Symposium Hemorrhoidectomy--How I Do It: C o m p l i c a t i o n s of C l o s e d H e m o r r h o i d e c t o m y LEANDRE I. BAUTISTA,
M.D.*
Ionia, Michigan
PATIENTS who have hemorrhoidal disease come to the clinic nearest to home. The community hospital provides an opportunity to evaluate the complications following surgical hemorrhoidectomy and their management. A proctologic work-up1 at our hospital consists of a history and physical examination.l-3 proctosigmoidoscopy, and a bariumenema examination. 1-~, 6 The technique of complete closed hemorrhoidectomy, using local infiltration anesthesia with 80 ml of 0.5 per cent lidocaine supplemented with light general anesthesia, is used to treat hemorrhoids. Materials
From January 1973 to September 1975, 232 cases were selected for this study (Table
TABLE 1. Sex Distribution Patients Number Male
104
45
Female
128
55
232
100
TOTAL
TABLE 2.
Age Distribution Patients Number
Per Cent
1-20 years
9
4
21-50years
158
68
51-80 years TOTAL
1). The preoperative findings, surgical procedures, and postoperative complications were tabulated. Preoperative Findings: There were 104 (45 per cent) male, and 128 (55 per cent) female patients in the series. The youngest was 8 years old and the oldest, 77 years old (Table 2). The most common symptoms found 3 were bleeding (87 per cent), pain (92 per cent), and mucosal prolapse (80 per cent). Constipation (13 per cent) and diarrhea (7 per cent) were not uncommon in the older patients, while anal pruritus (21 per cent) and burning (30 per
Per Cent
65
28
232
100
cent) were more' prevalent in the anxious patients (Table 3). There were 51 patients (22 per cent) who had thrombosis; other anal pathologic symptoms encountered were anal ulcers in 66 patients (28 per cent), anal fistulas in 43 patients (18 per cent), polyps in 12 patients (5 per cent), and anal condylomas in six (2 per cent). Two or more of the above-mentioned findings were present in the same patient (Table 4). Surgical Treatment: Closed hemorrhoidectomy as described by Ferguson et al. 1-a was used. One to five radical incisions were
* Ionia Medical Center, 910 E. Lincoln Avenue, Ionia, Michigan 48846.
183 Dis. Col. &Rect. April, 1977
Volume 20 Number 3
Dis. Col. & Reef.
BAUTISTA
184 TABLE 3. Symptoms and Duration Patients
Symptom Bleeding Pain Mucosal prolapse Constipation Diarrhea Anal and para-anal pruritus Duration of symptoms 1 day-1 month I-6 months 6 months-5 years
Number
Per Cent
202 213 186 29 16
87 92 80 13 7
49
21
161 37 34
69 16 15
TABLE 4. Proctologic Findings Patients
Anal ulcer Anal fistula Rectal and rectosigmoidal polyp Anal condyloma acumina turn Severe thrombosis
Number
Per Cent
66 43
28 18
12
5
6 51
2 22
TABLE 5. Incisions Used in Closed Hemorrhoidectomy
April, 1977
C o m p l i c a t i o n s : P o s t o p e r a t i v e l y , the con> p l i c a t i o n s e n c o u n t e r e d were v o i d i n g difficulties, u r i n a r y cystitis, s l i g h t to severe b l e e d i n g , stool i m p a c t i o n s , a n d abscess form a t i o n ( T a b l e 7).3-s Difficulty i n v o i d i n g n e c e s s i t a t i n g catheteri z a t i o n was e x p e r i e n c e d b y 40 p a t i e n t s (17 p e r cent). T h i r t y - o n e (13 p e r cent) of these 40 p a t i e n t s also h a d u r i n a r y cystitis w i t h pus cells a n d b a c t e r i u r i a ; t e n of t h e m (4 p e r cent) h a d p r e - e x i s t i n g b a c t e r i u r i a . T w e n t y - f i v e (11 p e r cent) of t h e 40 p a t i e n t s were c a t h e t e r i z e d once, w h i l e 15 (6 p e r cent) n e e d e d a F o l e y c a t h e t e r for o n e to two days. T h e necessity for c a t h e t e r i z a t i o n was significantly d i m i n i s h e d b y w a i t i n g u n t i l the p a t i e n t was o b s e r v e d to have dist e n t i o n of the u r i n a r y b l a d d e r . A r o u t i n e p o s t o p e r a t i v e o r d e r to c a t h e t e r i z e the pat i e n t was deleted. Slight b l e e d i n g was t r e a t e d c o n s e r v a t i v e l y in two p a t i e n t s (.8
TABLE 6. Other Surgical Procedures Patients
Anal ulcerectomy Fistulectomy Polypectomy Subcutaneous neurotomy (cloverleaf operation) Superficial external anal sphincterotomy
Number
Per Cent
66 43 12
28 18 5
15
6
.59
25
Patients
Incisions, Number
Number
Per Cent
2 3 4
7 123 94
8 53 41
5
8
3
m a d e in the a n o r e c t a l c a n a l w i t h preservat i o n of the i n t e r v e n i n g mucosal islands. T a b l e 5 shows the n u m b e r s of incisions. T a b l e 6 shows o t h e r surgical p r o c e d u r e s p e r f o r m e d w i t h the h e m o r r h o i d e c t o m i e s .
