RESUMEN
PURPOSE: Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes. METHODS: From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA. RESULTS: Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01). CONCLUSIONS: A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.
Asunto(s)
Empleo , Hemorroides/cirugía , Engrapadoras Quirúrgicas , Suturas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hemorroides/patología , Humanos , Masculino , Persona de Mediana Edad , Narcóticos/uso terapéutico , Complicaciones Posoperatorias , Estudios ProspectivosRESUMEN
BACKGROUND: Major comorbidities are recognized risk factors in colorectal surgery. We examine here the feasibility and safety of laparoscopic colorectal surgery (LC) in the complicated, high-risk patient. METHODS: From July 2003 to October 2004, 107 consecutive patients undergoing LC were prospectively studied. Complicated patients were defined as age >80 years, body mass index (BMI) >30, and/or American Society of Anesthesiology level III or IV. A group of case-matched controls undergoing open surgery (OC) during a similar time period were retrospectively reviewed. The 2 groups were compared and assessed for major and minor morbidity and mortality. RESULTS: Overall morbidity was higher in the OC group 52% versus 26%. Minor complications compared at 31% OC versus 9% LC and major at 21% and 17%, respectively. With LC, advancement to discharge was more rapid and discharge home more likely than to a care facility. CONCLUSION: With proper patient selection and laparoscopic experience, LC can be performed in the complicated patient without undue morbidity and mortality.