Factors affecting the postoperative healing in ferguson technique for hemorrhoidectomy

Nội dung text: Factors affecting the postoperative healing in ferguson technique for hemorrhoidectomy

1. Journal of military pharmaco-medicine n o2-2018 FACTORS AFFECTING THE POSTOPERATIVE HEALING IN FERGUSON TECHNIQUE FOR HEMORRHOIDECTOMY Phan Sy Thanh Ha*; Tran Minh Dao* Nguyen Xuan Hung*; Nguyen Van Xuyen** SUMMARY Objectives: To study several factors affecting the postoperative healing with Ferguson technique for hemorrhoidectomy. Subjects and methods: 190 patients with third-degree and fourth-degree hemorrhoids underwent the Ferguson procedures at Vietnam-Germany Hospital from 01 Sep 2012 to 31 Dec 2013. Results: 82.1% had the incision wound healed in phase 1 and 17.9% in phase 2. There was a correlation between the duration of healing and the form of feces at the first postoperative bowel movement (p < 0.05). There was no correlation between the duration of healing and the degree of hemorrhoids and numbers of cut hemorrhoids (p > 0.05). Conclusion: Ferguson technique for hemorrhoidectomy is safe with good treatment outcome, rapid healing, simple postoperative care and patients soon return to normal life and work. * Keywords: Hemorrhoids; Ferguson technique; Postoperative healing. INTRODUCTION surgeons are still cautious to choose There are many methods of treatment this method as the closure of skin and for hemorrhoids, including adjustment of rectal mucous membranes by suturing diets and sanitary care, procedure, surgery, may cause postoperative abscesses oriental medicine, occidental medicine or and infections. In 2010, the first report combination of oriental and occidental by Nguyen Xuan Hung showed that medicine. Surgical methods aim to cure Ferguson procedure was safe and effective hemorrhoids completely. The Ferguson with simple postoperative care so it procedure was introduced in 1959 as an should be applied [2]. Some brief reports improvement of the Milligan-Morgan on this procedure were also available but procedure and has been widely applied in they failed to clarify the postoperative the United States [1]. The method is the treatment and care and factors affecting most commonly indicated for hemorrhoids the healing process [1, 2, 3]. Therefore, for its ability of good bleeding control, this article aimed: To study several factors simple postoperative care, rapid healing, affecting the postoperative healing in early return to normal life and work. Some Ferguson technique for hemorrhoidectomy. * 198 Hospital ** 103 Military Hospital Corresponding author: Phan Sy Thanh Ha (drha198@gmail.com) Date received: 14/11/2017 Date accepted: 22/01/2018 142
2. Journal of military pharmaco-medicine n o2-2018 SUBJECTS AND METHODS - Age, sex. 1. Subjects. - Healing: healing phase 1: 7 - 10 days, phase 2: > 10 days. 190 patients with third-degree and fourth-degree hemorrhoids underwent the Study of the correlation between the duration of healing: Ferguson procedures at Vietnam-Germany Hospital from 01 September, 2012 to 31 - Degrees of hemorrhoid (third-degree December, 2013. and fourth-degree hemorrhoids). - Numbers of hemorrhoidectomy, form 2. Methods. of feces at the first postoperative bowel A prospective descriptive study, clinical movement. intervention and longitudinal study. The data were processed using SPSS * Research criteria: 22.0. RESULTS Table 1: Age groups per sex . Sex Male Female Total Age group n % n % n % ≤ 20 1 0.5 0 0.0 1 0.5 21 - 40 36 18.9 41 21.6 77 40.5 41 - 60 52 27.4 27 14.2 97 41.6 61 - 80 18 9.5 12 6.3 30 15.8 > 80 2 1.1 1 0.5 3 1.6 Total 109 57.4% 81 42.6% 190 100% The most common age group was 21 - 60, accounting for 82.1%, the average age was 46.58 ± 14.72 years old. The oldest patient was 83 years old and the youngest was 18 years old. Male accounted for 57.4%, female 42.6%. Table 2: Duration of healing per degree of hemorrhoids. Degree Third-degree Fourth-degree Total p Healing n % n % n % Healing phase 1 113 81.9 43 82.7 156 82.1 Healing phase 2 25 18.1 9 17.3 34 17.9 0.89 Total 138 100 52 100 190 100 82.1% of the patients had their incisions healed in phase 1 and 17.9% had wound dehiscence. There was no correlation between the healing ratio and the degree of hemorrhoids. 143