TABLE 7. Postoperative Complications Patients
Voiding difficulty; urinary cystitis Minimal bleeding Severe bleeding necessitating surgical treatment Stool impaction Perianal abscess Acute bronchitis
Number
Per Cent
40 2
17 .8
5 5 1 15
2 2 .4 6
Volume 20
Number 3
COMPLICATIONS OF CLOSED TECHNIQUE
p e r cent), a n d five (2 p e r cent) n e e d e d surgical p r o c e d u r e s for hemostasis. Stool i m p a c t i o n in 12 p a t i e n t s (5 p e r cent) necess i t a t e d a F l e e t e n e m a o n the t h i r d o r f o u r t h p o s t o p e r a t i v e day to " p r i m e " the b o w e l m o v e m e n t . O n e p a t i e n t h a d a superficial p e r i a n a l abscess d u e to an i n f e c t e d sinus missed at the t i m e of the first o p e r a tion. B r o n c h i t i s was f o u n d in 15 p a t i e n t s (6 p e r cent), ten (4 p e r cent) of w h o m h a d p r e - e x i s t i n g c h r o n i c o b s t r u c t i v e pulm o n a r y disease. A n t i m i c r o b i a l s were given to this g r o u p . Comments O f the p o s t o p e r a t i v e complications, voidi n g difficulties (17 p e r cent), u r i n a r y cystitis (13 p e r cent), a n d b r o n c h i t i s (6 p e r cent) were f o u n d to be the most c o m m o n . P a i n was m i n i m a l , n e c e s s i t a t i n g t h r e e to f o u r i n j e c t i o n s on the first two p o s t o p e r a tive days. H o s p i t a l stays a v e r a g e d five days,
185
a n d the p a t i e n t s were a b l e to r e t u r n to w o r k in f o u r to five weeks, d e p e n d i n g o n t h e i r jobs. P o s t o p e r a t i v e visits a v e r a g e d two to three. T h i s r e p o r t m a y serve as a basis for a c o m p a r a t i v e s t u d y of the t r e a t m e n t of hemo r r h o i d s in o t h e r s m a l l c o m m u n i t y hospitals. References 1. Ferguson JA, Heaton JR: Closed hemorrhoidectomy. Dis Colon Rectum 2: 176, 1959 2. Ferguson JA, Mazier WP, Ganchrow MI, et al: The closed technique of hemorrhoidectomy. Surgery 70: 480, 1971 3. Ganchrow MI, Mazier WP, Friend WG, et al: Hemorrhoidectomy r e v i s i t e d - a computer analysis of 2,038 cases. Dis Colon Rectum 14: 128, 1971 4. Granet E: Hemorrhoidectomy failures: Causes, prevention and management. Dis Colon Rectum 11:45, 1968 5. McCarty RL: Hemorrhoidectomy: Postoperative results of 547 consecutive patients. 6: 367, 1963 6. Minvielle L, Cervantes R, Velasco JM: A closed technic in anorectal surgery. Dis Colon Rectum 12: 40, 1969
M.D.*
Ionia, Michigan
PATIENTS who have hemorrhoidal disease come to the clinic nearest to home. The community hospital provides an opportunity to evaluate the complications following surgical hemorrhoidectomy and their management. A proctologic work-up1 at our hospital consists of a history and physical examination.l-3 proctosigmoidoscopy, and a bariumenema examination. 1-~, 6 The technique of complete closed hemorrhoidectomy, using local infiltration anesthesia with 80 ml of 0.5 per cent lidocaine supplemented with light general anesthesia, is used to treat hemorrhoids. Materials
From January 1973 to September 1975, 232 cases were selected for this study (Table
TABLE 1. Sex Distribution Patients Number Male
104
45
Female
128
55
232
100
TOTAL
TABLE 2.
