Viscous Lidocaine as a Posthemorrhoidectomy Analgesic*
STUART L. SMITH, M.D., ROBERT SIMON, M.D.
Wheat Ridge, Colorado
CONTROL OF PAIN following h e m o r r h o i d e c t o m y is o f great concern to both patients and physicians. A safe, effective analgesic that has none o f a narcotic's side effects is a desirable adjunct to the surgeon's arm a m e n t a r i u m . T h e present study reports the use o f lidocaine, 2 per cent, in s o d i u m c a r b o x y m e t h y l celluloset as a topical analgesic in a consecutive series o f private patients u n d e r g o i n g h e m o r r h o i d e c t o m i e s in a c o m m u n i t y hospital.
previous hemorrhoidectomy. Fifty-four patients sought t r e a t m e n t because o f acute exacerbation o f chronic symptoms.
Techniques and Results W h e n the operation had been completed, and before application o f a d r y gauze pressure dressing, a conventional 16-gauge plastic catheter was fixed to the skin o f the right buttock using two sutures o f 00 silk. T h e catheter tip was thus positioned to deliver medication 1 cm above the dentate line, and the proximal end o f the catheter was taped loosely to the anterior thigh. T h e first dose o f 5 to 7.5 ml o f analgesic solution was injected as the dressing was applied at the end o f the operation; the patient t h e n received a 2.5-ml injection o f viscous lidocaine per c a t h e t e r every h o u r for 12 doses and every two hours for an additional 12 doses, making a 36-hour p e r i o d o f intermittent analgesia with lidocaine postoperatively. Sitz baths were begun not later than the following morning, and on the m o r n i n g o f the second day the apparatus was discarded. T h e patient received a conventional, nonnarcotic analgesic after leaving the recovery room. Seven per cent o f the patients in the series asked for a n d r e c e i v e d at least o n e i n j e c t i o n o f n a r c o t i c analgesic, usually, m o r p h i n e , given intramuscularly. Ninety-three per cent o f the patients received viscous lidocaine in additon to p r o p o x y p h e n e and salicylate. In 17 cases in which complications occurred, there were 14 cases o f urinary retention, two cases o f postoperative bleeding, and one case o f bronchitis. Total hospital stays averaged 4.4 days. T h e r e was no correlation between the use o f narcotics and the development of complications.
Material and Methods This r e p o r t is based on 227 cases o f patients who u n d e r w e n t submucosal h e m o r r h o i d e c t o m i e s d u r i n g the period from 1972 t h r o u g h 1976. Most operations were p e r f o r m e d using a general anesthetic, with the patient in the dorsal lithotomy position. Sigmoidoscopy, s p h i n c t e r o t o m y , a n d r e c t o c e l e r e p a i r were c o m m o n l y included. T h e most f r e q u e n t o p e r a t i o n was submucosal h e m o r r h o i d dissection as described by Parks? All hospital charts were retrospectively reviewed for d e m o g r a p h i c and clinical data and for complications. Fifty patients' office records were e x a m i n e d by their private physician (R. S.) and, in addition, all patients were seen for six-month followup examinations, forming at least in part a one-tofive-year retrospective review. T h e r e were two cases o f h e m o r r h o i d r e c u r r e n c e , necessitating r e o p e r a tions. No subsequent colonic surgical procedures for cancer, diverticular disease, or colitis were recorded. Preoperative office evaluation of each patient included a careful history, physical examination, sigmoidoscopy, and usually b a r i u m - e n e m a examination. As m i g h t be e x p e c t e d , diverticulosis and colonic polyps were the most c o m m o n associated a b n o r malities. T h e subjects, two thirds o f whom were men, ayeraged 42 years o f age, and had had symptoms for nearly ten years. Seventeen per cent had u n d e r g o n e Received for publication July 17, 1978. Address reprint requests to Dr. Smith: 7805 West 38th Avenue, Wheat Ridge, Colorado 80033. t Xylocaine Viscous, Astra Pharmaceutical Products, Inc., Worcester, Mass.
