Routine Internal Sphincterotomy with Hemorrhoidectomy: A Prospective Study

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1 Original Article DOI:./ijss// Routine Internal Hemorrhoidectomy: A Prospective Study S Harish, R Raxith Sringeri, G Ajay Associate Professor, Department of Surgery, JSS University, Mysore, Karnataka, India, Post-graduate, Department of General Surgery, JSS University, Mysore, Karnataka, India Abstract Aim: The aim of this is to compare open hemorrhoidectomy /out internal regard to post-operative pain, post-operative complications and wound healing. Materials and Methods: Patients admitted to JSS Hospital second-degree hemorrhoids refractory to medical. A total of patients were randomly divided into two groups: Group A - Control Group ( patients): Patients undergoing open hemorrhoidectomy. Group B - Study group ( patients): Patients undergoing open hemorrhoidectomy internal. Results: On post-operative day- (POD-), the group which underwent had lesser complications regard to pain (P <.), bleeding (P =.), constipation (P =.), urinary retention (P =.). On POD-, pain (P <.), bleeding (P =.), and constipation (.) were signifi cantly lesser in group. At weeks post-operative follow-up, the rate of complete wound healing was % in group, whereas in out group it was %. The fi ndings are statistically signifi cant as indicated by the P value. Conclusion: Addition of internal to open hemorrhoidectomy is an effective method to reduce post open hemorrhoidectomy pain, complications as well as reduce the duration of complete wound healing out any signifi cant morbidity. Key words: Hemorrhoids, Internal, Open hemorrhoidectomy, Post-hemorrhoidectomy pain INTRODUCTION Hemorrhoids are common clinical conditions. About half of the population has hemorrhoids by the age of years. It is estimated that % of people aged over years have the disease in the USA. - Almost one-third of these patients present to surgeons for treatment. Hemorrhoids can occur at any age, and they affect both men and women. Exact incidence in developing countries is unknown, but the disease is being more frequently encountered, perhaps due to westernized lifestyle. Hemorrhoids have plagued humans since they attained the erect posture. - Access this article online Month of Submission : - Month of Peer Review : - Month of Acceptance : - Month of Publishing : - The word hemorrhoid is derived from Greek word hemorrhoids, meaning flowing of blood (haem = blood, rhoos = flowing). The word piles comes from Latin word pila meaning a pill or ball. To be accurate, we should call the disease as piles when the patient complains of a swelling and hemorrhoids when he or she complains of bleeding.,9- The most common method of treatment of hemorrhoids is by Hemorrhoidectomy which involves excision of pile mass, either by open hemorrhoidectomy (Milligan-Morgan) or closed hemorrhoidectomy (Ferguson) method. MATERIALS AND METHODS Method of : It is a prospective of patients admitted in JSS Hospital Mysore Duration of : November -October Sample size: cases, ( cases of Milligan-Morgan hemorrhoidectomy out sphincetrotomy and cases of open hemorrhoidectomy ). The source of the data: All patients Grade II, III and Grade IV hemorrhoids coming to the General Corresponding Author: Dr. R Raxith Sringeri, Department of Surgery, JSS Hospital, Mysore, Karnataka, India. raxith@gmail.com International Journal of Scientific Study February Vol Issue