3. Journal of military pharmaco-medicine n o2-2018 Table 3: Duration of healing per numbers of hemorrhoidectomy. Number of 1 2 3 4 hemorrhoidectomy hemorrhoid hemorrhoids hemorrhoids hemorrhoids p Healing n % n % n % n % Healing phase 1 28 87.5 51 85.0 72 80.9 5 55.6 Healing phase 2 4 12.5 9 15.0 17 19.1 4 44.4 0.15 Total 32 100 60 100 89 100 9 100 There was no correlation between the duration of healing and the numbers of hemorrhoidectomy. Table 4: Duration of healing per form of feces at the first postoperative bowel movement. Healing Phase 1 Phase 2 Total p Form of feces n % n % n % Liquid 0 0.0 13 38.2 13 6.8 Mushy 49 31.4 20 58.8 69 36.3 Normal 99 63.5 1 2.9 100 52.6 0.001 Lumpy 8 5.1 0 0.0 8 4.2 Total 156 100 34 100 190 100 33/34 patients (97.1%) with liquid and mushy feces suffered from wound dehiscence. The difference in the duration of healing and the form of feces at the first postoperative bowel movement was statistically significant . DISCUSSION 3 showed that there was no correlation Postoperative complications of infections between the duration of healing and the and abscesses in Ferguson technique for degree of hemorrhoids and numbers of hemorrhoidectomy are always the special hemorrhoidectomy (p > 0.05). Table 4 concern of the surgeons. That is one of showed that 33/34 patients (97.1%) with the reasons why so far only some liquid and mushy feces at the first Vietnamese surgeons have chosen this postoperative bowel movement suffered method to treat hemorrhoids. 100% of from wound dehiscence. The difference in patients in this article were found not to the duration of healing and the form of have postoperative abscesses and feces at the first postoperative bowel infections. 156 patients had their incision movement was statistically significant healed in phase 1, accounting for 82.1%, (p < 0.05). This can be explained that phase 2: 17.9% (34 patients). Table 2 and liquid and mushy feces at the postoperative 144
4. Journal of military pharmaco-medicine n o2-2018 bowel movement moisten the anal area, wound dehiscence occurred in 5 patients cause the incision to have infections and (10.8%) from emergency operations wound dehiscence. 8 weeks after the and 7 patients (11.7%) from scheduled procedure, all patients in the study had operations; this difference was not significant their incision completely healed. Patients (p = 0.12). No new case of wound were always advised not to immerse their dehiscence was found after 4 weeks, anus but always leave the anus dry. all patients had their incision healed Among 50 patients underwent the completely. Pattana-arun J et al delivered Ferguson procedure by Aziz A, 62% had the Ferguson procedure to 1,184 patients their incision healed in the first week and with third-degree and fourth-degree 82% after 4 weeks [4]. In the study by Ho hemorrhoids . Out of 416 emergency K.S, 33.3% of the patient suffered from operations and 786 scheduled operations wound dehiscence within the first 2 weeks for treatment of prolapsing internal and after 8 weeks this rate was 13.8% [5]. hemorrhoid, bleeding hemorrhoid and Khubchandani I et al (2009) conducted a thrombosed external hemorrhoid, after study on 3.247 patients, 6 patients 2 weeks of operation, 24 patients suffered (0.22%) suffered from abscesses, of from wound dehiscence, accounting for which 4 patients (0.12%) did not require 2.03%. After 4 weeks, all patients had intervention. 2 patients (0.06%) required their incision completely healed with no re-operation. 163 patients (4.97%) suffered stenosis. Among 130 patients undergoing from partial wound dehiscence. 2 patients the Ferguson procedure by Khalil-ur- (0.06%) suffered from complete wound Rehman et al, 100% had their incision dehiscence. In the study by Khanna R et healed after 2 weeks [6]. Malik A.G (2009) al, 20 patients (14%) undergoing the delivered the Ferguson procedure to 30 Ferguson procedure suffered from wound patients and found that their healing dehiscence [7]. In a study on 1,184 process only took < 2 weeks. 3.03% of patients by Wesarachawit W (2007), the patients in the study by Nguyen Sy 4 patients suffered from wound Tuan Anh suffered from wound dehiscence dehiscence after 2 weeks of procedure. and no case had infections and abscesses No new case of wound dehiscence was [1]. 27.7% of the patients in the study by found after 4 weeks, most patients had Nguyen Van Lam suffered from wound their incision healed with no stenosis. dehiscence, no case had infections and According to Pattana-Arun J, 100 patients abscesses; according to this author, with third-degree and fourth-degree hemostasis in Ferguson procedure should hemorrhoids might have complications, be performed carefully and thoroughly of which 46 cases were performed to avoid hematoma which may cause emergency operations and 54 patients infections and over-tight incision . Coagulator were scheduled operations. The author may be used for effective hemostasis. compared the outcomes of the two However, this device causes tissue damage groups. After 2 weeks of the procedure, around the edge of the incision and 145