Age Distribution Patients Number
Per Cent
1-20 years
9
4
21-50years
158
68
51-80 years TOTAL
1). The preoperative findings, surgical procedures, and postoperative complications were tabulated. Preoperative Findings: There were 104 (45 per cent) male, and 128 (55 per cent) female patients in the series. The youngest was 8 years old and the oldest, 77 years old (Table 2). The most common symptoms found 3 were bleeding (87 per cent), pain (92 per cent), and mucosal prolapse (80 per cent). Constipation (13 per cent) and diarrhea (7 per cent) were not uncommon in the older patients, while anal pruritus (21 per cent) and burning (30 per
Per Cent
65
28
232
100
cent) were more' prevalent in the anxious patients (Table 3). There were 51 patients (22 per cent) who had thrombosis; other anal pathologic symptoms encountered were anal ulcers in 66 patients (28 per cent), anal fistulas in 43 patients (18 per cent), polyps in 12 patients (5 per cent), and anal condylomas in six (2 per cent). Two or more of the above-mentioned findings were present in the same patient (Table 4). Surgical Treatment: Closed hemorrhoidectomy as described by Ferguson et al. 1-a was used. One to five radical incisions were
* Ionia Medical Center, 910 E. Lincoln Avenue, Ionia, Michigan 48846.
183 Dis. Col. &Rect. April, 1977
Volume 20 Number 3
Dis. Col. & Reef.
BAUTISTA
184 TABLE 3. Symptoms and Duration Patients
Symptom Bleeding Pain Mucosal prolapse Constipation Diarrhea Anal and para-anal pruritus Duration of symptoms 1 day-1 month I-6 months 6 months-5 years
Number
Per Cent
202 213 186 29 16
87 92 80 13 7
49
21
161 37 34
69 16 15
TABLE 4. Proctologic Findings Patients
Anal ulcer Anal fistula Rectal and rectosigmoidal polyp Anal condyloma acumina turn Severe thrombosis
Number
Per Cent
66 43
28 18
12
5
6 51
2 22
TABLE 5. Incisions Used in Closed Hemorrhoidectomy
April, 1977
C o m p l i c a t i o n s : P o s t o p e r a t i v e l y , the con> p l i c a t i o n s e n c o u n t e r e d were v o i d i n g difficulties, u r i n a r y cystitis, s l i g h t to severe b l e e d i n g , stool i m p a c t i o n s , a n d abscess form a t i o n ( T a b l e 7).3-s Difficulty i n v o i d i n g n e c e s s i t a t i n g catheteri z a t i o n was e x p e r i e n c e d b y 40 p a t i e n t s (17 p e r cent). T h i r t y - o n e (13 p e r cent) of these 40 p a t i e n t s also h a d u r i n a r y cystitis w i t h pus cells a n d b a c t e r i u r i a ; t e n of t h e m (4 p e r cent) h a d p r e - e x i s t i n g b a c t e r i u r i a . T w e n t y - f i v e (11 p e r cent) of t h e 40 p a t i e n t s were c a t h e t e r i z e d once, w h i l e 15 (6 p e r cent) n e e d e d a F o l e y c a t h e t e r for o n e to two days. T h e necessity for c a t h e t e r i z a t i o n was significantly d i m i n i s h e d b y w a i t i n g u n t i l the p a t i e n t was o b s e r v e d to have dist e n t i o n of the u r i n a r y b l a d d e r . A r o u t i n e p o s t o p e r a t i v e o r d e r to c a t h e t e r i z e the pat i e n t was deleted. Slight b l e e d i n g was t r e a t e d c o n s e r v a t i v e l y in two p a t i e n t s (.8
TABLE 6. Other Surgical Procedures Patients
Anal ulcerectomy Fistulectomy Polypectomy Subcutaneous neurotomy (cloverleaf operation) Superficial external anal sphincterotomy
Number
Per Cent
66 43 12
28 18 5
15
6
.59
25
Patients
Incisions, Number
Number
Per Cent
2 3 4
7 123 94
8 53 41
5
8
3
m a d e in the a n o r e c t a l c a n a l w i t h preservat i o n of the i n t e r v e n i n g mucosal islands. T a b l e 5 shows the n u m b e r s of incisions. T a b l e 6 shows o t h e r surgical p r o c e d u r e s p e r f o r m e d w i t h the h e m o r r h o i d e c t o m i e s .