2 Harish, et al.: Routine Internal Hemorrhoidectomy Surgery Department of JSSH, Mysore will be included for the. A. Inclusion criteria. Age - years. Diagnosed to have second-degree hemorrhoids refractory to medical treatment. Third-degree hemorrhoids. Fourth-degree hemorrhoids. B. Exclusion criteria. First- and second-degree hemorrhoids, managed by medical line of the treatment. Patients medical co-morbidites - Diabetes mellitus, hypertension, ischemic heart disease, asthma. H/O anal fissures/anal fistula/perianal abscess. Previous hemorrhoidal surgeries. Fecal incontinence. Previously treated sclerotherapy and other modalities for hemorrhoids. Methodology A randomized case control trial prospective data collection of patients. Randomization process will be carried out by odd and even numbers. Patients admitted will undergo standard screening for anaesthetic fitness and will be operated under spinal block. Patients will have to sign the informed consent before participating in the. Standard antibiotic prophylaxis and bowel preparation will be carried out. The severity of post-operative pain was assessed according to frequency of administration of analgesic, needed to control the pain for a patient which followed an on the patient s demand protocol. Pain will be categorized as: Mild (Grade ) - if analgesics were administered -/ hours to control pain Moderate (Grade ) - if analgesics were administered -/ h, and Severe (Grade ) - if analgesics were administered > / h. The patients will be followed up at pouch of douglas, and at weeks, weeks, once a month for months, under the following criteria:. Pain. Post-operative urinary retention. Constipation. Rectal bleeding. Wound hematoma. Submucosal abscess. Stenosis and. Wound healing. Statistical methods used are:. Descriptive statistics. Chi-square test. Contingency co-efficient tests. t test independent RESULTS Age Distribution In my, patients were of the mean age of. years in out group, and. in group (Table and Graph ). Sex Distribution A number of females in the group were in out group and in group, i.e. % and %, respectively. Number of males in the group were in out group and 9 in group, i.e. % and %, respectively (Table and Graph ). Distribution of grade of hemorrhoids out group. Grade : %, Grade : %, Grade : %. group Grade : %, Grade : %, and Grade : % (Table ). Assessment of pain: Table and Graph : Post-operative - day-. All the patients will be given diclofenac as an analgesic intramuscularly. Details of the time and number of injections used will be recorded against each patient. Visual Analogue Scale (VAS) VAS is a single item vertical scale of mm for pain intensity, categorized as: No pain (- mm) Mild pain (- mm) Moderate pain (- mm) Severe pain (- mm). Mean age in years.. Graph : Age distribution International Journal of Scientific Study February Vol Issue

3 Harish, et al.: Routine Internal Hemorrhoidectomy Assessment of pain - post-operative day- (POD-) pain was assessed using two variables, i.e. VAS and numbered of analgesics given on day-, patients who underwent hmerrhoidectomy out had more pain (P <.) when compared to patients who underwent (Table and Graph ). No.of participants 9 Graph : Sex distribution Male Female Table and Graph : Post-operative - day - : Assessment of complication. Assessment of complications: On POD-, patients who did not undergo had more Table : Age distribution Group Age P=., Independent t test, SD: Standard deviation Table : Sex distribution Sex Group (n (%)) Female (.) (.) Male (.) 9 (.) P=., Chi-square test Table : Distribution of grade of hemorrhoids Grade of hemorrhoids Group (n (%)) Median. Grade (.) (.) Grade (.) (.) Grade (.) (.) P=.9, Chi-square test No of participants Post op Day PAIN (VAS) Post op Day no. Of ANALGESICS GIVEN Graph : Assessment of pain post-operative - day- Post op day URINARY RETENTION Post op day CONSTIPATION Post op day RECTAL BLEEDING Graph : Post-operative day : Assessment of complication Table : Assessment of pain: Post-operative - day- Pain Group P POD- pain (VAS) <. POD- (analgesics given) <. VAS: Visual analogue scale, -, SD: Standard deviation Table : Post-operative - day - : Assessment of complication Complications Group (n (%)) P POD- - Urinary retention No (.) (9.). Yes (.) (.) POD- - Constipation No (.) (9.). Yes (.) (.) POD- - Rectal bleeding No (.) (9.). Yes (.) (.) International Journal of Scientific Study February Vol Issue

