Excision of Thrombosed External Hemorrhoid Under Local Anesthesia

Transcription

1 Excision of Thrombosed External Hemorrhoid Under Local Anesthesia A Retrospective Evaluation of 340 Patients Johannes Jongen, M.D., Sebastian Bach, M.D., Sven Henrik Stübinger, M.D., Jens-Uwe Bock, M.D. From the Proctological Office and Department of Surgical Proctology, Park-Klinik, Kiel, Germany PURPOSE: This study was a retrospective analysis of complication rates, symptom recurrence, long-term results, and patient satisfaction after outpatient excision (local anesthesia) of thrombosed external hemorrhoids. METHODS: From 1995 to 2000, 340 patients (166 males) underwent officebased excision of thrombosed external hemorrhoids under local anesthesia. Data regarding complications, operations because of recurrence, residual symptoms, patient s satisfaction with anesthesia, and wound treatment were obtained by questionnaire. Response was solicited at a minimum of 9 months postprocedure. RESULTS: Complete follow-up data was available in 88 percent of patients (mean follow-up, 17.3 months). Recurrent thrombosed external hemorrhoid requiring a procedure developed in 22 (6.5 percent) patients. Other complications that required operative intervention were one (0.3 percent) incidence of postoperative bleeding and seven (2.1 percent) perianal abscess/fistula. The majority of patients (66 percent) had no anal complaints at follow-up. Local anesthesia would be preferred if a repeat excision was required in 79 percent, whereas 11 percent would prefer another form of anesthesia and 10 percent were unsure. CONCLUSION: Outpatient excision under local anesthesia of a thrombosed external hemorrhoid can be safely performed with a low recurrence and complication rate while offering a high level of patient of acceptance and satisfaction. [Key words: Thrombosed external hemorrhoid; Perianal thrombosis; Outpatient; Local anesthesia] Jongen J, Bach S, Stübinger SH, Bock J-U. Excision of thrombosed external hemorrhoid under local anesthesia: a retrospective evaluation of 340 patients. Dis Colon Rectum 2003; 46: T hrombosed external hemorrhoid is not a lifethreatening disease; however, it produces significant acute pain, often resulting in the need for emergent medical care. The diagnosis occurs most frequently in young professionals of either gender, which results in an economic impact because of lost work, cost of ointments and painkillers, reduction of quality of life, etc. A variety of guidelines and technical notes exist for the management of thrombosed Presented at the Bundeskongress des BNC, Nürnberg, Germany, March 1 to 3, Address reprint requests to Dr. Jongen: Consultant Surgeon, Park- Klinik, Department of Surgical Proctology, Goethestrasse 11, Kiel, Germany external hemorrhoids; however, there is little guidance regarding outcomes after surgical treatment. 1 3 In fact, the majority of data is based on inpatient, operative treatment of thrombosed internal hemorrhoids performed under general or spinal anesthesia. There is only one United States series (50 male soldiers) and one German study, which describe results after outpatient excision of thrombosed external hemorrhoid with local anesthesia. 4,5 Both studies had limited follow-up (10 weeks) and no information regarding patient satisfaction. We have followed patients who had an outpatient excision of thrombosed external hemorrhoid under local anesthesia since 1995 with a high rate of data collection for each year. PATIENTS AND METHODS All patients who underwent an office-based excision for thrombosed external hemorrhoid(s) from 1995 to 2000 were eligible for study. Operative indications were severe pain, necrosis or perforation of overlying skin, and persistent bleeding after perforation of the overlying skin. Nonoperative treatment was used for less severe symptoms, a freely mobile thrombosis, resorbing clot, or rejection of a surgical option by the patient. Nonoperative treatment consisted of topical corticosteroid ointments and oral nonsteroidal anti-inflammatories. The operation is performed after perianal shaving and infiltration of a solution of mepivacaine (1 percent), epinephrine ( percent; until 2001), and from November 1997, sodium bicarbonate (8.4 percent). 6 This regimen is occasionally painful during infiltration; however, anesthesia is instantaneous and allows the procedure to begin immediately. The thrombosed external hemorrhoid is excised, starting perianally, dissecting into the anal canal and continuing to the dentate line. Complete excision avoids the potential development of a hypertrophic papilla with wound healing. The wound is left open for healing by

