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Pain Management in Anorectal Surgery
Pain Management in Anorectal Surgery Michael J. Stamos and Terry C. Hicks Pain is often viewed as an inevitable experience following anorectal surgery. While this may be true, great strides have been made in managing postoperative pain following anorectal operations. The recognition that preoperative, intraoperative, and postoperative issues affect postoperative pain is important in improving outcomes. Additionally, the concept of multimodal analgesia and the use of parenteral nonsteroidal anti-inflammatory drugs (NSAID’s) have allowed the performance of most anorectal operations in the ambulatory setting. Semin Colon Rectal Surg 17:125-130 © 2006 Elsevier Inc. All rights reserved.
P
ain has been described as an unpleasant sensory and emotional experience arising from actual or potential tissue damage, or described in terms of such damage.1 Pain is actually a complex and incompletely understood phenomenon which is difficult to evaluate because of great variation in individual tolerance and expectations. A recent report evaluating over ten thousand patients undergoing outpatient procedures found that only 5.3% of patients queried had severe pain, 34% had moderate pain, 25% had mild pain and almost 15% reported no pain. Interestingly, the majority of patients with severe pain were younger, with a higher body mass index, and were better anesthetic risks than those patients who perceived less severe pain. Not surprisingly, both the complexity and duration of the operative procedure were also predictors of pain intensity.2 Additionally, pain is a dynamic process, as sensory input from surgically injured tissue reaches spinal cord neurons, and this input causes subsequent responses to be enhanced. This so called “central sensitization” also occurs in the peripheral neurons where it is termed “peripheral sensitization.” Numerous clinical and animal studies have demonstrated long lasting changes in cells within the spinal cord pain pathways after even a brief painful stimulus,3-5 creating a “hypersensitive” state. The consequence of this sensitization or “wind-up” is a cycle of ever increasing pain if treatment is not initiated. The clinical implication of this knowledge is that preemptive analgesia should be beneficial, and that patients should be encouraged to use pain medications at the earliest onset of pain and to not wait until the pain becomes severe and difficult to control.
University of California Irvine School of Medicine, Orange, CA. Address reprint requests to Michael J. Stamos, MD, FACS, FASCRS, University of California Irvine School of Medicine, Chief, Division of Colon & Rectal Surgery, University California, Irvine Medical Center, Orange, CA.
1043-1489/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2006.07.002
In recent years it has been recognized that unrelieved postoperative pain is not inevitable or harmless.6 Recognition of the wide spread inadequacy of pain control has prompted numerous actions. The American Pain Society, since 1995, has urged that the evaluation of pain be treated as a fifth vital sign and this concept has recently been accepted and adopted by the American Nursing Association.7 In February 1999, the Veterans Health Administration launched a system wide effort to reduce pain and suffering for its patients, and the foundation of this effort was based on this concept of pain as the fifth vital sign. This implementation meant that the nurses and doctors were instructed to assess and record patient pain just as often as they would other vital signs such as blood pressure, pulse, temperature, and respiratory rate. More recently, state licensing boards have also been requiring physicians to demonstrate knowledge of pain assessment evaluation, and in California license renewal is contingent on continuing medical education (CME). Finally, new Joint Commission on Accreditation of Health care Organization (JCAHO) guidelines require health care providers to ask patients about pain, and JCAHO surveyors will be assessing compliance to this dictum. Anorectal surgery has long been recognized as causing significant and even extreme postoperative pain. Indeed, this belief has kept many patients away from beneficial treatment. In the last two decades, the majority of these operations have moved from inpatient to ambulatory venues. Not coincidentally, this trend has followed advances in perioperative management of the patient, most specifically advances in pain management, albeit influenced by socioeconomic pressures and trends. Because most anorectal operations are currently conducted in the outpatient setting, this manuscript will deal exclusively with pain management in the ambulatory patient. An important concept to recognize is that pain management 125
126 does not begin in the postoperative period. There are preoperative, intraoperative, and postoperative aspects in consideration of optimal patient care and pain control. We will consider each of these areas separately.
Preoperative Management Preoperative considerations specific to the management of postoperative pain will include a detailed history from the patient focusing on prior surgical experiences, and prior experiences with pain medications, particularly narcotics, as well as comorbidities and past medical conditions which might influence the choice of anesthesia and pain management. These would include such factors as coagulation disorders that would preclude regional anesthetic techniques, peptic ulcer disease which might preclude or influence duration of nonsteroidal anti-inflammatory drug (NSAID) use, and history of opioid abuse or addiction. A history of allergic reactions or intolerance of medications due to side effects would be obviously important to elicit, and better to discern preoperatively than in the perioperative or postoperative period. A detailed list of current medications focusing on chronic use of nonsteroidal (NSAID) and or other pain medication is obviously critical, and a history of the individual patient’s normal “bowel function” is also important. Prior or chronic history of constipation or straining is best dealt with before the introduction of narcotics that may exacerbate this problem. Judicious use of stool softeners and or laxatives in the perioperative period may be advisable to prevent an early postoperative impaction that would lead to a pain exacerbation and commonly to an emergency department visit. The next step in the preoperative preparation of the patient undergoing an anorectal operation would be to educate and prepare the patient with realistic expectations of their “impending” pain experience. The anesthetic technique will likely vary based on the magnitude of the operation, and may indeed be influenced by the anesthetist, but an early discussion with the patient regarding the planned or possible approach to anesthetic management is helpful in the preoperative period to allow the patient to feel more comfortable and confident going in to the hospital and through the operative experience. Providing the patient with this education as well as a preprinted postoperative instruction sheet (Appendix A) will also give the patient confidence that the surgeon is interested and attentive to not only the operative procedure but also the recovery. Giving the patient a detailed description of the planned procedure, the expected postoperative pain level, and instructions aimed at decreasing post procedural pain has been shown to decrease self reported pain, analgesic use, and increase the success of planned outpatient treatments.8-10 Finally, providing the patient with prescriptions for postoperative pain medications will continue imparting this caring attitude, and also will allow the patient and their family a more smooth transition from the operating room facility to their home.