4 Harish, et al.: Routine Internal Hemorrhoidectomy complication is regard to urinary retention (P =.), constipation (P =.), and bleeding (P =.) (Table and Graph ). Assessment of Pain On POD-, pain in out group (P <.) for VAS and number of Analgesics given was significantly more than group (Table and Graph ). Assessment of Complications On POD-, constipation (P =.), rectal bleeding (P =.) were significantly more in out group when compared to group (Table and Graph ). In our, as mentioned, assessment of pain was carried out two variables,. VAS. Number of analgesics administered. Median..... Post op Day PAIN (VAS) Graph : Post-operative - day - assessment of pain No. of subjects Post op Day no. Of ANALGESICS GIVEN Post op Day CONSTIPATION Post op Day RECTAL BLEEDING Graph : Post-operative -day - assessment of complications On comparison, using both variables in patients of both groups, i.e. and out in open hememorrhoidectomy, it was found that pain was significantly lesser in group (P <.) on POD,,, week and weeks. The patients undergoing open hemorrhoidectomy had early relief of pain when compared to patients undergoing open hemorrhoidectomy out (Table and Graph ). In our, on comparing both the groups, i.e., and out post open hamemorrhoidetomy, it was found that post-operative rectal bleeding was significantly more in out group (Table 9 and Graph ). Table : Post-operative - day - assessment of pain Pain Group P POD- - Pain (VAS) <. POD- - Pain (analgesics given) <. VAS: Visual analogue scale,, SD: Standard deviation Table : Post-operative - day - : Assessment of complications Complications Group (n (%)) P POD- - Constipation No (9.) 9 (9.). Yes (.) (.) POD- - Rectal bleeding No (.) 9 (9.). Yes (.) (.) Table : Assessment of post-operative pain VAS Group P POD- - Pain <. POD- - Pain <. POD- - Pain <. weeks - Pain <. weeks - Pain NS months - Pain NS months - Pain NS months - Pain NS VAS: Visual analogue scale,, SD: Standard deviation International Journal of Scientific Study February Vol Issue

5 Harish, et al.: Routine Internal Hemorrhoidectomy POD- (P =.) POD- (P =.) POD- (P =.) Post-operative weeks (.) Post-operative weeks (.) In our, postoperatively, patients had constipation only in the early post-operative period, i.e. POD- and day. On comparing both the groups, it was found that patients who underwent hemorrhoidectomy had significantly lesser episode of post-operative Meadian VAS score No. of participants rectal bleeding No. of participants constipation 9 Day Day Day Week Week Month Month Month Graph : Assessment of post-operative pain Day Day Day Week Week Month Month Month Graph : Assessment of post-operative rectal bleeding Post op day Post op day Graph 9: Assessment of post-operative constipation Table 9: Assessment of post-operative rectal bleeding Rectal bleeding Group (n (%)) POD- No (.) (9.). Yes (.) (.) POD- No (.) 9 (9.). Yes (.) (.) POD- No (.) 9 (9.). Yes (.) (.) weeks No (9.) (.). Yes (.) () weeks No (9.) (.). Yes (.) () months No (.) (.) NS months No (.) (.) NS months No (.) (.) NS Table : Assessment of post-operative constipation Constipation Group (n (%)) P POD- - Constipation No (.) (9.). Yes (.) (.) POD- - Constipation No (9.) 9 (9.). Yes (.) (.) Table : Assessment of complete wound healing post-operative Complete wound healing Group (n (%)) weeks No (.) (). Yes (.) (.) weeks No (.) (.). Yes (.) () P P International Journal of Scientific Study February Vol Issue

