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Ambulatory proctology

Bruno Roche

Unit of Proctology

University Hospital of Geneva

Bruno.Roche@hcuge.ch

www.proctology.ch

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Advantages

Life minimally disturbedAnxiety reducedLess nosocomial infectionsEarlier return to activitiesWork time off reduced

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Advantages

Administrative management Costs of outpatient < inpatient Overall health expenditure reducedHospital beds for severe cases

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Disadvantages

Preoperative instructionsPreoperative preparation difficultiesTransportation problemsAssistance at homeNecessity of resuscitative back-upAnalgesia management

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Selection criteria: Medical

Age (no more)ASA I and ASA II (no more)Medical condition controlledNo anti-aggregate medication

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Selection criteria: Social

Positive for outpatient surgeryNot alone during 24 hoursSocial circumstances adaptedEasy access to a bathroom and toiletsTelephone should be accessible

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Selection criteria: General

Not drive to go home

Distance home hospital:

60 to 100 km

Transportation facilities

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Selection criteria: Physician

Emergency accessible 24 hours a day

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Anesthesia

Local anesthesiaPosterior perineal block

Caudal or rachianesthesiaGeneral anesthesia

Short duration Low side effects

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Goals:- Deep and long-lasting analgesia - Relaxation of the anal canal- Blood-free operative field- No side effects on the bladder- Suppression of vagal reflex- Easy use in outpatients

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Local anesthaesia and perineal block:

60 ml 0.5% lidocaine + epinephrine12 ml Natrium Bicarbonate 8,4 %

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Practical organisation Practical organisation

No starving

No bowel preparation

No depilation

Premedication only for anxious people

Empty bladder and rectum pre-op

No venous access for LA and PPB

Resuscitation material in the room

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Practical organisation

The patients receives

- Instructions

postoperative care

- Prescription

- Appointment for day 5

Time needed:

60 to 90 minutes

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Postoperative management

Sit Baths Shower: 3 - 6 x / DTopical wound healing cream:

MitosylPanthenolIalugen-Plus

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Postoperative management

Laxatives: MucillageMineral oilDuphalac

Anti-inflammatory drugsPainkillers

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Postoperative control

On day 5 WeeklyAs necessary

No routine digital examination Silver Nitrate if granulation

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Possible procedures:

Thrombosed haemorroidectomyHaemorroidectomySphincterotomyAbscess drainageFistulectomySliding flapsAnoplastyAnal warts excisionLow located villous adenomaSinus pilonidalis

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0

100

200

300

400

500

600

700

Patients

1978 1982 1986 1990 1994 1998 2002

Années

Iinterventions proctologiques ambulatoires1978 à 2004

Iinterventionsproctologiquesambulatoires

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Ambulatory procedure in L.A. 1993 to 2004

  RECOVERED AMBULATORY

     

Haemorrhoids 887 1042

Fissures 46 545

Fistulas 331 686

Pylonidal Sinus 16 786

Condyloma 37 289

Tumours, polypes 49 175

Anoplasty 17 20

Others 24 182

     

Total 1407 3725

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COMPLICATIONS OF 3725 PROCEDURES

 Bleeding (18) 

 4 post fistulectomy8 post pylonidal sinus 5 post haemorrhoïdectomy1 post sphincterotomy    

Infections 0 

Fecaloma 3 

Urinary Retention 5 

Hospitalisation 17 

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Can we prevent postoperative complications

Pain ?

Bleeding ?

Bladder Retention ?

Fecal Impaction ?

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Postoperative pain control

We can’t determine preoperatively Tolerance of postoperative pain Sensitive person

We should routinely :Infiltration long lasting ALStrong painkillers

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Pre-emptive analgesia in post operative pain controlPre-emptive analgesia in post operative pain control

Double blind randomised study Ropivacaïne vs. Placeboon 100 consecutive perineal surgery in general anaesthesia

VAS evolution in post-operative pain

0

1

2

3

4

5

6

7

J1 J2 J3 J4 J5 J6 J7

Post op Days

VA

S 0

to

10

infiltration AL pré-op.

Sans infiltration AL

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Prevention of urinary retention

Operation with empty bladder

Restriction of fluid administration

Posterior Perineal Block < 0.5 %

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Prevention of faecal impaction

Preoperative dietHigh fibbers rate

PostoperativeParaffin oil dailyOsmotic laxatives one week

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FUTURE:

Quality control studies Evaluation the outcomesAssess patients satisfaction index

If patients are not happyindications will never be enlarged

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Operative indications enlarged

Rectoceles

Sphincteroplasty

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Better Proct. outpatient surgery:

Short anesthesia low of side effectsOperative indications increaseOvercome postoperative painStimulate wound healing

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Conclusions:

Proctological outpatient surgery can be performed in a safe way:- few complications- high patient satisfaction index

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Indications will be enlarged if:

General anesthesia shorter and saferLong lasting local anesthesiaBetter pain killersMore effective wound healing drugs

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Indications will be enlarged if:

Patient satisfaction index highStimulation from insurances