M.J. Stamos and T.C. Hicks
Intraoperative Management The intraoperative or immediate perioperative aspects of pain control can be further separated into components. First is the selection of the type and timing of anesthesia and analgesia. Second, is the choice of and conduct of operative technique. Third is the use of adjuncts. The majority of studies looking at postoperative pain following anorectal surgery are small, single institution studies looking at a population of patients undergoing hemorrhoidectomy. The selection of hemorrhoidectomy patients to study most likely stems from the frequency of this operation, the acknowledgment that this is a painful operation, and recognition that it is a rather standardized operation that lends itself to comparison. Unfortunately, the vast majority of studies are not well performed or are inadequately powered. Anesthetic technique for anorectal surgery varies greatly from institution to institution, surgeon to surgeon, and also by patient and procedure. A number of studies have looked at anesthetic technique and outcome. Li and co-workers11 randomized 93 adult patients undergoing anorectal surgery to one of three groups. Group 1 received local anesthesia combined with intravenous sedation, group 2 received a spinal block, and group 3 received general anesthesia. Groups 1 and 2 had significantly less need for pain medication and group one patients were more highly satisfied and had significantly decreased cost compared with groups 2 and 3. In a similar sized prospective but nonrandomized study, Fleischer and co-workers12 reported that patients receiving local anesthesia (N ⫽ 53) compared with spinal anesthesia (N ⫽ 28) had a more rapid recovery, although no difference was seen in pain medication requirements. A small study by Pryn and coworkers13 found contradictory results. The authors studied 44 patients who were randomized to either caudal or local anesthetic block utilizing bupivacaine. This was performed as an adjunct to a general anesthetic technique for a surgical hemorrhoidectomy. Patients undergoing caudal anesthetic had significantly less pain in the early postoperative period as well as on first bowel movement. A much larger study reported by Read and co-workers14 looked prospectively at 413 consecutively patients undergoing a variety of anorectal surgical procedures. A total of 273 patients received intravenous sedation plus local anesthesia, 127 patients received regional anesthetic (spinal or epidural), and 13 patients were treated under general anesthesia either utilizing an endotracheal tube or mask. Unfortunately, the authors did not evaluate postoperative pain directly but rather evaluated safety and time until discharge. They did find that the use of local anesthetic plus intravenous sedation was safe and cost effective, with a significant decrease in time from operation until discharge home. Although it is difficult to draw conclusions from these studies and the remaining available literature, local anesthetic techniques with intravenous sedation seems to be safe and cost effective and associated with at least equivalent early postoperative pain control compared with regional anesthetic techniques. Regional anesthetic techniques as well as local anesthetic techniques all utilize (intentionally or inad-
Pain management in anorectal surgery vertently) the concept of preemptive analgesia. This concept was actually originally proposed back in the early 20th century by Crile15 who suggested that pain was exaggerated by central nervous system influences and he proposed peripheral block combined with general anesthetic techniques. Wolff, beginning in the early 1980s, “dusted off” this theory, resurrecting it with an elegant set of animal experiments and subsequently with clinical evaluation.16,17 Blocking peripheral pain impulses would prevent central hypersensitivity which could produce a vicious circle whereby peripheral painful stimuli produce an ever increasingly exaggerated response to pain due to increase receptivity of the central dorsal horn neuron. While the concept of preemptive analgesia is well founded, and animal studies give support, clinical studies have been contradictory.18,19 This contradictory data may stem more from imperfect and imprecise study design then from lack of efficacy.20-23 The effect, if any, of preemptive analgesia may not be limited to blockade of central or peripheral sensitization, but may be also secondary to a decrease in proinflammatory cytokine production.24 Operative technique is perhaps the most studied component in the evaluation of postoperative pain. Most recently, this has lead to the propagation of stapled hemorrhoidectomy or anorectopexy as compared with conventional open hemorrhoidectomy. The stapling technique has been shown to improve postoperative pain parameters, although not all patients are amenable to this approach.25-29 Other technologies have also been compared with standard operative hemorrhoidectomy techniques, including bipolar diathermy (Ligasure), ultrasonic devices (Harmonic Scalpel) as well as the CO2 and YAG laser.30-34 While these techniques may have other advantages, only the Harmonic Scalpel has shown to have a proven benefit in reducing pain following hemorrhoidectomy. Other investigators have examined the influence of open compared with closed hemorrhoidectomy wounds.35-38 Reaching conclusions from these prospective randomized trials is difficult because of disparate results. Two of the studies found that closed wounds lead to more rapid healing, while one study found the opposite effect. Two of the four studies found no difference in pain or analgesic usage, while two of the studies found that the closed technique was met with increased analgesic use or pain in the early postoperative period. While the precise technique of hemorrhoidectomy and of other anorectal operations is undoubtedly important in the development of postoperative pain, it is difficult to be dogmatic and each individual patient presents with a different spectrum of disease, and each surgeon performs the given operation in a slightly different manner. It does seem logical to minimize tissue trauma, particularly in the area of the sensitive anoderm, and perhaps utilize subcuticular sutures in closing this sensitive anoderm to avoid pressure and ischemia at the skin level. A number of adjuncts have been suggested to improve postoperative discomfort and pain following anorectal surgery. Anal stretch, and more recently lateral internal anal sphincterectomy has been studied by a number of investigators as a means of reducing pain associated with hemorrhoid-
127 ectomy, including several prospective randomized trials.39-41 Once again the results from the trials are mixed, with two of the three investigators35,36 reporting no advantage for adding the sphincterotomy in terms of pain control, and with an increased risk of disturbance in fecal continence. Galizia and co-workers37 found different results, with lateral internal sphincterotomy improving postoperative pain and also apparently preventing anal stenosis. They also found no increased risk of fecal incontinence with the added sphincterotomy. With the concept of “chemical sphincterotomy” gaining enthusiasm for the treatment of anal fissure disease, perhaps the postoperative use of a nitric oxide donor or calcium channel blocker will be equally efficacious without the risk of incontinence. A randomized prospective trial reported by Wasvary and co-workers42 compared the use of nitroglycerin ointment versus placebo and the effect on pain following hemorrhoidectomy. They found a significant reduction in pain with the use of nitroglycerin on postop day 2 only, but also found that over 40% of patients suffered the side effect of a headache. Diltiazem and Nifedepine have been shown to be efficacious in treating anal fissures when compared with nitroglycerin, but have not yet been evaluated for use following hemorrhoidectomy.43,44 The one adjunct that has received wide spread use and is well founded and supported in the literature is the use of ketorolac. Whether it is given intramuscular, intravenous, or into the surgical site seems to have little influence on the beneficial effect.45 Additionally, when utilized, ketorolac should be continued in the postoperative period for three to five days.46,47 When utilized in this fashion, and when the total duration of drug administration is five days or less, there appears to be minimal toxicity and side effects.48 Additional adjuncts which have been evaluated and utilized infrequently include parenteral or rectal steroid administration.49,50 and the addition of clonidine to the local anesthetic.51,52 Finally, administration of a long acting anesthetic within the surgical site at the completion of the operation (if not utilized preemptively) seems to be beneficial,53 and the avoidance of gauze type packs within the anal canal has been shown to significantly improve postoperative pain.54
