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LOCAL ANESTHESIA VERSUS SPINAL ANESTHESIA FOR HEMORRHOIDECTOMY Hassan E.A. Younes*, Yasser H. Metwally*, Ahmad Fathy El-Hussainy, Mohamed Elshahat Elsayed** and Mahmoud S. Ahmad*** *Department of General Surgery, Faculty of Medicine, Al-Azhar University. **Department of Anesthesia, Faculty of Medicine, Al-Azhar University. ***Department of General Surgery, Faculty of Medicine, Aswan University. ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Objectives: To evaluate the feasibility of hemorrhoidectomy under local anesthesia and compare this with spinal anesthesia. Patients and Methods: A prospective randomized study was carried out in the Department of surgery Al- Hussein hospital, Al-Azhar University. A total of 70 patients, who were diagnosed as grade III and IV hemorrhoids and underwent hemorrhoidectomy were included in this study, patients were randomized into two groups 35 patient each. Group A underwent surgery under Local anesthesia (mixture of bupivacaine and lidocaine with adrenaline) with IV sedation given to facilitate injection of local anesthesia. Group B had hemorrhoidectomy under spinal anesthesia. Results: Mean pain scores were similar in both groups at 1,2,4 & 12 hrs except at 6 hrs the pain scores in the LA group were significantly lower than SA group (P<0.05), postoperative urine retention, headache and hypotension was significantly lower in LA group than SA group (P<0.05). There was non-significant difference between both groups as regarding operative time, failure rate, postoperative bleeding, postoperative infection, and delayed wound healing. Conclusion: local anesthesia for hemorrhoidectomy with IV sedation is a safe technique and should be considered as an alternative to regional anesthesia as it provides more postoperative analgesia with lower pain scores, no hypotension headache or urine retention.
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SUPLL - 2 Key Words: Hemorrhoidectomy, Local anesthesia, Spinal anesthesia. INTRODUCTION Hemorrhoids or piles are a common ailment among adults. More than half of men and women aged 50 years and older will develop hemorrhoid symptoms during their lifetime [1]. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions [2]. Clinically hemorrhoidal disease had classified into four grades. Open hemorrhoidectomy is the most commonly used technique and widely considered to be the most effective treatment for grade III and IV hemorrhoids[3]. The method was developed in 1937, by surgeons Milligan and Morgan in the UK [4]. Excisional hemorrhoidectomy including the Milligan-Morgan technique and its modification is traditionally viewed as a painful procedure [5]. In an attempt to reduce postoperative pain several procedures were developed as limited incisions, suturing the vascular pedicle without incisions, stapled hemorrhoidectomy. Today, various medications have been studied for postoperative analgesia as suppositories, local anesthesia, or oral preparations [6]. Local anesthesia was tried to decrease postoperative pain after hemorrhoidal surgery under general anesthesia or as the only anesthesia for hemorrhoidectomy [7,8]. The advantages of local anesthesia include postoperative analgesia, early recovery and early discharge, the major problem in performing hemorrhoidectomy under local anesthesia is severe pain that occurred during injection of the local anesthetic through the sensitive anoderm [9, 10]. On the other hand general or spinal anesthesia have their complications, need preoperative preparation and require postoperative hospitalization for observation till complete recovery.