2 Vol. 46, No. 9 OUTPATIENT EXCISION OF THROMBOSED HEMORRHOID 1227 secondary intention. The specimen is submitted for histopathology. Patients are advised to take sitz baths (3 4 times per day, after each defecation) and change the wound dressings (gauze with dexpanthenol ointment) accordingly. Postoperative analgesia is obtained with oral diclofenac or ibuprofen (paracetamol for pregnant patients). All patients received printed information regarding wound care, analgesia, potential complications, and how to reach the surgeon. Postoperative evaluation occurred on Days 1, 10, 21, and (if necessary) 42. Patients were contacted in either the autumn of the following year ( ) or in the spring of the second year after operation ( ) by questionnaire with a request to complete the form and return it in the addressed and stamped envelope. RESULTS During the study period, 340 patients (166 male, 174 female) were operated using our technique. Twenty-two females were in the second or third trimester of pregnancy. Three elderly people took phenprocoumon, an anticoagulant. One patient had idiopathic thrombocytopenic purpura, one patient was post-heart transplant, and one patient required antibiotic prophylaxis for a congenital heart valve malformation. Twenty patients had undergone incision and clot evacuation by another physician within three days before our intervention 3 (Table 1). Office follow-up until complete wound healing was possible in 238 (70 percent) patients. Proctologic History Data The incidence of previous proctologic treatments, previous thrombosed external hemorrhoids, and incidence of staining at stool are shown in Table 2. The age distribution shows that most patients were between 20 and 50 years of age (Fig. 1). Figure 2 shows the localization of the perianal thrombosis at the anal verge (lithotomy position): most findings (66 percent) were located at the left lateral and dorsal quadrants. In two patients, the position of the thrombosis was not documented. Seventy percent of the patients could be followed until complete closure of the wound. The other patients did not show up for any more appointments despite the agreement. Recurrences and Complications Twenty-two (6.5 percent) patients developed a recurrent thrombosed external hemorrhoid 2 months after the initial excision. Postoperative complications included one (0.3 percent) postoperative bleeding controlled under local anesthesia and seven (2.1 percent) developed a fistula or an abscess. After complete wound healing, 56 patients required rubber band ligation for hemorrhoidal complaints. Interestingly, patients treated with rubber bands had a higher recurrence rate than patients not undergoing ligation (17.9 vs. 4.2 percent). Follow-up A total of 298 (87.6 percent) patients returned the questionnaire. Five patients had died in the meantime. No patient died of proctologic complications. The remainder of patients could not be traced. RESULTS OF THE FOLLOW-UP BY QUESTIONNAIRE Secondary Operations. Aside from the acute complications, which required surgical treatment (see above-mentioned), no other patients had subsequent anorectal operations. Residual Proctologic Complaints. The majority of patients had no ongoing anorectal complaints at the time of follow-up (66.4 percent). The distribution of postoperative anorectal symptoms is shown in Table 3, and the incidence of these symptoms was unaf- Table 1. Data of Patients Who Were Operated for Thrombosed External Hemorrhoid Patients Total N Male Female Pregnant Oral anticoagulants Previous operation

3 1228 JONGEN ET AL Dis Colon Rectum, September 2003 Table 2. Anamnestic Data of 340 Patients With Thrombosed External Hemorrhoid Anamnestic Data Total N Previous proctologic treatment Previous thrombosed external hemorrhoid Straining provocation Straining at defecation management, whereas 1.6 percent were indecisive or not satisfied. DISCUSSION Figure 1. Age distribution of 340 patients, who were operated on for thrombosed external hemorrhoid under local anesthesia. Figure 2. Localization of the thrombosed external hemorrhoid at the anal verge (lithotomy position) in 338 patients. fected by later rubber band ligation (72 percent treated; 65 percent not treated). Patient s Satisfaction with Local Anesthesia and Treatment of the Anal Wound. Local anesthesia for another excision of a thrombosed external hemorrhoid would be accepted by 78.5 percent of patients, 10.1 percent were indecisive, and 11.4 percent declined another operation for thrombosed external hemorrhoid in local anesthesia. Ninety-eight percent of patients were satisfied with postoperative wound Thrombosed external hemorrhoid is probably one of the most frequently diagnosed anorectal emergencies, and as a result excision is a frequently performed anorectal emergency operation. Despite the high incidence, it is astonishing that there are so few publications on the surgical treatment of thrombosed external hemorrhoids. The available data describes general guidelines and provides personal and technical notes regarding options; however, few outcome data are available. 7,8 Examples of treatment options include 1) (complete) circular thrombosed anal and hemorrhoidal prolapse (fourth-degree hemorrhoids), 9 2) need for general, spinal, or epidural anesthesia (with intravenous sedation), ) inpatient treatment, 9,11 and 4) use of three- or four-quadrant hemorrhoidectomy. 9,11,12 Only two publications 4,5 could be found in which the results after excision of thrombosed external hemorrhoid in local anesthesia were reported (outpatient treatment). Follow-up was not more than 6 to 10 weeks. This was despite an extensive Medline search (perianal thrombosis, perianal hematoma, external hemorrhoid), which identified the United States publication. 4 The German publication 5 was not listed on Medline. Therefore, the data we present are the first to define both short- and long-term outcome after excision of thrombosed external hemorrhoid performed as an outpatient procedure under local anesthesia. We specifically addressed the incidence of residual complaints after excision and overall patient satisfaction with the outpatient procedure. Patients also were asked whether they would accept another operation for thrombosed external hemorrhoid in the same fashion.

