Anorectal surgery has traditionally been associated with pain, prolonged hospitalization and complications following surgery. Over the last decade, there have been considerable improvements in the management of common anorectal problems like piles and fissures, ultimately resulting in decreased post operative pain and lesser complications, thus, enabling patients to return home and to their regular work, early.
Anaesthesia – Most anal surgeries that were being done under general or regional anaesthesia are now being done under local anaesthesia. The technique of local anaesthesia has a short learning curve, which can be easily mastered. Even if the surgery is not done under local anaesthesia, 0.25% bupivacaine can be injected circumferentially around the anus to give an effective and prolonged post operative analgesia. Decreased post operative pain means early ambulation, with further decrease in post operative complications, like urinary retention, ultimately leading to early discharge from hospital. There is growing evidence to show that the use of local anaesthesia in anorectal surgery enables these surgeries to be done as day care.
Surgical Procedures
Better understanding of the disease process along with new technological improvements; have enabled more procedures to be performed as day care procedure.
Piles
Piles are classified into various grades. In grade 1 and 2, there is bleeding, but the piles may or may not prolapse, reducing spontaneously if they prolapse. In grade 3 and 4, along with the bleeding, the piles prolapse outside the anus requiring manual reduction or in severe cases may be irreducible. However, most cases of piles are grade 1 and 2, which can easily be treated by “office procedures” like banding, sclerotherapy or Infrared coagulation. Most of these procedures can be performed under surface anaesthesia without requiring hospitalization. Thus, almost 60-70% of piles can be treated as ‘out patient’ cases with these simple procedures. Grade 3 and 4 piles, which were traditionally being treated by haemorrhoidectomy, now can be operated by a stapler (PPH, MIPH), which is a day care procedure. In this procedure, the mucosa above the dentate line, which contains part of the pile mass, is excised and stapled with the stapler gun, thus taking care of bleeding and prolapse – the two major components of piles. Since this procedure is done at a spot which does not have somatic nerve supply, it causes minimal post-operative pain. Additionally there is no incision on the perianal skin or lower part of anal canal and the wound in the anal mucosa is also primarily closed with a stapler, thus, there is no need to do any post operative dressing. Almost all cases of piles can be treated as day care, with overnight stay being an exception.
Fissure in ano
Basic pathology in anal fissure is: raised anal pressure, which ultimately prevents healing of the fissure. Most cases of anal fissure are treated conservatively. Those patients, who do not respond to conservative measures, or have repeated attacks of pain, need surgical intervention. Surgical treatment of fissure-in-ano consists of dividing the internal sphincter, which lowers the anal pressure, helping in the healing of the fissure. This procedure, which is called internal sphincterotomy, is easily performed under local anaesthesia as a day care procedure; in select cases, it can be done as an out patient procedure. Thus, all cases of anal fissures can be treated as out patient or day care procedures.
Fistula-in-ano
Small subcutaneous and simple fistula-in-ano can also be operated as a day care procedure, but the patients have to be selected and followed-up closely.
Other anal procedures like excision of warts, cauterization of anal lesions and draining of small abscesses can all be done as day care procedures.
One should however be aware of complications and limitations of various procedures. There should not be any hesitation in keeping these patients overnight for observation if any complication is anticipated or occurred.
On discharge proper instructions about the drugs and wound care, if required, is explained to the patient.
Thus, most ano-rectal surgeries for benign diseases are now being performed as day care all over the world. In our country too, where cost plays a major role, ambulatory surgery can help lower the cost. At the same time improvements in surgical techniques and the use of local anaesthesia has helped in ensuring minimal post operative pain and decreased complications; thus enabling patients to return to work early.
CHILDREN WITH SORE THROAT MAY NOT BENEFIT FROM PENICILLIN
Giving penicillin to children with a sore throat may not be beneficial. Zwart and collaborators found no differences between the groups in terms of duration and recurrence of symptoms, use of analgesic, and days missed at school. After treatment with penicillin, streptococcal sequelae (such as quinsy, impetigo, and scarlet fever) tended to be less common, these can be safely dealt with as they happen, the authors say, and the possibility of sequelae does not justify treating all children with a sore throat.
BMJ, 2003; 327 : 1324. |
|