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The aim of this study is to assess the feasibility of open hemorrhoidectomy under local infiltration anesthesia; IV sedation was given to facilitate injection of the local anesthetic, and compare this technique with spinal anesthesia. PATIENTS AND METHODS A prospective study was carried out in the Department of surgery Al- Hussein hospital, Al-Azhar University; Cairo, Egypt; From August 2012 to January 2014. A total of 70 patients diagnosed clinically as third and fourth degree piles and underwent conventional hemorrhoidectomy were included in the study. Patients were randomized into two groups 35 patient each; Group A had surgery under local anesthesia with IV sedation; Group B underwent surgery under spinal anesthesia. Inclusion Criteria: Patients with third and fourth degree hemorrhoids. Exclusion Criteria: Patients with bleeding tendencies, or on anticoagulant therapy. Patients with history of anorectal operations. Patients with associated anorectal problems. (Fissures, fistulas…..etc.) Patients with the diagnosis of first and second degree piles who were given medical treatment or other non-operative measures. All patients were subjected to: I-Preoperative evaluation: 1- Full history taking: Detailed history including personal data, presenting symptoms (bleeding, prolapse, pain & pruritus ani). History of chronic illness (DM. HTN, Heart disease…..etc) previous operations, medications, allergy or blood transfusion. 2- Clinical examination: For detection of hemorrhoids, it’s grading, complications and presence of other associated anorectal diseases. 3- Investigations:
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Coagulation profile for all patients. Preoperative investigations as needed according to patients' condition. Colonoscopy in selected patients. II- Operation: Conventional diathermy hemorrhoidectomy. Sedation: IV midazolam (0.05mg/ kg) and fentanyl (1mcg/ kg) Local anesthesia: A 30 ml mixture of local anesthetic (10 ml lidocaine hydrochloride 2 % with adrenaline, 10 ml bupivacaine hydrochloride 0.5 % and 10 ml normal saline to increase the volume for injection) was injected as follows: 5-7 ml were injected in each side into the intersphincteric plane at 3& 9 clock positions for pudendal nerve block introducing the needle at the mucocutaneous junction anterolaterally, the remaining amount in the subcutaneous and submucosal tissues at the anal verge. Relaxation of the anal sphincter was noticed. After this, the procedure was performed by the standard diathermy hemorrhoidectomy in lithotomy position. III-Postoperative: All patients were observed in the surgical ward. Pain scores were evaluated using Numerical rating scale (NRS)at 1,2,4,6 & 12 hours postoperatively (a scale of 0 to 10 was used, the patient was instructed to encircle the appropriate number that best describes his/her current pain where 0 indicated no pain and 10 the worst pain ever experienced) [11]. Occurrence of urine retention, hypotension, headache or other complications was recorded. Analgesics were given according to patient need. Discharge in the same or next day with follow up at outpatient clinic after 1,2,4 and 6 weeks and after three months. Statistical Analysis: Standard methods using SPSS version 19 for statistical analysis, Chi-square was used in appropriate situation. P value ≤ 0.05 is considered the level of significance.
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RESULTS Preoperative data: (Table: 1) Age & sex: Among the 70 patients included in this study 48 (68.7%) were males and 22 (31.3%) were females. The age of patients' ranges from 18 to 56 years with mean of age was (35.3 ± 9.1) years. There was no significant difference between the groups as regarding age and sex. Clinical Diagnosis: It was found that of 70 patients underwent hemorrhoidectomy 38 (54.3%) had 3rd degree and 32 (45.7%) patients had 4th degree piles. Table (1): Preoperative data: LA group SA group P value Males (48) 22 26 Sex 0.43 Females (22) 13 9 Mean 34.6 (± 8.9) 36.1 (± 9.3) Age 0.68 Range (18 - 54) (19 - 56) Piles 3rd degree (38) 20 18 0.63 degree 4th degree (32) 15 17 Operative data: Table (2) Failure rate: The operation had to be completed under general anesthesia in two patients (5.72%) in LA group and one patient (2.86%) in SA group. These three patients were excluded from the postoperative data analysis. Operative time: The mean operative time in LA group was (23.5 ± 7.1 min.) while in SA group was (21.3 ± 5.4 min.) Table (2): Operative data: LA group SA group P value Need for general 2/ 35 (5.72%) 1/ 35 (2.86%) 0.55 anesthesia Operative Mean (23.5 ± 7.1 min.) (21.3 ± 5.4 min.) 0.15 time Range (14 - 43) (13 - 39)
