Anorectal Procedures Research Articles

A Prospective, Randomized, Controlled Multicenter Trial Comparing Stapled Hemorrhoidopexy and Ferguson Hemorrhoidectomy: Perioperative and One-Year Results

There is a growing body of evidence supporting the lesser degrees of pain with stapled hemorrhoidopexy, also called the procedure for prolapse and hemorrhoids. However, there have been few randomized comparisons assessing both perioperative and long-term outcomes of the procedure for prolapse and hemorrhoids and Ferguson hemorrhoidectomy. Results are presented here from the first prospective, randomized, multicenter trial comparing these hemorrhoid procedures in the United States. Patients with prolapsing hemorrhoids (Grade III) were randomized to undergo the procedure for prolapse and hemorrhoids or Ferguson hemorrhoidectomy by colorectal surgeons who had training in using the stapling technique. Primary end points were acute postoperative pain, and hemorrhoid symptom recurrence requiring additional treatment at one-year follow-up from surgery. A total of 156 patients (procedure for prolapse and hemorrhoids, 77; Ferguson, 79) completed randomization and the surgical procedure, 18 (procedure for prolapse and hemorrhoids, 12; Ferguson, 6) had significant protocol violations. One hundred seventeen patients (procedure for prolapse and hemorrhoids, 59; Ferguson, 58) returned for one-year follow-up. Demographic parameters, hemorrhoid symptoms, preoperative pain scores, and bowel habits were similar between groups. There were a similar number of patients with adverse events in each group (procedure for prolapse and hemorrhoids, 28 (36.4 percent) vs. Ferguson, 38 (48.1 percent); P = 0.138). Reoperation for an adverse effect was required in six (7.6 percent) Ferguson patients and in 0 patients having the procedure for prolapse and hemorrhoids (P = 0.028). Postoperative pain during the first 14 days, pain at first bowel movement, and need for postoperative analgesics were significantly less in the procedure for prolapse and hemorrhoids group. Control of hemorrhoid symptoms was similar between groups; however, significantly fewer patients having the procedure for prolapse and hemorrhoids required additional anorectal procedures during one-year follow-up (procedure for prolapse and hemorrhoids, 2 (2.6 percent), vs. Ferguson, 11 (13.9 percent); P = 0.01). Only four of the Ferguson patients (5 interventions) required additional procedures more than 30 days after surgery. These data demonstrate that stapled hemorrhoidopexy offers the benefits of less postoperative pain, less requirement for analgesics, and less pain at first bowel movement, while providing similar control of symptoms and need for additional hemorrhoid treatment at one-year follow-up from surgery.

Management of postoperative urinary retention: a randomized trial of in‐out versus overnight catheterization

Background: There has been no consensus on the best catheterization strategy for the management of postoperative urinary retention. A prospective randomized trial was undertaken to establish the best practice guidelines for the management of postoperative urinary retention. We also evaluated the contemporary incidence of urinary retention following different categories of general surgery and examined risk factors associated with its occurrence.Methods: All patients who underwent elective inpatient surgery between January 2002 and June 2003 were recruited in the study. Patients who developed postoperative urinary retention were randomized to either having in‐out catheterization or placement of an indwelling catheter for 24 h after surgery.Results: A total of 1448 patients were recruited. The overall incidence of urinary retention was 4.1% (n=60). Significant risk factors associated with postoperative urinary retention included old age, anorectal procedures and use of spinal anaesthesia. Comparison of re‐catheterization and urinary tract infection rates between patients who were treated with in‐out versus overnight catheterization showed no significant differences.Conclusions: Postoperative urinary retention should be managed by in‐out catheterization. Indwelling catheterization for 24 h appeared to bestow no additional benefits. The incidence of urinary retention increased with age, anorectal procedures and the use of spinal anaesthesia.

A modified technique using the Yankauer sucker and argon plasma coagulation for anorectal procedures.

Argon plasma coagulation (APC) is a useful and effective treatment for some anorectal conditions. We describe a modification of the APC instrumentation that aids the application of APC in such cases.

Lateral internal anal sphincterotomy for anal fissure: with or without associated anorectal procedures.

