|Ahead of print publication
A minimalistic approach to benign anorectal pathologies: Retrospective analysis of 100 patients in armed forces
Anshul Jain1, Deep Shikha Mishra2
1 Department of Surgery, Military Hospital, Leimakhong, Imphal, Manipur, India
2 Department of General Surgery, Military Hospital, Bathinda, Punjab, India
|Date of Submission||13-Feb-2020|
|Date of Decision||09-May-2020|
|Date of Acceptance||30-Aug-2020|
|Date of Web Publication||01-Apr-2021|
Deep Shikha Mishra,
Department of General Surgery, Military Hospital, Bathinda - 151 004, Punjab
Source of Support: None, Conflict of Interest: None
Background: Patients with benign anorectal conditions who are treated surgically have long been subjected to fluid diet and and bowel cleansing with either laxatives or enema. Materials and Methods: This study is a retrospective analysis of prospectively maintained data from July 2016 to May 2019 at a secondary level hospital. The study assessed 100 patients who underwent surgical management for fissure-in-ano, fistula-in-ano, and internal hemorrhoids. Results: The intraoperative fecal encounter occurred in five patients (5%). Eighty-nine patients were pain free on postoperative day 3. No patient developed local or systemic sepsis or fecal incontinence. Recurrence was seen in five patients (5%). Conclusion: The study reiterates the fact that surgical management for benign anorectal diseases is straightforward, without the need for extensive perioperative interventions
Keywords: Anorectal surgery, antibiotics, bowel preparation, diet
| Introduction|| |
Anorectal surgeries for benign diseases are one of the most common surgeries performed worldwide by general surgeons. The conditions included are fissure-in-ano, fistula-in-ano, and internal hemorrhoids. Almost all surgeons encounter patients who present with these conditions and require surgical intervention for relief. Although the surgeries are usually straightforward with laid down guidelines, it is the perioperative management that requires attention. The practices have varied widely over time between institutions and individual surgeons. It includes keeping patients on fluids only on the day preceding surgery and/or giving laxatives or enema and many a times administration of antibiotics in the perioperative period. The aim behind these rituals is to get a clean area to operate upon and prevent local or systemic sepsis in the postoperative period.
Fasting before surgery is a prerequisite for all surgeries requiring anesthesia. However, those undergoing rectal surgeries have had to bear a fasting period of almost 24 h. Thus, keeping a patient on fluid diet before surgery and further nil orally 4–6 h postsurgery effectively leaves him hungry for approximately 36 h. Similarly, prescribing oral laxatives may annoy the patient due to frequent defecation, especially the elderly, and administration of enemas requires staff; as in our setting, patients are admitted a day before surgery.
In the present era of antibiotic resistance, it is emphasized time and again to use antimicrobial agents judiciously. The practice of antibiotic administration is unnecessary in such surgeries as the flora is native to anorectal region; however, the practice still continues. All these practices lead to patient distress, increased cost, requiring additional staff, and translate into a prolonged hospital stay.
The present study aims to analyze the results of anorectal surgeries without the use of fluid diet, bowel preparation, and perioperative antibiotics, with the end points being encounter of feces during the procedure, postoperative pain, passage of flatus and stools in the postoperative period, incontinence, and sepsis – local or systemic and recurrence.
| Materials and Methods|| |
This study was conducted as a retrospective analysis of prospectively maintained data from July 2016 to May 2019 at a secondary level hospital in Armed Forces. During this period, 130 patients underwent 136 anorectal procedures. The surgeries included open lateral internal sphincterotomy (LIS) with or without sentinel pile excision for chronic fissure, fistulotomy with or without setoning for fistula-in-ano, and open hemorrhoidectomy for Grade 3 and 4 internal hemorrhoids. Subarachnoid block was the anesthesia in all except one female patient who was given total intravenous anesthesia due to spinal deformity. Thirty patients who were administered bowel preparation, antibiotics, or kept on liquid diet were excluded from this study. No imaging was performed for patients with fistula-in-ano in the form of conventional or magnetic resonance (MR) fistulogram.
The 100 patients observed in this study were evaluated clinically with digital rectal examination and anoscopy. They had normal diet till the night before surgery, given psyllium husk at night, kept nil per os (NPO) after midnight till surgery and 4–6 h thereafter, and no laxative or enema was administered. Perioperative antibiotics, either parenteral or oral, were not administered to any patient except one (70-year-old male with anemia and chronic obstructive pulmonary disease [COPD]). Patients were encouraged to take a high-fiber diet, plenty of oral fluids, and sitz baths during the postoperative period for comfortable recovery. They were prescribed Nonsteroidal anti-inflammatory drugs 8 hourly on the 1st postoperative day (POD) and 12 hourly on the 2nd POD for pain relief and psyllium husk as a stool softener. All patients were followed up for at least 6 months.
| Results|| |
Of the 100 patients, two-thirds were male. The incidence of fissure-in-ano was equal in females and males, while fistula-in-ano and hemorrhoids predominantly affected males (81.5% and 84.6%, respectively). The age of occurrence was earlier for fissure-in-ano and fistula-in-ano, while hemorrhoids occurred almost a decade later. Fissure-in-ano and fistula-in-ano were predominantly seen in the third to sixth decades of life (n = 49 and 38, respectively); internal hemorrhoids were present in the fifth to seventh decades (n = 13) [Table 1].