Postoperative Management Following minor anorectal operations, such as sphincterotomy or fistulotomy, patients are generally adequately managed with non narcotic pain medications. Utilization of warm baths, NSAID analgesics, and dietary fiber supplementation (Psyllium), typically provide adequate control of pain. Selected patients undergoing these minor operations may need breakthrough narcotic pain medication such as oxycodone or codeine. For more extensive anorectal operations such as open hemorrhoidectomy, anal sphincterplasty, and anoplasty the concept of “balanced analgesia” is appropriate and should be followed. Balanced analgesia is designed to minimize the adverse effects of the pain medication regimen. This typically involves the use of different methods of analgesia, with the main goal being “opioid sparing,” or the use of smaller doses
M.J. Stamos and T.C. Hicks
128 of opioids than would otherwise be required. The options for non opioid approaches for outpatient anorectal operations include the use of local anesthetics as previously outlined, the use of acetaminophen (Tylenol), and of nonsteroidal anti inflammatory drugs (NSAID).55,56 These drugs are generally well tolerated and have a good therapeutic benefit to toxicity ratio, especially with short term use. Care should be taken however when utilizing NSAIDs in concert with other drugs that may contain acetaminophen or NSAIDs (eg, Percodan, Vicoprofen, Darvocet) because of increased risk of nephrotoxicity. Acetaminophen (Tylenol) is an analgesic that inhibits central prostaglandin synthesis. It has reasonable efficacy as an analgesic although recent data suggests that NSAIDs are preferable.57 Acetaminophen has a very favorable side effect/toxicity profile although caution should be used in patients with liver disease as the drug is metabolized by the liver. Recommended maximal dose of acetaminophen is 1 g orally every 6 hours for adults and 15 mg per kg orally Q6 hours for pediatric patients.58 NSAIDs have become more popular since the availability of parenteral ketorolac. NSAIDs block the synthesis of prostaglandins through inhibition of the cyclooxygenase (COX) enzyme. This effectively blocks the production of the acute inflammatory response and hence decreases peripheral nociception. More recent data has revealed an alternative or additional mechanism of action in the spinal cord, also because of inhibition of prostaglandin synthesis.59 The most commonly utilized NSAIDs in postoperative patients are oral ibuprofen, and intravenous followed by oral ketorolac. The recommended maximal dose of ibuprofen is 800 mg three times per day60 and the maximal dose of ketorolac for adults is 60 mg intravenously with the oral dose of 10 mg QID continued for no longer than 5 days. The most common toxicity from NSAIDs is gastrointestinal bleeding resulting from gastric or duodenal ulceration. The risk is small when the drugs are utilized for short duration, but may be increased in elderly patients and in those with a history of gastrointestinal bleeding.61 Renal and hepatic toxicity are also potential side effects, typically seen only with high dose, long duration use. More recent attempts at diminishing toxicity include the development of the COX-2 specific NSAIDs. Two oral forms of these drugs have been widely available and utilized for the past several years (Celecoxib and Rofecoxib). They have been studied for their effect on postoperative analgesia and seem to be equivalent or perhaps slightly more effective than acetaminophen.62 COX-2 NSAIDs seem to have slightly less risk of gastrointestinal bleeding but may have increased risk of cardiovascular events. They are contraindicated in patients who have known hypersensitivity to aspirin or NSAIDs and in patients who are allergic to sulfa drugs. Currently the increased cost of these drugs does not seem to warrant their use in the majority of patients because the safety of NSAIDs for short course postoperative care is quite favorable. Opioids are typically necessary and appropriate, at least for break through pain, in many patients undergoing anorectal operations. Opioids act at central nervous system receptors to modulate the pain response. Opioids have significant po-
tential toxicity including respiratory depression, sedation, nausea, vomiting, urinary retention, and a significant risk of dependence. Toxicity is directly related to the dose, and therefore, limiting administration of opioids and utilizing them for break through pain typically minimizes these adverse effects.62,63 Commonly used opioids include codeine, oxycodone, and hydrocodone. These are often used in combination with acetaminophen or NSAIDs. Transdermal application of opioids (Fentanyl patch) seems an ideal way to deliver narcotics64 following anorectal operations, as it achieves a steady state balance, avoiding the peaks and valleys attendant with oral formulations. When utilized in combination with NSAIDs, optimal analgesia could be expected.65,66 Unfortunately, adverse events associated with the use of this medication has limited its applicability, largely because of medical legal concerns.67-69 Other postoperative adjuncts utilized with some frequency include application of ice packs,70,71 topical anesthetic ointments,72 oral metronidazole,73,74 and transcutaneous electrical nerve stimulation.75 Of these adjuncts, metronidazole has been the best studied, with two randomized prospective trials. Unfortunately, both trials were small (40 patients) and showed somewhat conflicting results. At best, a modest reduction in postoperative pain will be achieved with these approaches. Finally, the commercial availability of subcutaneous drug delivery systems has led to interest in studying postoperative delivery of local anesthetics or narcotics into the wound bed.76,77
Appendix A Instructions for Patients Following Anal and Rectal Surgery 1. Purchase the following: A. Konsyl (Regular or Easy Mix) or Metamucil B. One small box of Dulcolax tablets C. Two plain fleet enemas D. Antibacterial body soap (non-scented is the best) E. Pain medications and antibiotics, if prescribed. 2. After your operation, remove the dressing at about 6:00 pm or sooner if you have a bowel movement, and take a warm bath for 15-20 minutes. Take at least 2 warm baths daily and always after a bowel movement. If you don’t have a bathtub you can use a hand held shower or buy a “portable” tub available cheaply at every drug store. After the bath, apply the tucks pads given to you at the time of discharge from the hospital. There may be a small amount of gelatin packing within the anal canal. This looks flesh colored and will pass with your first movement. 3. You should restrict your physical activity for the first 2 weeks following operation. No heavy lifting, no sports, and no lengthy auto rides. Walking and climbing stairs is permitted. Too much activity during the first 2 weeks may result in serious bleeding.