To confirm or refute the validity of the fear associated with anal sphincterotomy for anal fissure, particularly when performed with other anorectal procedures. Descriptive study. Surgical Wings - Medicare Hospital and Fatima Medical Center, Multan, over a period of 8 years from January 1994 to December 2001. Records of 112 anal fissure patients, 46 (41.0%) males and 66 (58.9%) females, ranging in age from 12-95 years (mean 39) were studied. All patients with acute or chronic anal fissures with or without other anorectal pathologies were included. Seventeen patients who had anal dilatation and 2 recurrent fissures were excluded. Open technique of anal sphincterotomy was employed in all cases. Results were recorded and analyzed. Fissures were acute in 16 (14.2 %) and chronic in 96 (85.7 %) patients. Anterior fissure was present in 20 (17.8%), posterior in 80 (71.4%), both in 9 (8.0%) and lateral or multiple fissures in 3 (2.6%) cases. Commonest associated pathology was haemorrhoids; encountered in 64 (57.1%) patients. Minor complications, taken together, occurred in 20 (17.8%) patients. Urinary retention was seen in 3 (2.6%) with lateral internal anal sphincterotomy (LIAS), and in 6 (5.3%) where haemorrhoidectomy was added. Haemorrhage in 2 (1.7%), temporary loss of flatus control in 3(2.6%) and soiling of clothes in 2 (1.7%) patients was encountered. No permanent loss of flatus or faecal control and recurrence has been reported to-date. Anal sphincterotomy with or without other anorectal procedures can be safely practiced in properly selected patients. Postoperatively, ablution with mild antiseptic added to plain water is adequate in maintaining hygiene to promote healing.

Transient Neurologic Syndrome in a Patient Receiving Hypobaric Lidocaine in the Prone Jack-Knife Position

Transient Neurologic Syndrome in a Patient Receiving Hypobaric Lidocaine in the Prone Jack-Knife Position

Laparoscopy-assisted loop ileostomy: an acceptable option for temporary fecal diversion after anorectal surgery.

Temporary fecal diversion may be desired after many anorectal procedures. The aim of this study was to describe a technique for laparoscopy-assisted creation of a loop ileostomy in patients undergoing anorectal and perineal surgery and to relate short-term outcomes. A retrospective review of the medical records of 53 consecutive patients who underwent laparoscopy-assisted creation of a loop ileostomy as an adjunct to anorectal or perineal surgery between 1993 and 1999 was performed. Data were obtained for age of the patient, previous abdominal surgical procedures, anorectal or perineal surgical procedure performed, American Society of Anesthesiology scores, operative times for both creation and takedown of the ileostomy, and postoperative return of bowel function. The average duration of operation for laparoscopy-assisted creation of the loop ileostomy was 47 (range, 28-75) minutes, with no conversions to laparotomy. All patients were able to tolerate a regular diet on the first postoperative day. Closure was accomplished 69 (range, 63-96) days later with an average operative time of 52 (range, 35-90) minutes. One patient developed ileus after takedown of his stoma. The other 52 patients were able to tolerate a regular diet by the second postoperative day. Laparoscopy-assisted creation of a loop ileostomy is an effective method for temporary fecal diversion in patients undergoing anorectal surgery.

Gastrointestinal disease following heart transplantation.

With advances in heart transplantation, a growing number of recipients are at risk of developing gastrointestinal disease. We reviewed our experience with gastrointestinal disease in 92 patients undergoing 93 heart transplants. All had follow-up, with the median time 4.8 years (range 0.5-9.6 years). During the period of the study we progressively adopted a policy of low immunosuppression aiming toward monotherapy with cyclosporine. Nineteen patients (20.6%) developed 28 diseases related to the gastrointestinal tract. Thirteen patients required 18 surgical interventions, five as emergencies: closure of a duodenal ulcer, five cholecystectomies (one with biliary tract drainage), a sigmoid resection for a diverticulitis with a colovesical fistula, a colostomy followed by a colostomy takedown for an iatrogenic colon perforation, appendectomy, two anorectal procedures, and six abdominal wall herniorrhaphies. At the onset of gastrointestinal disease, 8 patients were on standard triple-drug immunosuppression, all of them within 6 months of transplantation; 13 were on double-drug immunosuppression; and 7 were on cyclosporine alone. All the patients with perforations/fistulas were on steroids. Among the 11 infectious or potentially infectious diseases, 10 were on triple- or double-drug immunosuppression. One death, a patient who was on triple-drug immunosuppression, had a postmortem diagnosis of necrotic and hemorrhagic pancreatitis. Except for an incisional hernia following a laparoscopic cholecystectomy, there was no morbidity and, importantly, no septic complications. We concluded that a low immunosuppression policy is likely to be responsible for the low morbidity and mortality of posttransplant gastrointestinal disease, with a lower incidence of viscous perforation/fistula and infectious gastrointestinal disease.

