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Perianal local block for stapled anopexy
Linköping University, Department of Clinical and Experimental Medicine, Surgery . Linköping University, Faculty of Health Sciences.
Colorectal Surgery, Department of Surgery, Salgrenska University Hospital, Östra, Göteborg, Sweden.
Colorectal Surgery, Department of Surgery, Karolinska University Hospital-Huddinge, Stockholm, Sweden.
2006 (English)In: Diseases of the colon and rectum, ISSN 0012-3706 (print) 1530-0358 (online), Vol. 49, no 12, 1914-1921 p.Article in journal (Refereed) Published
Abstract [en]

Purpose This study was designed to demonstrate the usefulness of a method of regional anesthesia for circular stapler anopexy for prolapsing hemorrhoids.

Methods Thirty-three patients consented to stapled anopexy under perianal local anesthesia. Eighteen patients with stapled anopexy under general anesthesia were controls. The perianal block was applied with 40 ml of ropivacaine, 4.75 mg/ml, injected immediately peripheral to the external sphincter. A submucosal block with 15 ml of ropivacaine, 2 mg/ml, was added after applying the pursestring suture. Postoperative pain was rated by the patient for 14 days by using a ten-point visual analogue scale. Patients also submitted a preoperative and postoperative (3–6 months) symptom questionnaire to rate anal symptoms.

Results No operation was converted to general anesthesia. Operation time was similar in both groups. All patients in the local anesthesia group were pain free at discharge. The sums of pain scores during 14 days for daily average pain and peak pain were similar in both groups (average pain 23 (local anesthesia) vs. 35 (general anesthesia); peak pain 39 (local anesthesia) vs. 50 (general anesthesia); P > 0.05). The preoperative symptom scores were 7.8 (local anesthesia) vs. 8.9 (general anesthesia) points, and the follow-up scores were 2.2 (local anesthesia) and 2.7 (general anesthesia), a significant improvement (P = 0.001) in both groups but not different between groups.

Conclusions A perianal local block is easy to apply and has a high degree of acceptance among patients. The operation time, postoperative pain, and success rates of the operation equaled those of stapled anopexy performed under general anesthesia. The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery.

Place, publisher, year, edition, pages
2006. Vol. 49, no 12, 1914-1921 p.
Keyword [en]
Hemorrhoids, Surgery, Perianal, Anesthesia, Ropivacaine, Anopexy, Stapler
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-13286DOI: 10.1007/s10350-006-0750-8OAI: diva2:18212
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-05-15
In thesis
1. Outcome After Haemorrhoidopexy
Open this publication in new window or tab >>Outcome After Haemorrhoidopexy
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: This dissertation is composed of five individual studies of the stapled haemorrhoidopexy operation. The operation was launched to an international audience in 1998 by the Italian surgeon Antonio Longo. In conventional surgery the prolapsed piles are excised from the anodermal part of the prolapse up through the anal canal into the lower rectal mucosa where the pile is divided with diathermy or suture ligated and excised. It leaves open wounds throughout the anal canal. These wounds can be very painful, especially at defecation, and will take from three to six weeks to heal. In the stapled haemorrhoidopexy operation symptomatic haemorrhoids are seen as a disease of anodermal, haemorrhoidal and rectal mucosal prolapse of varying degree. The main component of the prolapse is the redundancy of rectal mucosa. By pushing back the prolapse into the anal canal followed by excision of the mucosal redundancy above the anal canal with a circular stapler devise a mucosal anastomosis is fashioned. This anastomosis is situated immediately above the haemorrhoids and will attach them to the rectal muscular wall to prevent further prolapse. The operation is associated with substantially less pain and a quicker recovery.

Methods: For the five studies, a total of 334 patients were operated for haemorrhoidal prolapse. The first operations were performed in February 1998. All patients were assessed preoperatively and postoperatively with the same set of protocols as follows. The symptoms of haemorrhoids were scored with a questionnaire to patients to obtain their independent statements of the frequency of each of five cardinal symptoms: pain, bleeding, pruritus, soiling and prolapse in need of manual reduction. A diary was used by patients to report daily pain scores, use of pain medication and speed of recovery within the first 14 postoperative days. The surgeon rated the deranged anal anatomy before and after surgery. We also developed an algorithm based on the patients’ statement of digital reduction of prolapse (grade 3) and the surgeon’s assessment of lesser prolapse at proctoscopy (grade 2). Absence of prolapse was grade 1. The surgeon also provided statements about the conduct of the operation and rated the technical complexity. The information, for all patients, was entered into an electronic data base.

Results: One registry based study and one prospective randomised controlled trial assessed the advantage of performing the operation under perianal local anaesthetic block. The postoperative pain and surgical outcome was independent of the type of anaesthesia. No operation under local block had to be converted to general anaesthesia. Anodermal prolapse is seen in 70 percent of the patients. In a registry-based study we found that excision of the anodermal folds did not increase the postoperative pain provided the excision stopped at the anal verge. In 270 patients with precise preoperative and postoperative classification we found that the symptomatic load was identical for grades 2 and 3. The symptoms were independent of the anodermal prolapse. The symptoms were greatly reduced when the operation turned out grade 1 prolapse. The long-term result was assessed in 153 patients operated 1 year to 6 years previously. The need for early re-intervention was 6.2 percent representing technical error to reduce the prolapse. At the final evaluation 12 patients (8.2 percent) complained of a mucoanal prolapse in need of digital reduction. The mean symptom burden had been reduced from 8.1 to 2.5 points but 17 percent had at least one cardinal symptom with a weekly frequency.

Conclusions: Stapled haemorrhoidopexy should be performed as day surgery under local anaesthesia. Any remaining anodermal prolapse should be excised. The optimal long-term outcome is grade 1A or 1B with low symptom score. There was an 87 percent chance of cure of the prolapse with the first haemorrhoidopexy. About half the failures were insufficient primary surgery and half a relapse of the prolapse.

Place, publisher, year, edition, pages
Linköping University Electronic Press, 2008. 76 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1064
Haemorrhoids, haemorrhoidopexy, surgery, local anaesthesia, classification, prolapse
National Category
urn:nbn:se:liu:diva-11797 (URN)978-91-7393-903-4 (ISBN)
Public defence
2008-05-30, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)

The original title of article IV was "Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. The new title after publishing the article is "Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients".

Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2015-11-19

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Gerjy, RogerNyström, Per-Olof
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