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Roche

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									Ambulatory proctology

         Bruno Roche
      Unit of Proctology
 University Hospital of Geneva
   Bruno.Roche@hcuge.ch
      www.proctology.ch
                                 Poli.Chir.
Advantages

Life minimally disturbed
Anxiety reduced
Less nosocomial infections
Earlier return to activities
Work time off reduced
                               Poli.Chir.
Advantages


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

                              Poli.Chir.
Disadvantages

Preoperative instructions
Preoperative preparation difficulties
Transportation problems
Assistance at home
Necessity of resuscitative back-up
Analgesia management
                                Poli.Chir.
Selection criteria: Medical


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

                               Poli.Chir.
Selection criteria: Social

Positive for outpatient surgery
Not alone during 24 hours
Social circumstances adapted
Easy access to a bathroom and toilets
Telephone should be accessible
                               Poli.Chir.
Selection criteria: General



Not drive to go home
Distance home hospital:
60 to 100 km
Transportation facilities



                              Poli.Chir.
Selection criteria: Physician



    Emergency accessible
      24 hours a day

                                Poli.Chir.
Anesthesia

Local anesthesia
Posterior perineal block
Caudal or rachianesthesia
General anesthesia
  Short duration
  Low side effects          Poli.Chir.
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
                                     Poli.Chir.
Local anesthaesia and perineal block:



    60 ml        0.5% lidocaine + epinephrine
    12 ml        Natrium Bicarbonate 8,4 %



                                           Poli.Chir.
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
                                        Poli.Chir.
Poli.Chir.
Practical organisation

The patients receives
  - Instructions
     postoperative care
  - Prescription
  - Appointment for day 5

Time needed:
60 to 90 minutes
                            Poli.Chir.
Postoperative management

Sit Baths Shower:
3-6x/D
Topical wound healing
cream:
   Mitosyl
   Panthenol
   Ialugen-Plus            Poli.Chir.
Postoperative management
Laxatives:
  Mucillage
  Mineral oil
  Duphalac
Anti-inflammatory drugs
Painkillers
                           Poli.Chir.
Postoperative control

On day 5
Weekly
As necessary

No routine digital examination
Silver Nitrate if granulation
                            Poli.Chir.
Possible procedures:

Thrombosed haemorroidectomy
Haemorroidectomy
Sphincterotomy
Abscess drainage
Fistulectomy
Sliding flaps
Anoplasty
Anal warts excision
Low located villous adenoma
Sinus pilonidalis
                              Poli.Chir.
                 Iinterventions proctologiques ambulatoires
                                 1978 à 2004

           700
           600
           500
           400
Patients
                                                              Iinterventions
           300
                                                              proctologiques
           200                                                ambulatoires

           100
            0
            1978 1982 1986 1990 1994 1998 2002
                               Années
                                                               Poli.Chir.
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      Poli.Chir.
     COMPLICATIONS OF 3725 PROCEDURES


Bleeding (18)       4 post fistulectomy
                    8 post pylonidal sinus
                    5 post haemorrhoïdectomy
                    1 post sphincterotomy
Infections          0

Fecaloma            3

Urinary Retention   5

Hospitalisation     17
                                               Poli.Chir.
Can we prevent postoperative complications



                 Pain ?
              Bleeding ?
         Bladder Retention ?
          Fecal Impaction ?
                                    Poli.Chir.
Postoperative pain control

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

We should routinely :
   Infiltration long lasting AL
   Strong painkillers
                                     Poli.Chir.
Pre-emptive analgesia in post operative pain control

Double blind randomised study Ropivacaïne vs. Placebo
on 100 consecutive perineal surgery in general anaesthesia
                            VAS evolution in post-operative pain

              7
              6
              5
VAS 0 to 10




              4                                                    infiltration AL pré-op.
              3                                                    Sans infiltration AL

              2
              1
              0
                  J1   J2     J3        J4        J5   J6   J7
                                   Post op Days

                                                                                             Poli.Chir.
Prevention of urinary retention

Operation with empty bladder

Restriction of fluid administration

Posterior Perineal Block < 0.5 %

                                  Poli.Chir.
Prevention of faecal impaction

Preoperative diet
   High fibbers rate

Postoperative
   Paraffin oil daily
   Osmotic laxatives one week
                                 Poli.Chir.
FUTURE:


Quality control studies
Evaluation the outcomes
Assess patients satisfaction index
If patients are not happy
indications will never be enlarged
                                 Poli.Chir.
Operative indications enlarged


Rectoceles

Sphincteroplasty


                                 Poli.Chir.
Better Proct. outpatient surgery:


Short anesthesia low of side effects
Operative indications increase
Overcome postoperative pain
Stimulate wound healing

                               Poli.Chir.
Conclusions:


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

                               Poli.Chir.
Indications will be enlarged if:


General anesthesia shorter and safer
Long lasting local anesthesia
Better pain killers
More effective wound healing drugs


                                   Poli.Chir.
Indications will be enlarged if:

Patient satisfaction index high
Stimulation from insurances




                                   Poli.Chir.

								
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