Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings

BACKGROUND

Transanal hemorrhoidal dearterialization (THD) is a recently developed procedure to minimize postoperative pain from hemorrhoidectomy. This technique utilizes Doppler signals to aid ligation of hemorrhoidal arteries followed by mucopexy of redundant mucosa if needed. The aim of the present study was to assess patient satisfaction after THD.

METHODS

This is a retrospective cohort study of patients who underwent THD at three different sites from April 2007 through October 2010. All procedures were performed in ambulatory settings according to protocol. Telephone surveys were conducted after a minimum of 1-month follow-up to assess patients' satisfaction on a scale of 1-10. Patients were asked whether the procedure had alleviated their symptoms. Patients were asked to recall duration of pain and time from surgery to return to work.

RESULTS

Between April 2007 and October 2010, 216 patients with grade III-IV hemorrhoids underwent THD. There were 165 males and 61 females. Average age was 52.2 ± 14.2 years. All patients were discharged the same day after meeting ambulatory surgery center discharge criteria. Postoperative difficulty urinating occurred in 37 (17 %) patients, and six of them required temporary urinary catheterization. Transitory postoperative bleeding was reported by 38 (18 %) patients. Transitory incontinence to stool and flatus occurred in 18 (9 %) and 16 patients (8 %), respectively. Pelvic muscle spasms occurred in 21 (10 %) patients. Median follow-up was 23 months (range 1-42 months) with 143 (66 %) having at least 9 months between procedure and interview. Mean patient satisfaction was 8.5 ± 0.7 (on a scale of 1-10 with 10 being the best), and 91.5 % of patients felt the procedure had "helped" them. Average number of days with discomfort was 6.7 ± 2.1. Patients returned to work after an average of 10.3 ± 3.2 days. Our study is limited by lack of long-term follow-up and by retrospective complication assessment.

CONCLUSIONS

Patient satisfaction with THD performed in ambulatory settings is high. Our data support performance of this procedure in an ambulatory setting.

Age and type of procedure influence the choice of patients for laparoscopic colectomy

BACKGROUND

The aim of this retrospective, case-matched controlled study was to determine the benefit of laparoscopic-assisted colectomy (LC) for the elderly (>75 years of age) and the young (<75 years of age) compared to an open colectomy (OC) control group.

METHODS

A retrospective review of 39 patients older than 75 years of age and 38 patients younger than 75 years of age who underwent LC for colorectal cancer between 1991 and 1999 was performed. LC patients were matched with an open control group for procedure, age, gender, year of procedure, and surgeon. Procedures included right and left colectomy, anterior resection of the rectosigmoid, and abdominoperineal resection. Measured intraoperative variables included anesthesia time, operative time, and estimated blood loss. Postoperative parameters consisted of duration of intravenous or epidural narcotic usage, return of bowel function (RBF), length of stay, and independence at discharge. These variables were compared in the entire group of 154 patients.

RESULTS

Mean ages were 81.4 and 81.8 years for LC and OC age >75 and 62.9 and 62.7 for LC and OC age <75. Mean anesthesia time and operative time were significantly longer (p < 0.05) for LC compared to OC (46.8 vs 39.3 and 159.3 vs 111.7 min, respectively) for age >75 and for age <75 (47.1 vs 40.3 and 182.8 vs 135.5 min, respectively). LC achieved faster recovery in both age groups: RBF (3.9 vs 4.9 days for age >75; 6.7 vs 7.7 days for age <75) (p < 0.05). Narcotic usage was shorter for the LC group age <75 (3.3 vs 4.4 days; p < 0.05). There was no significant difference in independence at discharge between LC and OC in either age group. Faster recovery was seen with left LC in age >75 and right LC in age <75 compared to OC.

CONCLUSION

The advantages of LC over OC are the same for the elderly and the young. There may be a selective benefit of laparoscopic left colectomy in the elderly and laparoscopic right colectomy in the young.

Latency to initiate locomotion elicited by stimulation of the diencephalon positively correlates in awake and anesthetized rats

Locomotor stepping can be elicited by brain stimulation at various diencephalic sites under moderate levels of Nembutal. This study determined if locomotor initiation measured under anesthesia provides a valid measure of the intersite factors which determine initiation in the awake condition. We compared the latencies to initiate locomotor stepping elicited by electrical stimulation (50 microA, 0.5-msec pulses, 10 to 160 Hz) by rats tested while awake and unrestrained in a rotary runway or anesthetized and held in a stereotaxic apparatus. In the latter tests, initial anesthesia was provided by Nembutal (25 mg/kg) and 2% halothane and maintenance anesthesia was provided by 7 mg/kg as needed and local injections of lidocaine. For 30 sites in 16 rats, average locomotor initiation latency in the awake condition and the shortest latencies in the anesthetized condition were positively correlated (r = .78). Locomotion at sites with long latencies in the awake condition was frequently blocked in the anesthetized condition, but sites with short latencies were rarely blocked. The results indicate that the shortest locomotor latencies in the anesthetized condition approximate the latencies measured in the awake condition. It is concluded that the anesthetized condition can provide valid initiation measures, but sites with long latencies in the awake condition are prone to depression under anesthesia.

Initiation and execution of locomotion elicited by diencephalic stimulation: regional differences in response to nembutal

At moderate levels of Nembutal, within the anesthetic range, locomotor stepping can be elicited by brain stimulation. We determined if Nembutal (7, 14 and 28 mg/kg) had different effects on locomotion elicited by stimulation at different brain regions. Two regions were compared: the medial forebrain bundle (MFB, 13 sites) and the areas medial and dorsal to it (MED/DORSAL, 20 sites). Locomotion was produced by electrical stimulation (50 microA, 0.5 msec pulses, 10 to 160 Hz) of unrestrained rats in a rotary runway. The latency to initiate locomotion and the time to complete 1 revolution of the rotary were measured. With no drug, MFB locomotion was initiated sooner but took longer to complete than MED/DORSAL locomotion. Nembutal at 7 mg/kg did not affect initiation of MFB or MED/DORSAL locomotion. Nembutal at 14 mg/kg shortened MFB initiations, but this dose prolonged MED/DORSAL initiations. Initiations with both types of sites were blocked with 28 mg/kg. The 7 and 14 mg/kg doses prolonged the locomotor completion times of the MFB sites but not of the MED/DORSAL sites. The results indicate that the response to Nembutal differs qualitatively for locomotion elicited by stimulation of the MFB and locomotion elicited by stimulation of the medial and dorsal hypothalamus. The mechanisms underlying the difference remain to be elucidated; they may relate to nonlocomotor behaviors also elicited by stimulation or to the motivational states reflected in those behaviors.