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SUPLL - 2 Post operative pain (Table: 3): In the operative day the pain as determined by NRS at 1,2,4,6 and 12 hours after the operation. Pain scores were similar in both groups. Except at 6 h where pain scores were significantly lower in LA group. Table (3): Postoperative pain scores: LA group SA group Pain score P value Mean range Mean range 1st hour 0.6 (0-4) 0.2 (0-4) 0.07 2nd hour 0.94 (0-4) 1.2 (0-5) 0.41 4th hour 2.1 (0-5) 2.4 (0-7) 0.46 6th hour 2.3 (0-7) 3.3 (0-8) 0.02* 12th hour 2.0 (0-4) 2.6 (0-4) 0.13 Postoperative complications: (Table: 4) Urine retention, headache and hypotension: No cases in the LA group had postoperative urine retention, headache or hypotension, while in SA group 4 patients had urine retention need catheterization, 8 patients had postoperative headache and 9 patients had postoperative hypotension. These differences were significant (P<0.05). Postoperative bleeding, infection and wound healing: No cases had primary or reactionary hemorrhage in both groups but 7 patients in LA group and 6 patients in SA group had minor bleeding in the first week managed conservatively. No deep wound infection occurred in both groups. Delayed wound healing (more than 6 weeks) occurred in one patient in LA group and 2 patients in SA group. There was no significant difference between the two groups. Table (4): Postoperative complications: LA group (33 pts.) SA group (34 pts.) P value Urine retention 0 4 (11.7%) 0.039* Headache 0 8 (23.5%) 0.003* Hypotension 0 9 (26.5%) 0.001* Bleeding 7 (21.2%) 6 (17.6%) 0.71 Deep infection 0 0 Delayed healing 1 (3%) 2 (5.9%) 0.57
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DISCUSSION Conventional hemorrhoidectomy as first described by Milligan and Morgan is still the most widely used and effective treatment for patients with third and fourth degree hemorrhoids. However, it associated with significant postoperative pain [12]. Control of pain after hemorrhoidectomy is of major importance, various medications were tried to improve pain as anal sphincter relaxants, injecting local anesthetics, anxiolytics, and parasympathomimetics [6]. Recent trials have shown the use of local anesthetic as the sole anesthetic method for anal operations [8-10]; a major disadvantage was severe pain on needle injection. In the current study we use IV sedation to avoid this problem. Among the 70 patients included in this study, the age of patients' ranges from 18 to 56 years with mean of age was (35.3 ± 9.1) years. 68.7% of patients were males and 31.3% were females. 38 patients (54.3%) had 3rd degree and 32 (45.7%) had 4th degree piles. Failure rate: The operation had to be completed under general anesthesia in one patient (2.86%) in SA group and two patients (5.7%) in LA group (non- significant difference). This was close to a study conducted by Alatise and his colleagues where failure rate was 4.5% with local anesthesia [13]. Operative time: The mean operative time in LA group was (23.5 ± 7.1 min.) while in SA group was (21.3 ± 5.4 min.) this was comparable to the results of the study provided by Ho and his colleagues when comparing local with general anesthesia for hemorrhoidectomy had operative time comparable with that time (16 ± 4 min.) for local anesthesia [9]. Postoperative pain: In the operative day the pain (determined by NRS at 1,2,4,6 and 12 hours after the operation) pain scores was similar in both groups except at 6 hrs where pain scores were significantly lower in LA group than SA
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group. These results were close to the results of Bansal et al; they found that: LA group has a significantly lower pain score at 6 hours [14]. No cases in the LA group had postoperative urine retention, headache or hypotension, while in SA group 4 patients had postoperative urine retention need catheterization, 8 patients had postoperative headache and 9 patients had postoperative hypotension from a total of 34 patients. This was a statistically significant difference. These results were agree with the results found by Bansal and his colleagues; In their study 36% of patients had urine retention, 24% had headache & 16% had hypotension [14]. CONCLUSION Local anesthesia for hemorrhoidectomy with IV sedation is a safe technique and should be considered an alternative to regional anesthesia as it provides more postoperative analgesia with lower pain scores, no hypotension, and headache or urine retention. This study supports the feasibility of anal operations under local anesthesia.
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REFERENCES
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3- Mastakov MY, Buettner PG and Ho Y-H (2008): Updated meta-analysis of randomized controlled trials comparing conventional excisional hemorrhoidectomy with Ligasure for hemorrhoids. Tech Coloproctol. September; 12(3): 229–239.
4- Milligan ETC, Morgan CN, Jones LE and Officer R. (1937): Surgical anatomy of the anal canal and the operative treatment of hemorrhoids. Lancet; 2: 1119-1124.
5- Bessa S. (2008): Ligasure vs. conventional diathermy in excisional hemorrhoidectomy: a prospective, randomized study. Dis Colon Rectum; 51(6):940–944.
6- Cintron JR and Abcarian H (2007): Benign Anorectal conditions: Hemorrhoids; In: Wolff BG, Fleshman JW, Beck DE et al. (Eds); The ASCRS Textbook of Colon and Rectal Surgery. (Springer Science-Business Media, New York, USA), chapter 11.
7- Luck AJ and Hewett PJ (2000): Ischiorectal fossa block decreases post- hemorrhoidectomy pain: randomized, prospective, double-blind clinical trial. Dis Colon Rectum; 43:142-5.
8- Delikoukos S and Gikas D (2007): The role of local anesthesia in ambulatory anal surgery. Ambulatory surgery 133; 64-66.
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9- Ho KS, Eu KW, Heah SM, Seow- Choen F and Chan YW (2000): Randomized clinical trial of hemorrhoidectomy under a mixture of local anesthesia versus general anesthesia. British J Surg. 87: 410-413.
10- Park SJ, Choi SI, Lee SH and Lee KY (2010): Local perianal block in anal surgery: The disadvantage of pain during Injection despite high patient satisfaction. J Korean Surg Soc; 78:106-110.