Pain management in anorectal surgery 4. Eat a regular diet with lots of fruits and vegetables. Avoid spicy foods and excess alcohol. Drink at least eight glasses of water or other non-alcoholic liquid daily. 5. If your bowels have not moved by bedtime on the third night after your operation, take 4 Dulcolax tablets at that time. If you do not have a movement by the next day, take a plain Fleet enema. Thereafter, you should have one or two bulky bowel movements per day. To accomplish this, take Konsyl or Metamucil one heaping teaspoon in 8 –12 ounces of juice 2 times daily for 5 days after your operation. Begin this the day after your operation. Continue the Konsyl or Metamucil indefinitely. If you do not have a bowel movement one day, take 2 Dulcolax tablets that night. If no movement the next day, use a plain Fleet Enema. 6. Take the prescription pain medications and antibiotics, if prescribed, as directed on the label. 7. Some bleeding and discharge from the anal area is to be expected and is normal unless heavy in amount (eg more than a cup) 8. It is common to experience difficulty in emptying your bladder following an operation. It may be helpful to urinate while in a hot bath or shower. Please notify us if you are having persistent urinary problems. 9. Pain following rectal surgery is expected and can be significant. This should subside progressively in the days following your operation. You will probably need to take pain medications at intervals for the first week to two. They will work best when taken before pain levels build. A warm bath is of great value in reducing pain. 10. Suture material used in rectal surgery is of the dissolving kind. It does not require removal. 11. Anal tags are fleshy prominences which may appear during the weeks after your operation. These are not recurrent hemorrhoids, but swelling of the skin. They will shrink as the healing process continues and are not cause for alarm. 12. Follow-up visits to the office are essential for good results. You will need to be seen at intervals for up to 3 months following your operation. Please call the office for an appointment for 2 weeks after surgery. 13. If questions arise do not hesitate to call our office for advice.
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129 7. Deleted in Proof 8. Schmitt F, Wooldridge PJ: Psychological preparation of surgical patients. Nursing Res 22:108-116, 1973 9. Voshall B: The effects of preoperative teaching on postoperative pain. Topics Clin Nurs 2:39-43, 1980 10. Hathaway D: Effect of preoperative instructions on postoperative outcomes: A meta-analysis. Nurs Res 35:269-275, 1986 [10366] 11. Li S, Coloma M, White P, Watcha M, Chiu JW, Li H, Huber P: Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anaesthesia 93:1225-1230, 2002 12. Fleischer M, Marini CP, Statman R, Capella J, Shevde K: Local Anesthesia is superior to spinal anesthesia for anorectal surgical procedures. Am Surg 60:812-815, 1994 13. Pryn SJ, Crosse M, Murison C, McGinn FP: Postoperative analgesia for haemorrhoidectomy. Anaesthesia 44:964-966, 1989 14. Read TE, Henry SE, Hovis RM, et al: Prospective evaluation of anesthetic technique for anorectal surgery. Dis Colon Rectum 45:15531560, 2002 15. Crile GW: The kinetic theory of shock and its prevention through anociassociation. Lancet 185:7-16, 1913 16. Woolf CJ, Chong MS: Preemptive analgesia- treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 77:362-379, 1993 17. Woolf CJ: Evidence for a central component of postinjury pain hypersensitivity. Nature 306:686-688, 1983 18. Richards JT, Read JR, Chambers WA: Epidural anaesthesia as a method of preemptive analgesia for abdominal hysterectomy. Anaesthesia 5:296-8, 1998 19. Gottschalk A, Smith DS, Jobes DR, et al: Preemptive epidural analgesia and recovery from radical prostatectomy: A randomized controlled trial. JAMA 279:1076-82, 1998 20. Schecter WP, Bongard FS, Gainor BJ, Weltz DL, Horn JK: Pain control in outpatient surgery. J Am Coll Surg 195:95-104, 2002 21. Moiniche S, Kehlet H, Dahl JB: A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: The role of timing of analgesia. Anaesthesia 96:725-741, 2002 22. Luck AJ, Hewett PJ: Ischiorectal fossa block decreases posthemorrhoidectomy pain: Randomized, prospective, double-blind clinical trial. Dis Colon Rectum 43:142-145, 2000 23. Vinson-Bonnet B, Coltat, Fingerhut A, Bonnet F: Local infiltration with ropivacaine improves immediate postoperative pain control after hemorrhoidal surgery. Dis Colon Rectum 45:104-108, 2002 24. Beilin B, Bessler H, Mayburd E, et al: Effects of preemptive analgesia on pain and cytokine productions in the postoperative period. Anaesthesia 98:151-155, 2003 25. Rowsell M, Bello M, Hemingway DM: Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: Randomized controlled trial. Lancet 355:779-781, 2000 26. Mehigan BJ, Monson JR, Hartley JE: Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: Randomized controlled trial. Lancet 355:782-785, 2000 27. Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S: Prospective randomized multicenter trial comparing stapled with open haemorrhoidectomy. Br J Surg 88:669-74, 2001 28. Peng BC, Jayne DG, Ho Y-H. Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Colon Rectum 46:291-297, 2003 29. Ortiz H, Marzo J, Armendariz P: Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg 89:1376-1381, 2002 30. Palazzo FF, Farncis DL, Clifton MA: Randomized clinical trial of ligasure versus open haemorrhoidectomy. Br J Surg 89:154-157, 2002 31. Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O’Riordain DS: Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg 89:428-432, 2002 32. Chia YW, Darzi A, Speakman Ct, Hill AD, Jameson JS, Henry MM: CO2 laser haemorrhoidectomy: Does it alter anorectal function or decrease pain compared to conventional haemorrhoidectomy? Int J Colorectal Dis 10:22-24, 1995
130 33. Senagore A, Mazier Wp, Luchtefeld MA, MacKeigan JM, Wengert T: Treatment of advanced hemorrhoidal disease: A prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser. Dis Colon Rectum 36:1042-1049, 1993 34. Armstrong DN, Ambroze WL, Schertzer ME, Orangio GR: Harmonic scalpel vs. electrocautery hemorrhoidectomy: A prospective evaluation. Dis Colon Rectum 44:558-564, 2001 35. Ho YH, Seow-Choen F, Tan M, Leong Af: Randomized controlled trial of open and closed haemorrhoidectomy. Br J Surg 84:1729-1730, 1997 36. Mikuni N, Oya M, Komatsu J, Yamana T: A prospective randomized comparison between an open hemorrhoidectomy and a semi-closed (semi-open) hemorrhoidectomy. Surg Today 32:40-47, 2002 37. Gencosmanoglu R, Sad O, Koc D, Inceoglu R: Hemorrhoidectomy: Open or closed technique? A prospective, randomized clinical trial. Dis Colon Rectum 45:70-75, 2002 38. Arbman G, Krook H, Haapaniemi S: Closed vs. open hemorrhoidectomy: Is there any difference? Dis Colon Rectum 43:31-34, 2000 39. Khubchandani IT: Internal sphincterotomy with hemorrhoidectomy does not relieve pain: A prospective randomized study. Dis Colon Rectum 45:1452-1457, 2002 40. Mathai V, Ong BC, Ho YH: Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy. Br J Surg 83:380382, 1996 41. Galizia G, Lieto E, Castellano P, Pelosio L, Imperatore V, Pigantelli C: Lateral internal sphincterotomy together with haemorrhoidectomy for treatment of haemorrhoids: A randomized