Laparoscopic stoma technique

Laparoscopic stoma creation may be performed as an independent intervention, in combination with local anorectal procedures or as a part of complex laparoscopic intestinal operations. With the exception of specialized methods to preserve continence, every type of stoma formation can be performed laparoscopically. Indications for laparoscopic fecal diversion do not differ from open surgery. Apparent advantages are the limitation of the laparotomy to the location of the stoma, rapid return of bowel function and less postoperative discomfort and morbidity, especially when intestinal diversion is required as an independent procedure. Previous surgery is not a contraindication for the laparoscopic procedure. However, dense adhesions may compromise the ability to identify the bowel segment to be exteriorized and require adhesiolysis. Therefore, the risk of intra- and postoperative complications and the frequency of conversions (reported between 4.1 and 15.7%) is increased in patients with previous surgery. The overall rate of complications reviewed in the literature, including stoma-related problems, seems to be similar or superior to conventional laparotomy. Still, laparoscopic enterostomies are not routinely performed in most institutions. Presently available data are limited and randomized trials have not been performed. We recommend the use of laparoscopic techniques for fecal diversion in patients with intestinal obstruction requiring palliative treatment and in patients with high probability for future abdominal surgery, e.g. in Crohn's disease.

Hook-needle puncture. A new technique of local anesthesia for anorectal surgery.

Anorectal surgery has been increasingly performed as an ambulatory procedure using general, regional, and local anesthesia. Local anesthesia is classically performed through infiltration of four quadrants around the anal verge, which renders the procedure painful and uncomfortable for most surgeons and patients. We present a new, painless technique of local anesthesia for anorectal surgery. Patients with surgical risk Classes I and II (American Society of Anesthesiologists) bearing anorectal pathologies were sedated and placed on the operating table in the prone jackknife position. After local antisepsis, the anal canal was lubricated with 2 percent lidocaine gel, and the mucosa was punctured by a hook-shaped, curved, 22-gauge needle just above the pectinate line. A solution of local anesthetics was slowly infused in all four quadrants to the submucosal level. If needed, more anesthetics were infused during the operation. This technique was easily and painlessly applied in more than 60 patients and permitted execution of several ambulatory anorectal procedures with comfort and safety. The hook-needle puncture for local anesthesia is an effective and safe procedure and may be routinely used for ambulatory anorectal surgery in selected patients.

Anal fissure in Crohn's disease

This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease. This is a retrospective review of patients with Crohn's disease and anal fissure. Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P = 0.05) or after abnormal surgery (29 percent; P = 0.03). This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

Colorectal operative experience. Results of a survey.

This study was designed to document the operative colorectal experience of members and fellows of The American Society of Colon and Rectal Surgeons. A mail survey of 900 members and fellows of The American Society of Colon and Rectal Surgeons was conducted. One hundred eighty questionnaires (20 percent) were returned; however, 25 respondents had retired or lacked accurate operative data. The remaining 155 surgeons averaged 49 (range, 35-83) years in age and had been in practice an average of 14.7 (range, 2-51) years. The respondents performed a median of 135 and a mean of 177 anorectal procedures per year (range, 20-1,471) and a median of 67 and a mean of 79 abdominal colorectal procedures (range, 6-443). Operative hemorrhoidectomy was the most common anorectal procedure (median, 25; mean, 47/year), while partial colectomy was the most common abdominal procedure (median, 18; mean, 26). The number of anorectal procedures correlated directly with the respondents' time in practice, and the number of abdominal procedures peaked between the tenth and fifteenth years. Despite the limitations associated with this type of study, the information is useful in assessing practice patterns and experience level.

Anorectal manometry: techniques and clinical applications.