11- Hartrick CT, Kovan JP and Shapiro S (2010): The numeric rating scale for clinical pain measurement: A ratio measure? Journal compilation, pain practice, world institute of pain. Volume 3 Issue 4, Pages; 310 - 316.
12- Jayne DG, Botterill I, Ambrose NS et al (2002): Randomized clinical trial of Ligasure versus conventional diathermy for day-case hemorrhoidectomy. Br J Surg 89:428-32.
13- Alatise OI, Agbakwurul AE, Takure AO, Adisa AO and Akinkuolie AA. (2010): Open hemorrhoidectomy under local anesthesia for symptomatic hemorrhoids; our experience in Ile –Ife, Nigeria. Afr J Health Sci; 17:42-46.
14- Bansal H, Jenaw RK, Mandia R and Yadav R (2012): How to do open hemorrhoidectomy under local anesthesia and its comparison with spinal anesthesia. Indian J Surg; 74(4):330–333.
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هقبرًة بيي إستخذام التخذير الووضعى و التخذير الٌصفى فى عوليبت استئصبل البواسير حسي السيذ يوًس*، يبسر حسيي هتولى*، أحوذ فتحى الحسيٌى*، ، هحوذ الشحبت السيذ** وهحوود صالح أحوذ*** قسن الجراحة العبهة *و قسن التخذير **- كلية الطب - جبهعة االزهر قسن الجراحة العبهة - كلية الطب – جبهعة أسواى*** ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ رهذف هزِ انذساسخ انً رمييى ايكبَيخ اسزئصبل انجىاسيش انششجيخ رحذ انًخذس انًىظعً و يمبسَخ رنك يع اسزخذاو انزخذيش انُصفً. و لذ رى اجشاء هزِ انذساسخ عهً 70 يشيعب ثبنجىاسيشانششجيخ يٍ انذسجخ انضبنضخ و انشاثعخ فً لسى انجشاحخ انعبيخ ثًسزشفً انحسيٍ - جبيعخ االصهش ثبنمبهشح فً انفزشح يٍ اغسطس 2012 و حزً يُبيش 2014، حيش رى رمسيى انًشظً انً يجًىعزيٍ )أ و ة ( رشًم كم يجًىعخ 35 يشيعب و لذ رى اسزئصبل انجىاسيش فً انًجًىعخ االونً )أ( رحذ انًخذس انًىظعً )خهيػ يٍ يبدح ثىثيفبكبييٍ و يبدح نيذوكبييٍ و االدسيُبنيٍ( يع حمٍ وسيذي نًبدرً ييذاصوالو و فيُزبَيم نزهذئخ انًشيط اصُبء حمٍ انًخذس انًىظعً ثيًُب رى اجشاء انجشاحخ فً انًجًىعخ انضبَيخ ثبسزخذاو انزخذيش انُصفً. الٌتبئج: كبٌ االحسبس وثبالل يزشبثهب فً انًجًىعزيٍ عُذ انسبعخ االونً و انضبَيخ و انشاثعخ و انضبَيخ عشش ثعذ انعًهيخ ونكٍ وجذ فبسق احصبئً فً دسجخ االنى عُذ انسبعخ انسبدسخ ثعذ انعًهيخ حيش كبٌ الم فً يشظً انًجًىعخ االونً،كزنك كبٌ يعذل حذوس االحزجبس انجىنً و انصذاع و اَخفبض ظغػ انذو الم ثذسجخ راد دالنخ احصبئيخ فً انًجًىعخ االونً عٍ انضبَيخ، ثيًُب نى رىجذ فشوق راد دالنخ احصبئيخ ثيٍ انًجًىعزيٍ فيًب يزعهك ثبنىلذ انالصو الجشاء انعًهيخ و يعذل فشم َىع - انزخذيشانًىظعً او انُصفً - و االحزيبط انً انًخذس انعبو السزكًبل انعًهيخ و كزنك َسجخ حذوس انٍ صيف و عذوي انجشوح او رأخش انزئبيهب ثعذ انعًهيخ. االستٌتبج: يعزجش اسزخذاو انزخذيش انًىظعً فً عًهيبد اسزئصبل انجىاسيش انششجيخ غشيمخ أيُخ و فعبنخ كجذيم نهزخذيش انُصفً ورنك نعذو حذوس يعبعفبد يضم االحزجبس انجىنً و انصذاع او اَخفبض ظغػ انذو وانزً رصبحت انزخذيش انُصفً.
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