Local anesthesia for stapled prolapsectomy in day surgery: results of a prospective trial

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.

Randomized sham-controlled trial of acupuncture for postoperative pain control after stapled haemorrhoidopexy

AIM

Haemorrhoidectomy usually causes moderate to strong postoperative pain. Chinese studies have found that acupuncture may have an analgesic effect in posthaemorrhoidectomy patients. This is the first Western study aiming assess the efficacy of acupuncture as an adjunct analgesic therapy after stapled haemorrhoidopexy.

METHOD

In a randomized controlled trial, 50 patients were allocated to three groups. Conventional drug therapy (oral diclofenac and metamizol, local lidocaine) served as baseline analgesia. In the control group (n = 17) only this regimen was used. In addition to baseline analgesia, 17 patients received verum acupuncture. Sham acupuncture was performed on 16 patients. Being the primary outcome measure, pain was measured twice daily using the numerical rating scale (NRS) and compared statistically by repeated-measures analysis of variance. The study was registered (DRKS00003116). Results  After verum acupuncture, pain intensity was not significantly lower when compared with conventional analgesia (primary hypothesis, P = 0.057), but was when compared to sham acupuncture (P = 0.007). In the afternoon of postoperative day 1, for example, NRS was 2.7 (SD 1.5) in the verum group, but 4.0 (1.0) in the sham group and 4.1 (1.9) under conventional analgesia. Furthermore, significantly fewer rescue analgesics were necessary if verum acupuncture was applied. Cardiovascular parameters were stable in all three groups, and no complications were recorded.

CONCLUSIONS

In posthaemorrhoidectomy patients, acupuncture appears to be an effective adjunct to conventional analgesia. Further studies are necessary to confirm these observations and to refine the acupuncture technique.

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.

Postoperative voiding criteria for ambulatory surgery patients

The number and types of surgeries being performed in ambulatory surgery facilities have increased during the past several years. Many surgeries that were once performed on an inpatient basis routinely occur in outpatient settings today. Patients are required to meet certain discharge requirements and, occasionally, voiding is included in this criteria. Requiring patients to void postoperatively, however, can unnecessarily delay a patient's discharge and contribute to increased anxiety for the patient. This article provides a case study with discussion, a literature review regarding postoperative voiding and urinary retention in ambulatory surgery, and recommendations for future research regarding postoperative voiding criteria for low-risk outpatients.