Anorectal procedures, such as haemorrhoidectomy; surgeries for abscess, fissure and fistula, are commonly considered „minor surgical interventions” and are generally safe, with a negligible percentage of postoperative complications. In addition to the commonly mentioned sequelae typical of surgeries involving the anal sphincters, such as gas and/or stool incontinence and relapses, atypical complications may also develop, coming as a surprise for both the patient and often the surgeon themselves. Below we present rare complications that can be encountered in an anorectal patient. We will also endeavour to answer the question of whether such complications can be predicted and prevented in any way.

Most patients do not report significant pain after anorectal surgeries. Patients that had undergone haemorrhoidectomy, which is associated with particularly severe pain for the first few postoperative days due to increased internal sphincter tone, are an exception. In my personal opinion, analgesics in the form of rectal ointments that relax the internal sphincter muscle fibres (e.g. calcium channel blockers), which are often recommended by Polish practitioners, are most effective. In some countries, strong narcotic analgesics are used excessively in such cases. For example, opioid overprescribing in the United States has given rise to a social problem that prompted researchers to formulate guidelines for opioid use after anorectal surgery (1). For example, a retrospective cohort study (2) assessed 174 anorectal surgery patients, including 72 haemorrhoidectomies, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous procedures: 14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions, to develop institutional guidelines for opioid prescribing practices. The number of prescribed medications varied (ranging from 3 to up to 80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients received no pills, 18% took all, and 5% needed refills. Interestingly, up to 63% of all prescribed pills were not consumed. Consumption varied significantly depending on surgery category, with a mean of 13.6 equianalgesic oxycodone 5-mg pills after haemorrhoidectomies, 6.3 after fistula-in-ano procedures, 5.8 after condyloma fulguration, and 2.9 tablets after miscellaneous surgeries. Based on the study group of patients, the authors proposed the following guidelines, which are intended to ultimately reduce the excess of prescribed prescription drugs (according to the authors, the reduction should be up to 41%): 27 equianalgesic oxycodone 5-mg pills after haemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous procedures, e.g. biopsy of a lesion in the anus.

The authors of the cited paper concluded that opioid prescribing patterns and consumption are widely variable after anorectal procedures and appear to be highly dependent on the operation category, which is consistent with our observations (haemorrhoidectomy is the most “painful” intervention). They also pointed out that 63% of opioids prescribed after anorectal surgeries were not used by patients.

It seems that there is no problem of overprescribing opioids to patients after anorectal interventions in Poland. Prevention of opioid addiction consists in postoperative analgesic setting of the patient (especially after haemorrhoidectomy, which is associated with intense postoperative pain) using a variety of agents, mainly topical medications in the form of rectal ointments that cause internal sphincter relaxation, as already mentioned above. Botulinum toxin is another effective way to reduce the sphincter tone, and thus reduce pain. The drug can be used intraoperatively or in the first postoperative days in a selected group of patients with significantly increased postoperative sphincteric tone.

Although pain is the most prevalent postoperative complication of haemorrhoidectomy, bleeding, urinary retention, and perianal infections are also common. Patients with inflammatory bowel disease (IBD), pregnant women, and individuals on immunosuppressive therapy have an increased risk of serious (usually septic) complications (3). Some authors propose combining different techniques, such as obliteration and external excision, especially in immunocompromised patients, to minimise the rate of complications (4).

Headaches are a well-known and common complication after epidural anaesthesia for anorectal surgeries. Apnoea associated with the “jackknife position”, used in fistula-in-ano surgery involving the anterior anal circumference, when the anaesthesia “goes too high” and involves the diaphragm, is a non-standard, rare complication. In such cases, the patient should be promptly turned onto their back, with the head and chest raised, ensuring airway patency. In these rare cases, the patient requires close anaesthesiologic supervision for several hours postoperatively. During my many years of work, I have only witnessed such a situation in a significantly overweight patient. Since this is an anaesthetic complication, discussing its aetiology remains beyond our competence.

Faecal and gas incontinence due to sphincter damage following anorectal procedures has been widely discussed in the literature (5, 6).