4 Vol. 46, No. 9 OUTPATIENT EXCISION OF THROMBOSED HEMORRHOID 1229 Table 3. Complaints About the Anal Region at Follow-up in 198 Patients After Operation for Thrombosed External Hemorrhoid Complaints at Follow-up Total % No complaints Pruritus ani Anal pain Anal lump Anal secretion Anal bleeding Anal skin tags Age and Gender Distribution Age distribution is congruent with the distribution mentioned in the literature: most patients are between 20 and 60 years of age, although it can present at the extremes of age. 4,9 15 There was a slight female predominance in our population, although it is typically reported to be a more common malady in males. 4,9 11,13,16 This bias may be because of our strong referral practice from family physicians and gynecology. Many (young) men do not have a regular family physician and are therefore not referred for operation to our practice. Predisposing Factors Pressure in the pelvic floor (diarrhea, constipation, straining at defecation, pregnancy, delivery, lifting heavy objects, etc.) was a frequent etiologic factor in our patients (22 percent) and is consistent with the literature. 4,9,12,13,17 A significant number of patients (35 percent) complained of frequent straining at defecation and 21 percent had a previous external hemorrhoid. This is much higher than reported by Grace and Creed 18 (5 percent), although Sakulsky et al. 4 reported a prior incidence in 26 percent of male patients. Previous anorectal treatment (operative and nonoperative) was performed in 87 patients (26 percent) and is similar to that reported by Blessing et al. 11 (38 percent) and Sakulsky et al. 4 (20 percent). Grace and Creed 18 reported previous therapy only in 8.5 percent of conservatively managed patients with prolapsing thrombosed hemorrhoids. Localization of the Findings at the Anal Verge The left lateral and dorsal quadrants of the anal verge showed most findings (68 percent). Oh 13 reports that more hemorrhoids are on the right side; however, thrombosed external hemorrhoids show a slight prevalence on the left side. Sakulsky et al. 4 found 48 percent on the left side and 42 percent on the right side. Complications A total of 238 patients (70 percent) were seen in the postoperative period until complete wound healing. Relocation, pain resolution, absence of symptoms, lack of time, or fear of pain at examination caused lack of follow-up to this conclusion. Postoperative complications were rare, and importantly, anal stenosis and urinary or fecal retention were not seen. This low complication rate is consistent with our recommendation of excision of thrombosed external hemorrhoid under local anesthesia in the office. Blessing et al. 11 reported a fissure with fistula in 1 of 32 patients (1-, 2-, or 3-quadrant hemorrhoidectomy), necessitating operation (3 percent). Saleeby et al. 12 had one postoperative hemorrhage in 25 pregnant women after 1-, 2-, or 3-quadrant hemorrhoidectomy, requiring a hemostatic pack (4 percent). Barrios and Khubchandani 9 reported urinary retention in 15 of 66 patients (3-quadrant hemorrhoidectomy; 23 percent), postoperative bleeding in two patients (3 percent), and anal stenosis in five patients (7.7 percent). Mazier 16 reported on 400 patients (mainly 3-quadrant hemorrhoidectomy as inpatient procedure) and identified nine postoperative hemorrhages necessitating operation (2.3 percent) and five anal stenoses (after 4-quadrant hemorrhoidectomy; 1.3 percent). Ganchrow et al. 10 from the same institution identified three delayed postoperative hemorrhages requiring surgery and one case of anal stenosis in another 130 patients operated with the Ferguson technique. Sakulsky et al. 4 had one postoperative hemorrhage (2 percent) and one fissure (2 percent). Giebel 5 reported