TABLE 7. Postoperative Complications Patients
Voiding difficulty; urinary cystitis Minimal bleeding Severe bleeding necessitating surgical treatment Stool impaction Perianal abscess Acute bronchitis
Number
Per Cent
40 2
17 .8
5 5 1 15
2 2 .4 6
Volume 20
Number 3
COMPLICATIONS OF CLOSED TECHNIQUE
p e r cent), a n d five (2 p e r cent) n e e d e d surgical p r o c e d u r e s for hemostasis. Stool i m p a c t i o n in 12 p a t i e n t s (5 p e r cent) necess i t a t e d a F l e e t e n e m a o n the t h i r d o r f o u r t h p o s t o p e r a t i v e day to " p r i m e " the b o w e l m o v e m e n t . O n e p a t i e n t h a d a superficial p e r i a n a l abscess d u e to an i n f e c t e d sinus missed at the t i m e of the first o p e r a tion. B r o n c h i t i s was f o u n d in 15 p a t i e n t s (6 p e r cent), ten (4 p e r cent) of w h o m h a d p r e - e x i s t i n g c h r o n i c o b s t r u c t i v e pulm o n a r y disease. A n t i m i c r o b i a l s were given to this g r o u p . Comments O f the p o s t o p e r a t i v e complications, voidi n g difficulties (17 p e r cent), u r i n a r y cystitis (13 p e r cent), a n d b r o n c h i t i s (6 p e r cent) were f o u n d to be the most c o m m o n . P a i n was m i n i m a l , n e c e s s i t a t i n g t h r e e to f o u r i n j e c t i o n s on the first two p o s t o p e r a tive days. H o s p i t a l stays a v e r a g e d five days,
185
a n d the p a t i e n t s were a b l e to r e t u r n to w o r k in f o u r to five weeks, d e p e n d i n g o n t h e i r jobs. P o s t o p e r a t i v e visits a v e r a g e d two to three. T h i s r e p o r t m a y serve as a basis for a c o m p a r a t i v e s t u d y of the t r e a t m e n t of hemo r r h o i d s in o t h e r s m a l l c o m m u n i t y hospitals. References 1. Ferguson JA, Heaton JR: Closed hemorrhoidectomy. Dis Colon Rectum 2: 176, 1959 2. Ferguson JA, Mazier WP, Ganchrow MI, et al: The closed technique of hemorrhoidectomy. Surgery 70: 480, 1971 3. Ganchrow MI, Mazier WP, Friend WG, et al: Hemorrhoidectomy r e v i s i t e d - a computer analysis of 2,038 cases. Dis Colon Rectum 14: 128, 1971 4. Granet E: Hemorrhoidectomy failures: Causes, prevention and management. Dis Colon Rectum 11:45, 1968 5. McCarty RL: Hemorrhoidectomy: Postoperative results of 547 consecutive patients. 6: 367, 1963 6. Minvielle L, Cervantes R, Velasco JM: A closed technic in anorectal surgery. Dis Colon Rectum 12: 40, 1969