Anorectal manometry has gained wide acceptance as a helpful method to objectively assess the apparatus of defecation provided by the anorectal sphincter. The standard manometric evaluation enables measurement of resting and squeeze pressures, as well as of the length of the functional anal canal (high pressure zone [HPZ]). More detailed assessment of radial and longitudinal pressure profiles can also be generated from vector volume and vector symmetry index assessment. Adjuvant techniques using an intrarectal balloon allow assessment of the rectoanal inhibitory reflex (RAIR), rectal sensitivity, capacity, and compliance. Although anorectal manometry can be used as a diagnostic test in diseases such as Hirschsprung's disease, more often it is used to assess common disorders such as chronic idiopathic constipation and fecal incontinence. Anorectal manometry has also been considered as a preoperative evaluation in patients having abdominal and anorectal procedures during which the state of continence can be jeopardized.

Do general surgery residency programs adequately train surgeons to perform anorectal surgery?

The management of anorectal disease remains a major component in the practice of the general surgeon. To assess the adequacy of general surgery residencies in addressing this educational need, data were obtained from the Residency Review Committee (RRC) for surgery on the anorectal experience of all graduating residents in accredited United States programs for a recent five-year period (1987-1991). The mean number of anorectal procedures in which a resident participated throughout the residency was 30.0. This is then further subdivided by type of procedure. It is concluded that general surgery residency programs tend to provide an inadequate training experience in anorectal surgery.

A regional audit of the investigation and treatment of colorectal and pelvic floor disorders (1984?1991)

The activities of a regional physiology unit established for the investigation of colorectal and pelvic floor physiology in health and disease in a clinically relevant setting has been audited and its evolution described over a period of eight years. Trends in surgical treatment of some of these disorders over the same period have also been documented in the Lothian Region. Although there has been little change in the number of patients investigated annually patterns of investigation appear to change. Sphincter manometry, proctometrography and somatosensory reflex measurements have remained the most frequently performed and useful investigations. Spinal stimulation studies increased transiently because of a collaborative investigation of bowel and bladder function in patients with spinal injuries. A considerable increase in surface EMG tests and dynamic proctography has occurred. These trends are thought to be related to interest in defining evacuation dysfunction of the rectum and related problems of the pelvic floor. Isotope proctography now rivals barium videoproctography; at the same time the use of manometric colonic motility studies has diminished. Anal ultrasonography has replaced sphincter mapping in the last year and is being applied to other aspects of anorectal pathology. The last 4 years have seen the introduction and increasing use of non-surgical therapeutic modalities for the treatment of faecal incontinence and constipation: reflex electronic sphincter stimulation, biofeedback and the use of a prokinetic agent to promote colonic motility. Concomitant changes in the surgery of constipation and reconstructive anorectal procedures have been observed. It is recommended that coloproctology units should have easy access to at least one such investigation laboratory within their catchment area together with appropriate auditing facilities.

Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management

Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception because of the need for parenteral narcotics postoperatively. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient posthemorrhoidectomy pain control. In Phase 1 of our study, 22 patients undergoing radical hemorrhoidectomy were started on an SQMP protocol postoperatively. Twenty-nine patients received conventional postoperative narcotic dosing. In Phase 2, 19 patients enrolled in an SQMP protocol underwent hemorrhoidectomy in an ambulatory setting. Length of hospitalization, catheterization rate, and pain control were evaluated. In Phase 1, zero patients in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rates of catheterization were similar between the two groups. Pain control was considered satisfactory in 21 of 22 study patients. There was no correlation between pain level and morphine dose. Eighteen of 22 patients experienced minor side effects, necessitating pump removal in two patients. In Phase 2, 18 of 19 patients on the SQMP were discharged from the recovery room. Cost analysis shows the combination of outpatient hemorrhoidectomy and the SQMP to be cost-effective in comparison with an inpatient stay. The SQMP enables hemorrhoidectomy to be done on an outpatient basis. It provides effective pain control, enjoys high patient acceptance, and is cost-effective.

Use of Toradol in anorectal surgery.

