Things That Go Bump in the Night: Rare, Severe, and Long-term Complications after Colorectal Surgery

Ira L. Leeds, MD, MBA, ScM, FACS, FASCRS

Oh, the places you'll go! There is fun to be done!

There are points to be scored. There are games to be won.

And the magical things you can do with that ball

Will make you the winning-est winner of all….

Except when they don't

Because, sometimes they won't.

I'm afraid that some times

You'll play lonely games too.

Games you can't win

‘cause you’ll play against you.

- Dr. Seuss, The Places You'll Go

Complications are intrinsic to the craft of surgery. No amount of comprehensive preplanning, meticulous intraoperative technique, or conscientious postoperative care can eliminate the inherent uncertainty of what we do. Those who suggest otherwise are the oft-quoted critics in Theodore Roosevelt's arena who know neither victory nor defeat. Complications are our regular reminder that what we do is serious, risky work and that requires us to reconcile the potential benefit of surgery versus the range of unfortunate and undesired, occasional consequences. However, I do not offer this perspective out of medical nihilism. While the elimination of surgical complications is a false ideal, we all share a moral imperative to take steps to reduce surgical complications, particularly those that contribute to long-term morbidity and mortality.

In this issue of Clinics in Colon and Rectal Surgery, we cover a range of issues related to the serious complications in colorectal surgery that are frequently discussed but less commonly encountered. Fortunately, most complications of colorectal surgery are minor and often not even accounted for in current surgical quality measures (e.g., superficial surgical site infection). In this issue, we address the large group of serious complications that are commonly quoted as 5% or less incidence but with notable long-term effects on quality of life and life expectancy.

Much of this issue is focused on the best management strategy for surgical complications—preventing them in the first place. We start the issue with a re-examination of the current state of preoperative risk stratification followed by what can be done to mitigate these risks. Continuing from there, we have gathered experts in their respective fields to discuss evidence-based perioperative strategies for reducing three of these complications: anastomotic leak, postdischarge venous thromboembolism, and incisional hernia.

The middle portion of the issue is dedicated to addressing how best to evaluate and ultimately treat some of the most refractory, long-term complications of colorectal surgery. Sexual dysfunction, low anterior resection syndrome, and anastomotic strictures share a common theme. These complications manifest typically well after the original indication for surgery has been “cured” and contribute to incomplete recovery of quality of life or worsening decisional regret.

In the last section, we turn to the contextual factors that often affect these complications. Often, surgeons are being asked to consider reintervention in non-curative follow-up scenarios. Beyond the surgical techniques and considerations for palliation, this section also addresses how should the possibility of these risks be discussed in the preoperative shared decision-making setting and how socioecological drivers of health impact these decisions and their consequences.

This issue accepts as an immutable fact that surgeons will have complications. What we are and will be measured by is (1) what we do to reduce or mitigate these complications, (2) how we respond to the occurrence of these complications, and (3) how we support patients through their decision to expose themselves to surgical risk. I hope that this issue provides opportunities for all of us to hone our craft as surgeons and deftly handle our toughest complications with the same second-nature ease as our best surgical successes.

But on you will go

though the weather be foul.

On you will go

though your enemies prowl….

Step with care and great tact

and remember that Life's

a Great Balancing Act.

- Dr. Seuss, The Places You'll Go

Publication History

Article published online:
09 April 2025