prospective study. Eur J Surg 166:223-228, 2000 42. Wasvary HJ, Hain J, Mosed-Vogel M, Bendick P, Barkel D, Klein S: Randomized, prospective, double-blind, placebocontrolled trial of effect of nitroglycerin ointment on pain after hemorrhoidectomy. Dis Colon Rectum 44:1069-1073, 2001 43. Jonas M, Speake W, Scholefield JH: Diltiazem heals glyceryl trinitrateresistant chronic anal fissures. Dis Colon Rectum 45:1091-1095, 2002 44. Perrotti P, Bove A, Antropoli C, et al: Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: Results of a prospective, randomized, double-blind study. Dis Colon Rectum 45:1468-75, 2002 45. Place RJ, Coloma M, White PF, et al: Ketorolac improves recovery after outpatient anorectal surgery. Dis Colon Rectum 43:804-808, 2000 46. Richman IM: Use of Toradol in anorectal surgery. Dis Colon Rectum 36:295-296, 1993 47. O’Donovan S, Ferrara A, Larach S, Williamson P: Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy. Dis Colon Rectum 37:793-799, 1994 48. Strom BL, Berlin JA, Kinman JL, et al: Parenteral Ketorolac and risk of gastrointestinal and operative site bleeding: A postmarketing surveillance study. JAMA 275:376-382, 1996 49. Aasobe V, Raeder JC, Groegaard B: Betamethasone reduces postoperative pain and nausea after ambulatory surgery. Anesth Analg 87:319323, 1998 50. Yadav S, McLatchie GR, Mackenzie I: Evaluation of proctofoam as a post-operative analgesic in patients undergoing haemorrhoidectomy. Br J Clin Pract 38:414-415, 1984 51. Tschernko EM, Klepetko H, Gruber E, et al: Clonidine added to the anesthetic solution enhances analgesia and improves oxygenation after intercostal nerve block for thoracotomy. Anesth Analg 87:107-111, 1998 52. Bernard JM, Macaire P: Dose-range effects of clonidine added to lidocaine for brachial plexus block. Anaesthesia 87:277-284, 1997 53. Hussein MK, Taha AM, Haddad FF, Bassim YR: Bupivacaine local injection in anorectal surgery. Int Surg 83:56-57, 1998 54. Ingram M, Wright TA, Ingoldby CJ: A prospective randomized study of calcium alginate (Sorbsan) versus standard gauze packing following haemorrhoidectomy. JR Coll Surg Edinb 43:308-309, 1998
M.J. Stamos and T.C. Hicks 55. Eriksson H, Tenhunen A, Korttila K: Balanced analgesia improves recovery and outcome after outpatient tubal liation. Acta Anaesthesiol Scand 40:151-155, 1996 56. Michaloliakou C, Chung F, Sharma S: Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 82:44-51, 1996 57. Raeder JC, Steine S, Vatsgar TT: Oral ibuprofen versus paracetamol plus codeine for analgesia after ambulatory surgery. Anesth Analg 92: 1470-2, 2001 58. Schecter WP, Bongard FS, Gainor BJ, Weltz DL, Horn JK: Pain control in outpatient surgery. J Am Coll Surg 195:95-104, 2002 59. Moiniche S, Kehlet H, Dahl JB: A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: The role of timing of analgesia. Anaesthesia 96:725-741, 2002 60. Raeder JC, Steine S, Vatsgar TT: Oral ibuprofen versus paracetamol plus codeine for analgesia after ambulatory surgery. Anesth Analg 92: 1470-2, 2001 61. Schecter WP, Bongard FS, Gainor BJ, Weltz DL, Horn JK: Pain control in outpatient surgery. J Am Coll Surg 195:95-104, 2002 62. Place RJ, Coloma M, White PF, et al: Ketorolac improves recovery after outpatient anorectal surgery. Dis Colon Rectum 43:804-808, 2000 63. Schecter WP, Bongard FS, Gainor BJ, Weltz DL, Horn JK: Pain control in outpatient surgery. J Am Coll Surg 195:95-104, 2002 64. Kilbride M, Morse M, Senagore A: Transdermal fentanyl improves management of postoperative hemorrhoidectomy pain. Dis Colon Rectum 37:1070-1072, 1994. 65. Reinhart DJ, Goldberg ME, Roth JV, et al: Transdermal fentanyl system plus in ketorolac for the treatment of postoperative pain. Can J Anaesth 44:377-384, 1997 66. Lehmann LJ, DeSio JM, Radvany T, Bikhazi GB: Transdermal fentanyl in postoperative pain. Reg Anesth 22:24-28, 1997 67. Biehl AG: Use of transdermal fentanyl. Dis Colon Rectum 38:556, 1995 68. Kilbride MJ, Senagore AJ, Morse M: Improving patients safety with transdermal-fentanyl for post-hemorrhoidectomy pain. Dis Colon Rectum 38:104, 1995 69. Bernstein KZ, Klausner MA: Potential dangers related to transdermal fentanyl (Duragesic) when used for postoperative pain. Dis Colon Rectum 37:1339-1340, 1994 70. Cohn BT, Draeger RI, Jackson DW: The effects of cold therapy in the postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 17:344-349, 1989 71. Brandner B, Munro B, Bromby LM, Hetreed M: Evaluation of the contribution to postoperative analgesia by local cooling of the wound. Anaesthesia 51:1021-1025, 1996 72. Smith SL, Simon R: Viscous lidocaine as a posthemorrhoidectomy analgesic. Dis Colon Rectum 22:40-41, 1979 73. Balfour L, Stojkovic SG, Botterill ID, Burke DA, Finan PJ, Sagar PM: A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy. Dis Colon Rectum 45:1186-1190, 2002 74. Carapeti EA, Kamm MA, McDonald PJ, Phillips RK: Double-blind randomised controlled trial of effect of metronidazole on pain after daycase haemorrhoidectomy. Lancet 351:169-172, 1998 75. Chiu JH, Chen WS, Chen CH, et al: Effect of transcutaneous electrical nerve stimulation for pain relief on patients undergoing hemorrhoidectomy: Prospective, randomized, controlled trial. Dis Colon Rectum 42:180-185, 1999 76. Goldstein ET, Williamson PR, Larach SW: Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management. Dis Colon Rectum 36:439-446, 1993 77. Zohar E, Fredman B, Phillipov A, Jedeikin R, Shapiro A: The analgesic efficacy of patient-controlled bupivacaine wound instillation after total abdominal hysterectomy with bilateral salpingo-oophorectomy. Anesth Analg 93:482-487, 2001
P
ain has been described as an unpleasant sensory and emotional experience arising from actual or potential tissue damage, or described in terms of such damage.1 Pain is actually a complex and incompletely understood phenomenon which is difficult to evaluate because of great variation in individual tolerance and expectations. A recent report evaluating over ten thousand patients undergoing outpatient procedures found that only 5.3% of patients queried had severe pain, 34% had moderate pain, 25% had mild pain and almost 15% reported no pain. Interestingly, the majority of patients with severe pain were younger, with a higher body mass index, and were better anesthetic risks than those patients who perceived less severe pain. Not surprisingly, both the complexity and duration of the operative procedure were also predictors of pain intensity.2 Additionally, pain is a dynamic process, as sensory input from surgically injured tissue reaches spinal cord neurons, and this input causes subsequent responses to be enhanced. This so called “central sensitization” also occurs in the peripheral neurons where it is termed “peripheral sensitization.” Numerous clinical and animal studies have demonstrated long lasting changes in cells within the spinal cord pain pathways after even a brief painful stimulus,3-5 creating a “hypersensitive” state. The consequence of this sensitization or “wind-up” is a cycle of ever increasing pain if treatment is not initiated. The clinical implication of this knowledge is that preemptive analgesia should be beneficial, and that patients should be encouraged to use pain medications at the earliest onset of pain and to not wait until the pain becomes severe and difficult to control.