Comments After reviewing this series, we concluded that gentle technique, a p p r o p r i a t e and timely operation, and an i n f o r m e d cooperative patient were the major con-
0012-3706/79/0100/0040/$00.60 9 American Society of Colon and Rectal Surgeons
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Volume 22 Number 1
v i s c o u s LIDOCAINE FOR HEMORRHOIDECTOMY PAIN
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tributors to operative success. However, additional benefits were derived f r o m postoperative comfort. Normal gastrointestinal function was most rapidly re-established by avoiding narcotics, using mild laxatives, and beginning a regular diet the day after operation. Patients had bowel movements by the third or f o r u t h postoperative day. All patients were fully ambulatory by the postoperative second day. Most were discharged to office care on the third postoperative day, after receiving instructions for a high-fiber diet f r o m the dietician. All patients were recalled for follow-up examinations at six months, and all are now considered c u r e d o f h e m o r r h o i d a l disease.
t h a t analgesic doses o f viscous lidocaine solution could be delivered to the site for the first 36 hours postoperatively. Although 14 patients had u r i n a r y retention that necessitated catheterization, no complication was attributed to the analgesic method. O f 227 patients, 92 per cent were treated with this m e t h o d plus orally administered nonnarcotic analgesics. Viscous lidocaine injected into t h e anus is concluded to provide safe, convenient analgesia following hemorrhoidectomy. Toxic reactions to lidocaine were not a problem because the doses were small, and the d r u g was used only intermittently o v e r a p e r i o d o f 36 hours."
Sumnl ary
References
During h e m o r r h o i d e c t o m y , a standard 16-gauge plastic catheter was sutured to the operative site so
I. Parks AG: Hemorrhoidectomy. Adv Surg 5: 1, 1971 2. AdrianiJ: Reactions to local anesthetics. JAMA 196: 405, 1966
STUART L. SMITH, M.D., ROBERT SIMON, M.D.
Wheat Ridge, Colorado
CONTROL OF PAIN following h e m o r r h o i d e c t o m y is o f great concern to both patients and physicians. A safe, effective analgesic that has none o f a narcotic's side effects is a desirable adjunct to the surgeon's arm a m e n t a r i u m . T h e present study reports the use o f lidocaine, 2 per cent, in s o d i u m c a r b o x y m e t h y l celluloset as a topical analgesic in a consecutive series o f private patients u n d e r g o i n g h e m o r r h o i d e c t o m i e s in a c o m m u n i t y hospital.
previous hemorrhoidectomy. Fifty-four patients sought t r e a t m e n t because o f acute exacerbation o f chronic symptoms.
Techniques and Results W h e n the operation had been completed, and before application o f a d r y gauze pressure dressing, a conventional 16-gauge plastic catheter was fixed to the skin o f the right buttock using two sutures o f 00 silk. T h e catheter tip was thus positioned to deliver medication 1 cm above the dentate line, and the proximal end o f the catheter was taped loosely to the anterior thigh. T h e first dose o f 5 to 7.5 ml o f analgesic solution was injected as the dressing was applied at the end o f the operation; the patient t h e n received a 2.5-ml injection o f viscous lidocaine per c a t h e t e r every h o u r for 12 doses and every two hours for an additional 12 doses, making a 36-hour p e r i o d o f intermittent analgesia with lidocaine postoperatively. Sitz baths were begun not later than the following morning, and on the m o r n i n g o f the second day the apparatus was discarded. T h e patient received a conventional, nonnarcotic analgesic after leaving the recovery room. Seven per cent o f the patients in the series asked for a n d r e c e i v e d at least o n e i n j e c t i o n o f n a r c o t i c analgesic, usually, m o r p h i n e , given intramuscularly. Ninety-three per cent o f the patients received viscous lidocaine in additon to p r o p o x y p h e n e and salicylate. In 17 cases in which complications occurred, there were 14 cases o f urinary retention, two cases o f postoperative bleeding, and one case o f bronchitis. Total hospital stays averaged 4.4 days. T h e r e was no correlation between the use o f narcotics and the development of complications.