Toradol (ketorolac tromethamine; Syntex Labs, Palo Alto, CA) is a nonsteroidal anti-inflammatory drug introduced for intramuscular injection to control postoperative pain. Its action is peripheral. Therefore, it seemed appropriate to inject it directly into the anal sphincter muscles when these are exposed during anorectal procedures. A total of 60 mg (2 cc) are used, divided among the quadrants resected. Four hours postoperatively, 30 mg are given intramuscularly, and the patient is discharged. Any patient who required medication stronger than Darvocet-N-100 (propoxyphene napsylate and acetaminophen; Eli Lilly and Co., Indianapolis, IN) for pain was considered a failure. Seventeen of 100 patients (17 percent) failed to have their pain controlled. Unexpectedly, only two patients (2 percent) needed catheterization for urinary retention. The usual incidence is 20 to 30 percent. To date we have seen none of the complications associated with the use of anti-inflammatory drugs.

DAY CASE ANORECTAL SURGERY

All patients referred to the University Department of Surgery, Wellington Hospital, Wellington, New Zealand, with minor anorectal conditions requiring surgery were considered for day case surgery. Eighty-three per cent of the patients were found suitable for day surgery. One hundred patients underwent 103 procedures under general anaesthesia. Admission to hospital from the day care facility was required for four patients; two for bleeding, one for pain and one for drowsiness. One patient required readmission due to inability to cope at home. Twenty-six per cent reported severe pain. Eighty-nine per cent found day surgery to be convenient and preferable to inpatient surgery. Eleven per cent found day surgery inconvenient and would prefer inpatient surgery in future. It is suggested that many anorectal procedures can be performed on a day case basis in selected patients, with safety and convenience. It is well tolerated and accepted.

An effective self-retaining retractor for anorectal procedures

A self-retaining retractor technique is described for anorectal surgery eliminating many of the problems inherent in the commonly used instruments. It is particularly useful in endorectal pull-through procedures in which the exact level of anastamosis within the anorectal canal is of great importance.

The effect of local anaesthetics on epinephrine absorption following rectal mucosal infiltration.

This study was undertaken to investigate the effects of lidocaine and bupivacaine on epinephrine absorption following rectal mucosal infiltration, to assess the cardiovascular and metabolic effects of the absorbed epinephrine and to compare the systemic absorption of the local anaesthetics employed. Three groups of five greyhounds received 1.5 micrograms.kg-1 of epinephrine 1:200,000 in lidocaine 0.5 per cent, bupivacaine 0.5 per cent or 0.9 per cent saline. Plasma epinephrine, lidocaine, bupivacaine, lactate, glucose and potassium concentrations were measured at 1, 2, 5, 10, 15 and 30 minutes following infiltration. Plasma epinephrine concentrations were significantly higher in the lidocaine group at one and two minutes following infiltration. Plasma bupivacaine concentrations were significantly higher than plasma lidocaine concentrations throughout the study period. There were no significant differences in metabolic or biochemical indices within or between the three groups. A local vasodilatory action of lidocaine may enhance epinephrine absorption. Differences in hepatic uptake and rate of metabolism may explain the increased plasma bupivacaine measured. Lidocaine may be the local anaesthetic of choice for ano-rectal procedures, especially when large volumes of local anaesthetic are being infiltrated.

The emerging pattern of pediatric day-care surgery

The utilization of short stay surgical facilities is increasing and indications for day-care surgery for children are becoming more diverse. These trends were observed in a review of day-care surgery performed at British Columbia Children's Hospital during the years 1982 to 1986. During 1984 and 1985, 688 hernia repairs were undertaken, as were 76 anorectal procedures such as anal fistulotomy, drainage of abscesses, etc. In addition, 127 orchidopexies were performed, which indicated a 40% increase when compared with earlier years. Further procedures included the excision of 38 branchial cleft anomalies and 17 salivary gland lesions, as well as the performance of 95 tracheobronchial endoscopies including the removal of 25 foreign bodies. Head and neck and endoscopic procedures now represent 21% of all general surgery day care cases, and have increased by 50% since 1982. Thirty-six children (1.6%) initially brought in for day care surgery required actual admission to the hospital for such reasons as (1) the procedure being more complex than initially anticipated (15 patients); (2) hemorrhage (5 patients); or (3) postanesthetic concern (11 patients). Two thirds of the anesthetic complications were in infants less than 3 months of age. A special subgroup of high-risk infants were identified--the previous premature less than 52 weeks conceptual age. In our opinion, infants who are less than 3 months of age, especially if born prematurely, should be admitted to the hospital for surgery.