017; 42: 34-40.