5. Journal of military pharmaco-medicine n o2-2018 impedes the healing process. Do not may cause mild stenosis; which is a very remove too much skin and mucous effective treatment for stenosis. Patients membranes of the anal canal in the were fed porridge 12 hours after the procedure which may cause the sutures surgery and could eat regular diets with to over-tight and lead to wound dehiscence. more fiber and water, avoid alcoholic All of these factors contribute to the stimulants, tobaco, spicy and hot food. occurrence of wound dehiscence. * Wound care: Change wound dressing Numerous clinical trials comparing the 24 hours after the surgery and using outcomes of the hemorrhoidectomy using betadine 10% daily. Milligan-Morgan and Ferguson techniques * Guide the patient to perform wound of international authors have concluded care: that the duration of healing in Ferguson - Keep the incision clean (clean the procedure is significantly shorter than that anus after bowel movement and dry by in Milligan-Morgan procedure despite the permeable materials). risk of wound dehiscence. Thus, from - Do not perform anal dilation without these outcomes, we can completely trust medical advice and do not immerse the the Ferguson technique for hemorrhoidectomy anus. Always keep the anus dry. incase the principles of surgery, those of treatment and patient care must be strictly If the patient has no bowel movement followed. for 4 days after the surgery, take a bottle of fleet phospho-soda or a bag of fortran * Postoperative treatment and care: 1 g to avoid fecal stagnation in the rectum After transferring the patient from the which may cause irritation, prolonged pain operating room to the treatment room. and incision infections. Inject 1,000 mL solution of 500 mL ringer ’s lactate solution + 500 mL glucose Monitor the patient ’s pulse, temperature, 5%. Pain relief after pain assessment: blood pressure and perception. Urinary Efferalgan 1 g IV x 2 vials/day each retention, incision status: postoperative 8 hours for the first day. Severe pain may bleeding, infections and abscesses. be treated with opioid. Paracetamol 0.5 g Hospital discharge standards: no fever, x 4 tablets/day for the following days. minor pain in the incision, no urinary Antibiotics: flagyl 0.5 g IV x 2 bottles/day retention, no bleeding, no infection, no for the first day, flagyl 250 mg x 4 abscess at the incision. Postoperative tablets/2 times (morning and afternoon) visit: 7 or 14 days afterward. /day for the following 5 - 7 days. Laxatives should be used to avoid fecal stagnation CONCLUSION in the rectum which may cause irritation Ferguson technique for hemorrhoidectomy and prolong pain. Place proctolog has the advantages of safety, good outcome, th suppositories into the anus from the 7 rapid healing, simple postoperative care. day after surgery when the incision was The incision rate was 82.1%. Do not soak physiologically healed and a slight shrink and squeez the anus everyday. Patients 146
6. Journal of military pharmaco-medicine n o2-2018 soon return to normal life, average time 4. Aziz A, Ali I, Alam S.N et al . 2.41 ± 0.76 days and quikly return to Open hemorrhoidectomy versus closed work, average time back to work was hemorrhoidetomy: The choice should be 13.63 ± 4.29 days. clear . Pakistan Journal of Surgery. 2008, 24 (4), pp.254-257. REFERENCES 5. Ho K.S, Ho Y.H. Prospective randomized 1. Nguy ễn S ỹ Tu ấn Anh. K ết qu ả điều tr ị trial comparing stapled hemorrhoidopexy versus bệnh tr ĩ b ằng ph ẫu thu ật Ferguson t ại B ệnh closed Ferguson hemorrhoidectomy . Techniques vi ện Vi ệt Đứ c. Luận án Tiến sỹ Y học. Đại học in Coloproctology. 2006, 10 (3), pp.193-197. Y. Hà N ội. 2011. 6. Khalil-ur-Rehman, Hasan A, Taimur M 2. Nguy ễn Xuân Hùng, Mark Helbraun, et al . A comparison between open and closed Ph ạm Đức Huân và CS . Ph ẫu thu ật Ferguson hemorrhoidectomy . J Ayub Med Coll Abbottabad. điều tr ị tr ĩ. Tạp chí Đại tràng. 2010, 5, tr.9-13. 2011, 23 (1), pp.114-116. 3. Nguy ễn V ăn Lâm, Mai V ăn Đợ i. Đánh 7. Khanna R, Khanna S, Bhadani S et al . giá k ết qu ả ph ẫu thu ật Ferguson điều tr ị b ệnh Comparison of ligasure hemorrhoidectomy tr ĩ t ại B ệnh vi ện Tr ường Đạ i h ọc Y Dược C ần with conventional Ferguson ’s hemorrhoidectomy . Th ơ. Tạp chí Y D ược h ọc. 2014, 421 (1), Indian Journal of Surgery. 2010, 72 (4), tr.12-15. pp.294-297. 147