Feasibility case-controlled study of day-case haemorrhoidectomy

Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis

PURPOSE

The aims of this study are to review the advantages and drawbacks of the ambulatory management of patients scheduled for haemorrhoidal surgery and to highlight the reasons for unplanned hospital admission and suggest preventive strategies.

METHODS

We conducted a systematic review of the literature from January 1999 to January 2013 using MEDLINE and EMBASE databases. Manuscripts were specifically analysed for failure and side effects of haemorrhoidal surgery in ambulatory settings.

RESULTS

Fifty relevant studies (6082 patients) were retrieved from the literature review. The rate of ambulatory management failure ranged between 0 and 61%. The main reasons for failure were urinary retention, postoperative haemorrhage and unsatisfactory pain control. Spinal anaesthesia was associated with the highest rates of urinary retention. Doppler-guided haemorrhoidal artery ligation has less frequent side effects susceptible to impair ambulatory management than haemorrhoidectomy and stapled haemorrhoidopexy. However, the fact that haemorrhoidopexy is less painful than haemorrhoidectomy may allow ambulatory management.

CONCLUSION

Day-case haemorrhoidal surgery can be performed whatever the surgical procedure. Postoperative pain deserves special prevention measures after haemorrhoidectomy, especially by using perineal block or infiltrations. Urinary retention is a common issue that can be responsible for failure; it requires a preventive strategy including short duration spinal anaesthesia. Doppler-guided haemorrhoidal artery ligation is easy to perform in outpatients but deserves more complete evaluation in this setting.

Open haemorrhoidectomy under local anaesthesia for symptomatic haemorrhoids: An experience from Nigeria

BACKGROUND AND STUDY AIMS

Ligation-excision haemorrhoidectomy is considered to be the gold-standard treatment for prolapsed haemorrhoids. The procedure is commonly done under general or regional anaesthesia. This study aimed to assess the feasibility and tolerability of open haemorrhoidectomy under local anaesthesia.

PATIENTS AND METHODS

This is a prospective study carried out in Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria, over a 5-year period. All consenting adult patients with prolapsing haemorrhoids were offered Milligan-Morgan haemorrhoidectomy under local anaesthesia. They were assessed for tolerance and complications.

RESULTS

More than 95% of the patients tolerated the procedure with manageable complications.

CONCLUSION

Open excisional haemorrhoidectomy under local anaesthesia is feasible, safe and well tolerated in our environment, and may encourage early presentation of patients with piles to hospital.

Day case haemorrhoidectomy

OBJECTIVE

Day case haemorrhoidectomy in a District General Hospital. We have investigated the uptake and outcome of day case haemorrhoidectomy in a small district general hospital.

METHOD

Case note review with completion of standard proforma for all patients undergoing haemorrhoidectomy as day case (same day admission and discharge) or inpatient over a 4-year period.

RESULTS

Sixty patients underwent day case closed haemorrhoidectomy, 2 day case stapled haemorrhoidectomy and 1 day case open haemorrhoidectomy, whilst 18 patients were treated as in-patients. One patient required re-admission within 31 days for reactionary haemorrhage after day case surgery. None suffered acute urinary retention. Concomitant medical disease or emergency admission were the only reasons for exclusion from day case haemorrhoidectomy. Of the 18 patients treated as in-patients haemorrhoidectomy two had unplanned readmission.

CONCLUSION

Closed haemorrhoidectomy with same day discharge should be offered to all patients that require surgical treatment of haemorrhoids and do not have other contra-indications to day case surgery.

Radiofrequency ablation and plication: a non-resectional therapy for advanced hemorrhoids

BACKGROUND

Radio frequency ablation followed by plication of the hemorrhoidal mass for patients who would otherwise require hemorrhoidectomy is being practiced at our hospital since last 5 years. This procedure accomplishes hemorrhoidal symptom relief with far less post-operative pain and other complications as compared to various other types of hemorrhoidectomies.

MATERIALS AND METHODS

A retrospective study of 1000 patients having grade III or grade IV hemorrhoids treated with the above technique over a period of 30 months is reported. A Ellman radiofrequency generator was used for ablation of the hemorrhoids. Follow-up record of these patients is presented. The post-operative outcome and procedure related complications are compared with conventional hemorrhoidectomy procedures.

RESULTS

With this procedure, the post-defecation pain score reported was between 1 and 4 (VAS) in the first week, which subsided thereafter. There were 42% patients who had post-defecation bleeding in the first 10 days. There were 82% patients able to resume duties on the 6th post-operative day. Of these, 5% of the patients had post-operative urinary retention needing catheterization for a single time, and 18 patients required readmission for secondary bleeding. None of the patients complained of fecal incontinence, sepsis, or anal stenosis. In the subsequent follow-up at a mean of 19 months, 4% of the patients had residual skin tags, 3% of them had symptomatic anal papillae, and 2% developed recurrence of hemorrhoids.

CONCLUSION

The combined procedure described above could be a feasible alternative for surgical treatment of hemorrhoids being quick and easy to perform. With this procedure, the hospital stay is short, post-operative pain is less, return to work is faster, and recurrence rate is low.

Ambulatory surgery in proctology

INTRODUCTION

In our institution we've had a lot of exerience in proctology. Ten years ago, we introduced one day surgery in our practice and had really good results in treating practically all patients who needed proctologic surgery.

MATERIALS, METHODS AND RESULTS

During this period of time 9.636 out of 73.235 outpatient cases were chosen for surgery. Among them, 2664 were patients with operations of perianal haematomas. We had some experiences with minor anal surgery (excisions of skin tags in 537 patients, excisions of papillas in 545 patients); patients with haemorrhoids, operated classically on Milligan-Morgan procedure (1116) or by the new PPH-- Longo procedure (270) and HAL technique (12). We also treated patients with fistulas--either with fistulotomy or excision of fistulae--and 1007patients with minor surgery. We made excisions of anorectal polyps in 265 patients, excisions of pilonidal cysts in 421 patients and treated 211 patients with anal abscesses. We had 282 patients with anal warts, 310 patients with anal fisures. In 35 patients we made some other small proctological interventions. In addition to proctology we made tension free operations of groin hernias in 627 patients, corrections of epigastric and umbillical hernias (26 patients) and corrections of stomas in 11 patients. The rest of our peogramm were small aseptic interventions (operations of fibromas, atheromas, verrucas, ganglions, lipomas etc.).

CONCLUSION

We have experienced ambulatory surgery (i.e. day surgery hospital) as an appropriate choice for treating the patients with proctologic pathology. However, it used to be the practice to treat all these patients in hospitals, where they occupied bed facilities that could be intended for other patients. To conclude, our present results have confirmed the decision for ambulatory surgery to be correct in the field of proctology.