The fecal contamination during surgery was encountered in five patients; three with fissure-in-ano (6%) and one each in fistula-in-ano (2.6%) and hemorrhoids (7.6%). There was no substantial increase in operative time due to contamination nor increase in postoperative pain. All patients were started on a regular diet within 4–6 h of surgery, and most of them passed flatus the same day and feces on POD-1 [Table 2]. The mean pain score was 4.3 on POD-1 with 89% pain free on POD-3 [Table 3]. All wounds were allowed to heal with secondary intention. No patient reported incontinence after LIS or fistulotomy and none presented with anal stenosis post hemorrhoidectomy. No patient developed local or systemic sepsis in the postoperative period requiring drainage or antibiotics.
Recurrence was seen in three (6%) patients with fissure, which was treated with repeat LIS in one and stool softener and diet in the other two. Two patients (15%) had intermittent bleeding post hemorrhoidectomy; one was managed with sclerotherapy and the other with stool softener. No recurrence was seen in patients with fistula-in-ano.
| Discussion|| |
The incidence of hemorrhoids peaks between 45 and 65 years, and it is unusual in a population younger than 20 years., Furthermore, it is a disease predominantly seen in men. The age and gender distribution in the present study is similar to existing literature. The excised hemorrhoid tissue was not sent for routine histopathological examination, as the incidence of unsuspected anal carcinoma is rare.
Literature reports equal distribution of fissure-in-ano in both sexes with a mean age of 39.9 years. The same findings were noted in this study with a mean age of 41.8 years and equal sex distribution (women – 51%, men – 49%). Internal sphincterotomy as the treatment of choice has been strongly recommended after conservative management fails,, and studies comparing various surgical approaches found that LIS fared best out of all the treatment options available., The patients in this study with fissure-in-ano were treated exclusively with open LIS using a 1 cm incision at 9 o' clock in anoderm and dividing the lower half of internal sphincter through it. No patient reported incontinence to flatus or feces, and only one (2%) required redo surgery for persistent symptoms, similar to reported in the majority of studies.,
Fistula-in-ano presents with discharge, pain, swelling, and diarrhea, and in the present study too, intermittent discharge and pain were the most common symptoms. In literature, the male-to-female ratio varies from 2:1 to 7:1, and this study had 4.5:1 gender ratio. The incidence in the study was between the third and sixth decades of life, similar to what is reported in literature. The distance of external opening from the anal margin correlates with the complication of upward extension. Fistulography may produce large false-positive results, thus being inconsistent when compared to intraoperative findings, causing needless and damaging surgeries. Imaging is recommended only in recurrent or complicated fistulas as an agreement between MR imaging and surgery is about 90%., We also did not order a conventional or MR fistulogram for any of the patients in our study. Only two patients (5.2%) who were found to have internal opening higher than puborectalis during examination under anesthesia underwent setoning.
Preoperative preparation for benign anorectal surgeries is simple. Bowel preparation is restricted to patients with a high rectal lesion, those undergoing sphincteroplasty and repair of recto-vaginal fistula, or those who have a possibility of perforation which may require abdominal exploration. The use of enema the night before and early morning of the day of surgery, for cleansing has been advocated, but in our study, we did not see any ill effect of omitting it. The diet was kept normal without limiting to clear fluids or liquid diet, and the ingestion of psyllium husk by the patients helped in smooth passage of stools in the postoperative period. The use of antibiotics should be limited to those with compromised immune function, systemic illness, or implanted with prosthetic valves. In our study, we administered a single dose of perioperative antibiotic to a 72-year-old male with anemia and COPD who underwent open hemorrhoidectomy. There was no incidence of local or systemic sepsis in any of our patients.
Restriction of fluids in the perioperative period does have a beneficial effect in preventing postoperative urinary retention, which has been proven conclusively. We did not pack the anorectum with paraffin gauze-wrapped swab routinely but restricted to those who underwent open hemorrhoidectmoy, and the pack was removed 6–8 h after the surgery. This is in consonance with literature, which suggests that intra-anal packing has no benefit, and it must be restricted to oozing wounds., Further, prolonged packing of anal canal with iodoform gauze may lead to incontinence by causing fibrosis of sphincter and a hard scar. Patients were started on liquids as soon as they were able to take orally and normal diet by postoperative evening with psyllium husk at night. The use of oral laxatives was limited to those who did not pass stools by POD-3 or had dyschezia. One patient (7.6%) following hemorrhoidectomy had bleed after removal of pack, which was managed nonoperatively with an antifibrinolytic drug. The incidence of bleeding in literature is about 4% for closed hemorrhoidectomy.
| Conclusion|| |
The aim of surgeries for benign anorectal diseases is comfort and economy for the patients. The avoidance of preoperative fluid diet, laxatives, or enema keeps the patient comfortable. The use of antibiotics to selected patients is economical and conforms to available evidence, with no increase in the risk of sepsis. Furthermore, clinical examination and evaluation under anesthesia is sufficient for most of the patients presenting with fistula-in-ano, with radio imaging reserved for atypical or recurrent disease, and therefore, no imaging was done in this study for patients with fistula-in-ano.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]