Journal of the Royal Society of Medicine Volume 71 January 1978
29
Lateral subcutaneous sphincterotomy: local or general anaesthetic?' D Gatehouse FRCS Y Arabi FRCS J Alexander-Williams chM FRCS M R B Keighley MS FRCS The General Hospital, Steelhouse Lane, Birmingham B4 6NH
Patients with fissure-in-ano and haemorrhoids have high anal pressures due to over activity of the internal anal sphincter (Eisenhammer 1974, Hancock & Smith 1975). It would therefore seem logical that reduction in anal pressure may lead to relief of symptoms. This may be achieved either by manual dilatation of the anus (MDA) (Lord 1969) or lateral subcutaneous sphincterotomy (LSS) (Notaras 1971). Sphincterotomy is a more precise technique than dilatation and it has also been suggested (Eisenhammer 1969) that sphincterotomy can be performed satisfactorily under local anaesthetic. We have therefore: (1) Examined whether LSS could be performed adequately under local anaesthetic as an outpatient procedure; (2) Compared anal pressure reduction by sphincterotomy under local anaesthetic (LA) with general anaesthetic (GA); (3) Observed the postoperative results of both procedures. The results have also been compared with a group of patients treated by MDA for the same conditions. Patients and methods Since July 1976 we have studied 59 patients requiring treatment for fissure-in-ano or with first or second degree haemorrhoids. Selection for treatment was non-randomized and depended on the availability of anaesthetic staff. Anal pressures were measured at the initial outpatient attendance, in the operating theatre before and after treatment and one month afterwards in the follow-up clinic. Recordings were obtained at 2, 3, 4 and 5 cm from the anal verge with a closed water-filled balloon probe as described by Hancock & Smith (1975). The results are expressed as the maximum anal pressure, which is the mean value of the highest pressures recorded. All patients were admitted to a day case ward. Sphincterotomy was performed in the lithotomy position if under GA and the left lateral position if under LA. Results Of the 37 patients treated by LSS: 21 were under GA (10 fissures, 11 haemorrhoids) and 16 under LA (6 fissures, 10 haemorrhoids). Results were compared with those of 22 patients treated by MDA (14 fissures, 8 haemorrhoids). The mean preoperative maximum anal pressures in both sphincterotomy groups were as follows: GA, 122+36 S/D cmH20; and LA, 127+32 S/D cmH20. These pressures were similar to patients treated by MDA (133 + 29 S/D cmH20) and were significantly higher than '
Paper read to Section of Proctology, 23 February 1977
30
Journal of the Royal Society of Medicine Volume 71 January 1978
those of 78 controls (88+34 S/D cmH20 P
29
Lateral subcutaneous sphincterotomy: local or general anaesthetic?' D Gatehouse FRCS Y Arabi FRCS J Alexander-Williams chM FRCS M R B Keighley MS FRCS The General Hospital, Steelhouse Lane, Birmingham B4 6NH
Patients with fissure-in-ano and haemorrhoids have high anal pressures due to over activity of the internal anal sphincter (Eisenhammer 1974, Hancock & Smith 1975). It would therefore seem logical that reduction in anal pressure may lead to relief of symptoms. This may be achieved either by manual dilatation of the anus (MDA) (Lord 1969) or lateral subcutaneous sphincterotomy (LSS) (Notaras 1971). Sphincterotomy is a more precise technique than dilatation and it has also been suggested (Eisenhammer 1969) that sphincterotomy can be performed satisfactorily under local anaesthetic. We have therefore: (1) Examined whether LSS could be performed adequately under local anaesthetic as an outpatient procedure; (2) Compared anal pressure reduction by sphincterotomy under local anaesthetic (LA) with general anaesthetic (GA); (3) Observed the postoperative results of both procedures. The results have also been compared with a group of patients treated by MDA for the same conditions. Patients and methods Since July 1976 we have studied 59 patients requiring treatment for fissure-in-ano or with first or second degree haemorrhoids. Selection for treatment was non-randomized and depended on the availability of anaesthetic staff. Anal pressures were measured at the initial outpatient attendance, in the operating theatre before and after treatment and one month afterwards in the follow-up clinic. Recordings were obtained at 2, 3, 4 and 5 cm from the anal verge with a closed water-filled balloon probe as described by Hancock & Smith (1975). The results are expressed as the maximum anal pressure, which is the mean value of the highest pressures recorded. All patients were admitted to a day case ward. Sphincterotomy was performed in the lithotomy position if under GA and the left lateral position if under LA. Results Of the 37 patients treated by LSS: 21 were under GA (10 fissures, 11 haemorrhoids) and 16 under LA (6 fissures, 10 haemorrhoids). Results were compared with those of 22 patients treated by MDA (14 fissures, 8 haemorrhoids). The mean preoperative maximum anal pressures in both sphincterotomy groups were as follows: GA, 122+36 S/D cmH20; and LA, 127+32 S/D cmH20. These pressures were similar to patients treated by MDA (133 + 29 S/D cmH20) and were significantly higher than '
Paper read to Section of Proctology, 23 February 1977
30
Journal of the Royal Society of Medicine Volume 71 January 1978
those of 78 controls (88+34 S/D cmH20 P