Material and Methods This r e p o r t is based on 227 cases o f patients who u n d e r w e n t submucosal h e m o r r h o i d e c t o m i e s d u r i n g the period from 1972 t h r o u g h 1976. Most operations were p e r f o r m e d using a general anesthetic, with the patient in the dorsal lithotomy position. Sigmoidoscopy, s p h i n c t e r o t o m y , a n d r e c t o c e l e r e p a i r were c o m m o n l y included. T h e most f r e q u e n t o p e r a t i o n was submucosal h e m o r r h o i d dissection as described by Parks? All hospital charts were retrospectively reviewed for d e m o g r a p h i c and clinical data and for complications. Fifty patients' office records were e x a m i n e d by their private physician (R. S.) and, in addition, all patients were seen for six-month followup examinations, forming at least in part a one-tofive-year retrospective review. T h e r e were two cases o f h e m o r r h o i d r e c u r r e n c e , necessitating r e o p e r a tions. No subsequent colonic surgical procedures for cancer, diverticular disease, or colitis were recorded. Preoperative office evaluation of each patient included a careful history, physical examination, sigmoidoscopy, and usually b a r i u m - e n e m a examination. As m i g h t be e x p e c t e d , diverticulosis and colonic polyps were the most c o m m o n associated a b n o r malities. T h e subjects, two thirds o f whom were men, ayeraged 42 years o f age, and had had symptoms for nearly ten years. Seventeen per cent had u n d e r g o n e Received for publication July 17, 1978. Address reprint requests to Dr. Smith: 7805 West 38th Avenue, Wheat Ridge, Colorado 80033. t Xylocaine Viscous, Astra Pharmaceutical Products, Inc., Worcester, Mass.
Comments After reviewing this series, we concluded that gentle technique, a p p r o p r i a t e and timely operation, and an i n f o r m e d cooperative patient were the major con-
0012-3706/79/0100/0040/$00.60 9 American Society of Colon and Rectal Surgeons
4O
Volume 22 Number 1
v i s c o u s LIDOCAINE FOR HEMORRHOIDECTOMY PAIN
41
tributors to operative success. However, additional benefits were derived f r o m postoperative comfort. Normal gastrointestinal function was most rapidly re-established by avoiding narcotics, using mild laxatives, and beginning a regular diet the day after operation. Patients had bowel movements by the third or f o r u t h postoperative day. All patients were fully ambulatory by the postoperative second day. Most were discharged to office care on the third postoperative day, after receiving instructions for a high-fiber diet f r o m the dietician. All patients were recalled for follow-up examinations at six months, and all are now considered c u r e d o f h e m o r r h o i d a l disease.
t h a t analgesic doses o f viscous lidocaine solution could be delivered to the site for the first 36 hours postoperatively. Although 14 patients had u r i n a r y retention that necessitated catheterization, no complication was attributed to the analgesic method. O f 227 patients, 92 per cent were treated with this m e t h o d plus orally administered nonnarcotic analgesics. Viscous lidocaine injected into t h e anus is concluded to provide safe, convenient analgesia following hemorrhoidectomy. Toxic reactions to lidocaine were not a problem because the doses were small, and the d r u g was used only intermittently o v e r a p e r i o d o f 36 hours."
Sumnl ary
References
During h e m o r r h o i d e c t o m y , a standard 16-gauge plastic catheter was sutured to the operative site so
I. Parks AG: Hemorrhoidectomy. Adv Surg 5: 1, 1971 2. AdrianiJ: Reactions to local anesthetics. JAMA 196: 405, 1966