6 Harish, et al.: Routine Internal Hemorrhoidectomy No. of particpants complete wound healing constipation (Table and Graph 9). POD- (P =.) and POD- (P =.). In our, on comparing open hemorrhoidectomy / out for assessment of complete wound healing, it was found that the time taken for complete wound healing was significantly more (P =.). It also showed that in patients who underwent, complete wound healing occurred by weeks (Table and Graph ). DISCUSSION Age and sex distribution Das et al. Das et al. Mean age. 9.. Male/female ratio / /9 / / The age and sex distribution among the group were compared a done by Das et al. In my, the mean age at presentation was about years more than that of the compared. The male: female ratio was almost similar in my, whereas in the compared males were more than females. Post-operative pain weeks weeks Das et al. Graph : Assessment of complete wound healing post-operative Das et al. Number of patients Mean pain score.... In my, the total number of patients in control and group were more when compared to the carried out by Das et al. The mean pain score in my was comparatively lesser in the group. Furthermore, in my, post-operative pain was statistically significant for the intial post-operative period in group, but in the later follow-up period, it was not significant. Therefore, hemorrhoidectomy post-operative pain was significantly lesser when compared to hemorrhoidectomy out. Complications Das et al. Das et al. Urinary retention Constipation Rectal bleeding Nil Nil Incontinence Nil Nil Nil Anal stenosis Nil Nil Nil In my, on comparing the complications in the post-operative period, in both groups, it was found that patients undergoing hemorrhoidectomy out had significantly more complications when compared to group. Furthermore, in my, no patients experienced any of the late complications such as incontinence or anal stenosis, whereas in the conducted by Das et al., patients in out group had flatus incontinence and patient in group had anal stenosis. Complete wound healing (%) Das et al. Das et al. Post-operative weeks Post-operative weeks - - Healing rates following /out after hemorrhoidectomy were compared between my and the conducted by Das et al. In the follow-up period post-operative, it was found that Complete wound healing occurred by weeks in group of both the studies. Thus, on comparison, healing rate was higher and early in hemorrhoidectomy group in my as well as the conducted by Das et al. CONCLUSION Hemorrhoids is one of the oldest diseases known to mankind causing significant discomfort to the patient. The most common clinical presentations being bleeding and International Journal of Scientific Study February Vol Issue

7 Harish, et al.: Routine Internal Hemorrhoidectomy mass per rectum. The most common surgical procedure for the treatment of hemorrhoids is Milligan Morgan or open hemorrhoidectomy. Post-operative pain and delayed wound healing is of concern, post-open hemorrhoidectomy, and hence the was done to compare the above procedure the addition of internal, respect to post-operative pain, post-operative complications and wound healing. The results of the conclude that post-operative pain, post-operative complications were lesser in open hemorrhoidectomy internal, early wound healing. REFERENCES. Cohen Z. Symposium on outpatient anorectal procedures. Alternatives to surgical hemorrhoidectomy. Can J Surg 9;:-.. Keighley MR, Williams NS. Surgery of Anus, Rectum and Colon. nd ed., Vol.. Philadelphia, PA: Saunders Publications;. p. -.. Ellesmore S, Windsor AC. Surgical history of haemorrhoids. In: Charles MV, editor. Surgical Treatment of Haemorrhoids. London: Springer;. p. -.. Shampo MA. Brief history of colorectal surgery. J Pelvic Surg 99;:9-.. Notaras MJ. The treatment ofanal fissure by lateral subcutneous internal a technique and results. Br J Surg 9;:9-.. Williams PL, Warwick R. Gray s Anatomy. th ed., Ch.. Edinburgh: Churchill Livingstone;. p. -.. Decker G, du Plessis DJ. Lee Mc Gregor s-synopsis of Surgical Anatomy. th ed. Bristol: John Wright and Sons; 9. p. -.. Sinnatam CS. Last s Anatomy-Regional and Applied. th ed. Edinburgh: Churchill Livingstone;. p Thomson WH. The nature of haemorrhoids. Br J Surg 9;:-.. Thomson WH. Haemorrhoids. In: Morris PJ, Malt RA, editors. Oxford Textbook of Surgery. Ch... New York: Oxford University Press; 99. p. -.. Gibbons CP, Bannister JJ, Read NW. Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids. Br J Surg 9;:-.. Gass OC, Adams J. Hemorrhoids; etiology and pathology. Am J Surg 9;9:-. How to cite this article: Harish S, Sringeri RR, Ajay G. Routine Internal Hemorrhoidectomy: A Prospective Study. Int J Sci Stud ; ():-. Source of Support: Nil, Conflict of Interest: None declared. International Journal of Scientific Study February Vol Issue