University of California Irvine School of Medicine, Orange, CA. Address reprint requests to Michael J. Stamos, MD, FACS, FASCRS, University of California Irvine School of Medicine, Chief, Division of Colon & Rectal Surgery, University California, Irvine Medical Center, Orange, CA.
1043-1489/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2006.07.002
In recent years it has been recognized that unrelieved postoperative pain is not inevitable or harmless.6 Recognition of the wide spread inadequacy of pain control has prompted numerous actions. The American Pain Society, since 1995, has urged that the evaluation of pain be treated as a fifth vital sign and this concept has recently been accepted and adopted by the American Nursing Association.7 In February 1999, the Veterans Health Administration launched a system wide effort to reduce pain and suffering for its patients, and the foundation of this effort was based on this concept of pain as the fifth vital sign. This implementation meant that the nurses and doctors were instructed to assess and record patient pain just as often as they would other vital signs such as blood pressure, pulse, temperature, and respiratory rate. More recently, state licensing boards have also been requiring physicians to demonstrate knowledge of pain assessment evaluation, and in California license renewal is contingent on continuing medical education (CME). Finally, new Joint Commission on Accreditation of Health care Organization (JCAHO) guidelines require health care providers to ask patients about pain, and JCAHO surveyors will be assessing compliance to this dictum. Anorectal surgery has long been recognized as causing significant and even extreme postoperative pain. Indeed, this belief has kept many patients away from beneficial treatment. In the last two decades, the majority of these operations have moved from inpatient to ambulatory venues. Not coincidentally, this trend has followed advances in perioperative management of the patient, most specifically advances in pain management, albeit influenced by socioeconomic pressures and trends. Because most anorectal operations are currently conducted in the outpatient setting, this manuscript will deal exclusively with pain management in the ambulatory patient. An important concept to recognize is that pain management 125
126 does not begin in the postoperative period. There are preoperative, intraoperative, and postoperative aspects in consideration of optimal patient care and pain control. We will consider each of these areas separately.
Preoperative Management Preoperative considerations specific to the management of postoperative pain will include a detailed history from the patient focusing on prior surgical experiences, and prior experiences with pain medications, particularly narcotics, as well as comorbidities and past medical conditions which might influence the choice of anesthesia and pain management. These would include such factors as coagulation disorders that would preclude regional anesthetic techniques, peptic ulcer disease which might preclude or influence duration of nonsteroidal anti-inflammatory drug (NSAID) use, and history of opioid abuse or addiction. A history of allergic reactions or intolerance of medications due to side effects would be obviously important to elicit, and better to discern preoperatively than in the perioperative or postoperative period. A detailed list of current medications focusing on chronic use of nonsteroidal (NSAID) and or other pain medication is obviously critical, and a history of the individual patient’s normal “bowel function” is also important. Prior or chronic history of constipation or straining is best dealt with before the introduction of narcotics that may exacerbate this problem. Judicious use of stool softeners and or laxatives in the perioperative period may be advisable to prevent an early postoperative impaction that would lead to a pain exacerbation and commonly to an emergency department visit. The next step in the preoperative preparation of the patient undergoing an anorectal operation would be to educate and prepare the patient with realistic expectations of their “impending” pain experience. The anesthetic technique will likely vary based on the magnitude of the operation, and may indeed be influenced by the anesthetist, but an early discussion with the patient regarding the planned or possible approach to anesthetic management is helpful in the preoperative period to allow the patient to feel more comfortable and confident going in to the hospital and through the operative experience. Providing the patient with this education as well as a preprinted postoperative instruction sheet (Appendix A) will also give the patient confidence that the surgeon is interested and attentive to not only the operative procedure but also the recovery. Giving the patient a detailed description of the planned procedure, the expected postoperative pain level, and instructions aimed at decreasing post procedural pain has been shown to decrease self reported pain, analgesic use, and increase the success of planned outpatient treatments.8-10 Finally, providing the patient with prescriptions for postoperative pain medications will continue imparting this caring attitude, and also will allow the patient and their family a more smooth transition from the operating room facility to their home.