5 1230 JONGEN ET AL Dis Colon Rectum, September 2003 healing by secondary intention after outpatient treatment of thrombosed external hemorrhoid in one patient (3.8 percent). Recurrences During follow-up (9 28 months after operation), 22 patients developed a recurrence that was again excised under local anesthesia on an outpatient basis. The incidence of this complication occurred much more frequently in patients who underwent rubber band ligation after the index excision (17.9 vs. 4.2 percent). Thrombosis and pain after rubber band ligation as complication are not unusual ; however, this is the first data suggesting rubber band ligation as a risk factor for recurrent thrombosis of external hemorrhoids. Previous data have demonstrated an absence of recurrent thrombosed hemorrhoids after inpatient treatment, 9,11,12,16 and data show similar benefit with outpatient treatment of thrombosed external hemorrhoids. 5 After conservative treatment of prolapsing thrombosed hemorrhoids, recurrence rate is 10.8 percent. 18 Anorectal Complaints at Follow-up The majority of patients were symptom-free during follow-up (66 percent); anal itching, pain, and skin tags were the most common symptoms reported. In the literature, the rate of complete (subjective) freedom of anorectal complaints/symptoms is and 52 percent (pregnant patients after 1-, 2-, or 3-quadrant hemorrhoidectomy). 12 After conservative treatment of prolapsing thrombosed hemorrhoids, only 13 percent 18 were completely free of anorectal complaints. The rate of complete freedom of complaints in our group is smaller compared with the rate after inpatient treatment of thrombosed hemorrhoids (2-, 3-, or 4-quadrant hemorrhoidectomy). This benefit may accrue because treatment under local anesthesia is focused only on the symptomatic segment of the anal canal. The rate of freedom of complaints is higher than that for conservative treatment of prolapsing, thrombosed hemorrhoids. 18 Patients Satisfaction with Local Anesthesia Seventy-nine percent of patients would accept local anesthesia again for this surgical intervention. Interestingly, there was a somewhat lower acceptance of local anesthesia in recent years despite our use of bicarbonate since November According to Corman, 6 this should reduce the pain of infiltration. Although the surgeons involved have the impression that patients better tolerate the injection of the carbonized solution, this does not increase the acceptance of patients to have another operation under local anesthesia. CONCLUSION The excision of a thrombosed external hemorrhoid under local anesthesia in an office-based setting can be safely performed with a low complication and recurrence rate. ACKNOWLEDGMENTS The authors thank Ms. Bannas, Ms. Hentschel, and Ms. Tolkmitt for their assistance in the yearly followup. Without their support and endurance this study would not have been possible. The authors also thank Dr. Anthony Senagore for kindly reading and correcting the manuscript. REFERENCES 1. Standard Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of hemorrhoids. Dis Colon Rectum 1993;36: Mlitz H, Wienert V. Leitlinie: analthrombose. Coloproctology 2002;24: Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician 2002;65: Sakulsky SB, Blumenthal JA, Lynch RH. Treatment of thrombosed hemorrhoids by excision. Am J Surg 1970; 120: Giebel GD. Analvenenthrombose. Coloproctology 1995;17(Sonderheft I): Corman ML. Colon and rectal surgery. 3rd ed. Philadelphia: JB Lippincott, 1984: Grosz CR. A surgical treatment of thrombosed external hemorrhoids. Dis Colon Rectum 1990;33: Iseli A. Office treatment of hemorrhoids and perianal haematoma. Aust Fam Physician 1991;20: Barrios G, Khubchandani M. Urgent hemorrhoidectomy for hemorrhoidal thrombosis. Dis Colon Rectum 1979; 22: Ganchrow MI, Bowman HE, Clark JF. Thrombosed hemorrhoids: a clinicopathologic study. Dis Colon Rectum 1971;14: Blessing H, Schläpfer HU, Ammann JF. Notfallmässige hämorrhoidektomie bei akuter hämorrhoidalthrombose. Helv Chir Acta 1982;49: Saleeby RG Jr, Rosen L, Stasik JJ, Riether RD, Sheets J,

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