M.J. Stamos and T.C. Hicks
Intraoperative Management The intraoperative or immediate perioperative aspects of pain control can be further separated into components. First is the selection of the type and timing of anesthesia and analgesia. Second, is the choice of and conduct of operative technique. Third is the use of adjuncts. The majority of studies looking at postoperative pain following anorectal surgery are small, single institution studies looking at a population of patients undergoing hemorrhoidectomy. The selection of hemorrhoidectomy patients to study most likely stems from the frequency of this operation, the acknowledgment that this is a painful operation, and recognition that it is a rather standardized operation that lends itself to comparison. Unfortunately, the vast majority of studies are not well performed or are inadequately powered. Anesthetic technique for anorectal surgery varies greatly from institution to institution, surgeon to surgeon, and also by patient and procedure. A number of studies have looked at anesthetic technique and outcome. Li and co-workers11 randomized 93 adult patients undergoing anorectal surgery to one of three groups. Group 1 received local anesthesia combined with intravenous sedation, group 2 received a spinal block, and group 3 received general anesthesia. Groups 1 and 2 had significantly less need for pain medication and group one patients were more highly satisfied and had significantly decreased cost compared with groups 2 and 3. In a similar sized prospective but nonrandomized study, Fleischer and co-workers12 reported that patients receiving local anesthesia (N ⫽ 53) compared with spinal anesthesia (N ⫽ 28) had a more rapid recovery, although no difference was seen in pain medication requirements. A small study by Pryn and coworkers13 found contradictory results. The authors studied 44 patients who were randomized to either caudal or local anesthetic block utilizing bupivacaine. This was performed as an adjunct to a general anesthetic technique for a surgical hemorrhoidectomy. Patients undergoing caudal anesthetic had significantly less pain in the early postoperative period as well as on first bowel movement. A much larger study reported by Read and co-workers14 looked prospectively at 413 consecutively patients undergoing a variety of anorectal surgical procedures. A total of 273 patients received intravenous sedation plus local anesthesia, 127 patients received regional anesthetic (spinal or epidural), and 13 patients were treated under general anesthesia either utilizing an endotracheal tube or mask. Unfortunately, the authors did not evaluate postoperative pain directly but rather evaluated safety and time until discharge. They did find that the use of local anesthetic plus intravenous sedation was safe and cost effective, with a significant decrease in time from operation until discharge home. Although it is difficult to draw conclusions from these studies and the remaining available literature, local anesthetic techniques with intravenous sedation seems to be safe and cost effective and associated with at least equivalent early postoperative pain control compared with regional anesthetic techniques. Regional anesthetic techniques as well as local anesthetic techniques all utilize (intentionally or inad-
Pain management in anorectal surgery vertently) the concept of preemptive analgesia. This concept was actually originally proposed back in the early 20th century by Crile15 who suggested that pain was exaggerated by central nervous system influences and he proposed peripheral block combined with general anesthetic techniques. Wolff, beginning in the early 1980s, “dusted off” this theory, resurrecting it with an elegant set of animal experiments and subsequently with clinical evaluation.16,17 Blocking peripheral pain impulses would prevent central hypersensitivity which could produce a vicious circle whereby peripheral painful stimuli produce an ever increasingly exaggerated response to pain due to increase receptivity of the central dorsal horn neuron. While the concept of preemptive analgesia is well founded, and animal studies give support, clinical studies have been contradictory.18,19 This contradictory data may stem more from imperfect and imprecise study design then from lack of efficacy.20-23 The effect, if any, of preemptive analgesia may not be limited to blockade of central or peripheral sensitization, but may be also secondary to a decrease in proinflammatory cytokine production.24 Operative technique is perhaps the most studied component in the evaluation of postoperative pain. Most recently, this has lead to the propagation of stapled hemorrhoidectomy or anorectopexy as compared with conventional open hemorrhoidectomy. The stapling technique has been shown to improve postoperative pain parameters, although not all patients are amenable to this approach.25-29 Other technologies have also been compared with standard operative hemorrhoidectomy techniques, including bipolar diathermy (Ligasure), ultrasonic devices (Harmonic Scalpel) as well as the CO2 and YAG laser.30-34 While these techniques may have other advantages, only the Harmonic Scalpel has shown to have a proven benefit in reducing pain following hemorrhoidectomy. Other investigators have examined the influence of open compared with closed hemorrhoidectomy wounds.35-38 Reaching conclusions from these prospective randomized trials is difficult because of disparate results. Two of the studies found that closed wounds lead to more rapid healing, while one study found the opposite effect. Two of the four studies found no difference in pain or analgesic usage, while two of the studies found that the closed technique was met with increased analgesic use or pain in the early postoperative period. While the precise technique of hemorrhoidectomy and of other anorectal operations is undoubtedly important in the development of postoperative pain, it is difficult to be dogmatic and each individual patient presents with a different spectrum of disease, and each surgeon performs the given operation in a slightly different manner. It does seem logical to minimize tissue trauma, particularly in the area of the sensitive anoderm, and perhaps utilize subcuticular sutures in closing this sensitive anoderm to avoid pressure and ischemia at the skin level. A number of adjuncts have been suggested to improve postoperative discomfort and pain following anorectal surgery. Anal stretch, and more recently lateral internal anal sphincterectomy has been studied by a number of investigators as a means of reducing pain associated with hemorrhoid-
127 ectomy, including several prospective randomized trials.39-41 Once again the results from the trials are mixed, with two of the three investigators35,36 reporting no advantage for adding the sphincterotomy in terms of pain control, and with an increased risk of disturbance in fecal continence. Galizia and co-workers37 found different results, with lateral internal sphincterotomy improving postoperative pain and also apparently preventing anal stenosis. They also found no increased risk of fecal incontinence with the added sphincterotomy. With the concept of “chemical sphincterotomy” gaining enthusiasm for the treatment of anal fissure disease, perhaps the postoperative use of a nitric oxide donor or calcium channel blocker will be equally efficacious without the risk of incontinence. A randomized prospective trial reported by Wasvary and co-workers42 compared the use of nitroglycerin ointment versus placebo and the effect on pain following hemorrhoidectomy. They found a significant reduction in pain with the use of nitroglycerin on postop day 2 only, but also found that over 40% of patients suffered the side effect of a headache. Diltiazem and Nifedepine have been shown to be efficacious in treating anal fissures when compared with nitroglycerin, but have not yet been evaluated for use following hemorrhoidectomy.43,44 The one adjunct that has received wide spread use and is well founded and supported in the literature is the use of ketorolac. Whether it is given intramuscular, intravenous, or into the surgical site seems to have little influence on the beneficial effect.45 Additionally, when utilized, ketorolac should be continued in the postoperative period for three to five days.46,47 When utilized in this fashion, and when the total duration of drug administration is five days or less, there appears to be minimal toxicity and side effects.48 Additional adjuncts which have been evaluated and utilized infrequently include parenteral or rectal steroid administration.49,50 and the addition of clonidine to the local anesthetic.51,52 Finally, administration of a long acting anesthetic within the surgical site at the completion of the operation (if not utilized preemptively) seems to be beneficial,53 and the avoidance of gauze type packs within the anal canal has been shown to significantly improve postoperative pain.54
Postoperative Management Following minor anorectal operations, such as sphincterotomy or fistulotomy, patients are generally adequately managed with non narcotic pain medications. Utilization of warm baths, NSAID analgesics, and dietary fiber supplementation (Psyllium), typically provide adequate control of pain. Selected patients undergoing these minor operations may need breakthrough narcotic pain medication such as oxycodone or codeine. For more extensive anorectal operations such as open hemorrhoidectomy, anal sphincterplasty, and anoplasty the concept of “balanced analgesia” is appropriate and should be followed. Balanced analgesia is designed to minimize the adverse effects of the pain medication regimen. This typically involves the use of different methods of analgesia, with the main goal being “opioid sparing,” or the use of smaller doses
M.J. Stamos and T.C. Hicks
128 of opioids than would otherwise be required. The options for non opioid approaches for outpatient anorectal operations include the use of local anesthetics as previously outlined, the use of acetaminophen (Tylenol), and of nonsteroidal anti inflammatory drugs (NSAID).55,56 These drugs are generally well tolerated and have a good therapeutic benefit to toxicity ratio, especially with short term use. Care should be taken however when utilizing NSAIDs in concert with other drugs that may contain acetaminophen or NSAIDs (eg, Percodan, Vicoprofen, Darvocet) because of increased risk of nephrotoxicity. Acetaminophen (Tylenol) is an analgesic that inhibits central prostaglandin synthesis. It has reasonable efficacy as an analgesic although recent data suggests that NSAIDs are preferable.57 Acetaminophen has a very favorable side effect/toxicity profile although caution should be used in patients with liver disease as the drug is metabolized by the liver. Recommended maximal dose of acetaminophen is 1 g orally every 6 hours for adults and 15 mg per kg orally Q6 hours for pediatric patients.58 NSAIDs have become more popular since the availability of parenteral ketorolac. NSAIDs block the synthesis of prostaglandins through inhibition of the cyclooxygenase (COX) enzyme. This effectively blocks the production of the acute inflammatory response and hence decreases peripheral nociception. More recent data has revealed an alternative or additional mechanism of action in the spinal cord, also because of inhibition of prostaglandin synthesis.59 The most commonly utilized NSAIDs in postoperative patients are oral ibuprofen, and intravenous followed by oral ketorolac. The recommended maximal dose of ibuprofen is 800 mg three times per day60 and the maximal dose of ketorolac for adults is 60 mg intravenously with the oral dose of 10 mg QID continued for no longer than 5 days. The most common toxicity from NSAIDs is gastrointestinal bleeding resulting from gastric or duodenal ulceration. The risk is small when the drugs are utilized for short duration, but may be increased in elderly patients and in those with a history of gastrointestinal bleeding.61 Renal and hepatic toxicity are also potential side effects, typically seen only with high dose, long duration use. More recent attempts at diminishing toxicity include the development of the COX-2 specific NSAIDs. Two oral forms of these drugs have been widely available and utilized for the past several years (Celecoxib and Rofecoxib). They have been studied for their effect on postoperative analgesia and seem to be equivalent or perhaps slightly more effective than acetaminophen.62 COX-2 NSAIDs seem to have slightly less risk of gastrointestinal bleeding but may have increased risk of cardiovascular events. They are contraindicated in patients who have known hypersensitivity to aspirin or NSAIDs and in patients who are allergic to sulfa drugs. Currently the increased cost of these drugs does not seem to warrant their use in the majority of patients because the safety of NSAIDs for short course postoperative care is quite favorable. Opioids are typically necessary and appropriate, at least for break through pain, in many patients undergoing anorectal operations. Opioids act at central nervous system receptors to modulate the pain response. Opioids have significant po-
tential toxicity including respiratory depression, sedation, nausea, vomiting, urinary retention, and a significant risk of dependence. Toxicity is directly related to the dose, and therefore, limiting administration of opioids and utilizing them for break through pain typically minimizes these adverse effects.62,63 Commonly used opioids include codeine, oxycodone, and hydrocodone. These are often used in combination with acetaminophen or NSAIDs. Transdermal application of opioids (Fentanyl patch) seems an ideal way to deliver narcotics64 following anorectal operations, as it achieves a steady state balance, avoiding the peaks and valleys attendant with oral formulations. When utilized in combination with NSAIDs, optimal analgesia could be expected.65,66 Unfortunately, adverse events associated with the use of this medication has limited its applicability, largely because of medical legal concerns.67-69 Other postoperative adjuncts utilized with some frequency include application of ice packs,70,71 topical anesthetic ointments,72 oral metronidazole,73,74 and transcutaneous electrical nerve stimulation.75 Of these adjuncts, metronidazole has been the best studied, with two randomized prospective trials. Unfortunately, both trials were small (40 patients) and showed somewhat conflicting results. At best, a modest reduction in postoperative pain will be achieved with these approaches. Finally, the commercial availability of subcutaneous drug delivery systems has led to interest in studying postoperative delivery of local anesthetics or narcotics into the wound bed.76,77
Appendix A Instructions for Patients Following Anal and Rectal Surgery 1. Purchase the following: A. Konsyl (Regular or Easy Mix) or Metamucil B. One small box of Dulcolax tablets C. Two plain fleet enemas D. Antibacterial body soap (non-scented is the best) E. Pain medications and antibiotics, if prescribed. 2. After your operation, remove the dressing at about 6:00 pm or sooner if you have a bowel movement, and take a warm bath for 15-20 minutes. Take at least 2 warm baths daily and always after a bowel movement. If you don’t have a bathtub you can use a hand held shower or buy a “portable” tub available cheaply at every drug store. After the bath, apply the tucks pads given to you at the time of discharge from the hospital. There may be a small amount of gelatin packing within the anal canal. This looks flesh colored and will pass with your first movement. 3. You should restrict your physical activity for the first 2 weeks following operation. No heavy lifting, no sports, and no lengthy auto rides. Walking and climbing stairs is permitted. Too much activity during the first 2 weeks may result in serious bleeding.
Pain management in anorectal surgery 4. Eat a regular diet with lots of fruits and vegetables. Avoid spicy foods and excess alcohol. Drink at least eight glasses of water or other non-alcoholic liquid daily. 5. If your bowels have not moved by bedtime on the third night after your operation, take 4 Dulcolax tablets at that time. If you do not have a movement by the next day, take a plain Fleet enema. Thereafter, you should have one or two bulky bowel movements per day. To accomplish this, take Konsyl or Metamucil one heaping teaspoon in 8 –12 ounces of juice 2 times daily for 5 days after your operation. Begin this the day after your operation. Continue the Konsyl or Metamucil indefinitely. If you do not have a bowel movement one day, take 2 Dulcolax tablets that night. If no movement the next day, use a plain Fleet Enema. 6. Take the prescription pain medications and antibiotics, if prescribed, as directed on the label. 7. Some bleeding and discharge from the anal area is to be expected and is normal unless heavy in amount (eg more than a cup) 8. It is common to experience difficulty in emptying your bladder following an operation. It may be helpful to urinate while in a hot bath or shower. Please notify us if you are having persistent urinary problems. 9. Pain following rectal surgery is expected and can be significant. This should subside progressively in the days following your operation. You will probably need to take pain medications at intervals for the first week to two. They will work best when taken before pain levels build. A warm bath is of great value in reducing pain. 10. Suture material used in rectal surgery is of the dissolving kind. It does not require removal. 11. Anal tags are fleshy prominences which may appear during the weeks after your operation. These are not recurrent hemorrhoids, but swelling of the skin. They will shrink as the healing process continues and are not cause for alarm. 12. Follow-up visits to the office are essential for good results. You will need to be seen at intervals for up to 3 months following your operation. Please call the office for an appointment for 2 weeks after surgery. 13. If questions arise do not hesitate to call our office for advice.
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