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5 Perioperative Management
91
Antibiotic Prophylaxis
The proper use of perioperative antibiotics to prevent surgical site infection (SSI) is certainly
important. However, a shallow glance at anorectal
surgery from anesthesiologists or hospital administrators may result in a large overestimation of
the risk for surgical site infection. When such
cases are lumped in with abdominal surgery under
the “colorectal” umbrella, or when the incision’s
location leads to a focus on the “contaminated” or
“dirty/infected” wound classication, surgeons
may feel external pressures to order antibiotics
even when there is no actual benet to the patient.
Despite its location within a contaminated eld,
the rate of surgical site infection after anorectal
surgery is very low. Patients develop transient bacteremia in roughly 8% of hemorrhoidectomies
[22, 23], but this rarely translates into a clinically
relevant infection. There are surprisingly few studies evaluating SSI after anorectal surgery. A 2014
study retrospectively reviewed over 852 patients
undergoing hemorrhoidectomy, and reported a
1.4% incidence of SSI, with routine perioperative
antibiotics showing no benet [24]. A 2014 randomized controlled trial of 100 patients undergoing hemorrhoidectomy also showed no benet to
perioperative antibiotics in regards to pain or
wound healing [25].
The exact reason for such low rates of infection are not entirely known, but presumably due
to the area’s excellent blood supply along with the
tendency of many sutured wounds to open up over
time, allowing adequate drainage. Currently, there
is no evidence that intravenous antibiotics should
be given in the perioperative period for routine
anorectal surgery. However, antibiotics may be
appropriate in select patients at increased risk of
SSI, including those with poorly controlled diabetes or other immunocompromised states.
Deep Vein Thrombosis (DVT) Prophylaxis
Venous thromboembolism (VTE) is a dreaded
complication of surgery, not only because it can
be fatal, but also because it is often preventable
through the proper use of DVT prophylaxis. For
abdominopelvic surgery, patients will typically
receive chemoprophylaxis with unfractionated or
low molecular weight heparin, along with
mechanical prophylaxis from sequential compression devices (SCDs).
The risk of DVT following ambulatory anorectal surgery is exceptionally low, with only a
single case reported in the literature [8]. In that
case series, the rate was 0.1% (1/969 patients),
and it occurred in a “calf vein” of a patient who
underwent drainage of an anal abscess 2weeks
after colectomy, so one could easily argue that
the anorectal surgery was not to blame for the
thrombosis. In general, the DVT risk following
ambulatory surgical operations remains quite low
across all procedures at 0.15%, with high variation between low risk and high-risk procedures
(0.06% vs. 1.18%) [26].
To the author’s knowledge, there is nothing
in the existing literature directly addressing the
risk of VTE after ambulatory anorectal surgery.
The ASCRS guidelines recommend that the
choice for DVT prophylaxis be catered to the
patient’s individual level of risk and the anticipated length of procedure [2]. In general, chemoprophylaxis can be safely omitted, and the
use of SCDs left at the discretion of the operating surgeon.
Perioperative Intravenous Fluids
Urinary retention has been reported in up to 34%
of patients undergoing anorectal surgery, with the
incidence being higher in male patients and in
surgeries that include multi-quadrant suturing
[27–29]. The result may be high rates of
unplanned postoperative catheterization [30], an
unpleasant experience requiring a visit to the
ofce or emergency room.
Urinary retention after anorectal surgery is
believed to be secondary to muscle spasm and
swelling. When such spasm occurs, aggressive
intravenous uid administration can lead to accumulation of high volumes of urine within the
bladder, causing overdistention and atony. In
order to avoid this problem, the surgeon must
92
S. J. Langenfeld
establish well-dened uid protocols and educate
other members of the surgery team on the dangers of aggressive uid administration. It is also
important that the surgeon maintain open communication with the anesthesia team and the perioperative nurses. One avenue to accomplish this
goal is to discuss the plan for uid restriction during the surgical time out.
Current ASCRS guidelines cite level 1b evidence that urinary retention can be reduced by
the restriction of perioperative uid administration [2]. In general, oral and intravenous uids
should be restricted to less than 1000 mL until
the patient has voided. Some expert groups recommend restricting uids even further to 250mL,
with low subsequent rates of retention [30, 31]. It
is easier to safely limit intravenous uid administration when a preoperative oral cathartic bowel
prep has been avoided.
Postoperative Care
Once the patient has undergone successful anorectal surgery, the next step is to ensure a quick
and uncomplicated recovery. In general, a proactive approach is more effective than a reactive
one, and many issues can be avoided by anticipating problems before they occur.
Enhanced Recovery
While the concept of “fast track” surgery or
Enhanced Recovery After Surgery (ERAS) typically refers to abdominopelvic colorectal surgery,
many of the same principles apply to anorectal
surgery as well. The concepts of preoperative
patient education, omission of bowel prep, and
limited intraoperative uids have already been
discussed. Many parallels to ERAS exist within
the postoperative care as well, where the surgeon
relies on multi-modal pain control to minimize
narcotics, and maintains a focus on early return
to normal activities and work.
Patient Education
As discussed earlier, patient education is of paramount importance, and this is central in the
recovery period. Due to anesthesia and narcotics,
most patients will not remember postoperative
interactions with adequate clarity. Friends and
family members who accompany the patient may
not have the necessary details of the patient’s
pathology, or the understanding and recall to be
reliable messengers. Therefore, it is helpful for
the surgeon to once again provide diagrams and
printed handouts so that the patient will know
what to expect during the recovery period
(Table5.3). Such an approach will reduce patient
confusion, eliminate phone calls, and generally
lead to a higher rate of patient and surgeon satisfaction. Currently, the use of electronic medical
records allows for standardized templates and
“smart phrases” to be used for patient education,
which can greatly enhance the speed and reproducibility of the process.
Antibiotics
Much like in the perioperative setting, antibiotics
do not have a role in the routine postoperative
care of anorectal surgery patients. The use of
postoperative oral antibiotics after incision and
drainage of anal abscess was studied in a 2011
randomized controlled trial [32]. This study
determined that antibiotics did not result in lower
rates of infection or subsequent stula formation
compared to placebo.
Oral metronidazole has not only been used for
control of postoperative infection, but also for
alleviation of postoperative pain. A small randomized controlled trial in 1998 showed
improved analgesia with metronidazole when
compared to placebo [33], but subsequent randomized trials have failed to show benet for
postoperative pain [34, 35]. Currently there is no
clear role for oral metronidazole in the postoperative period.
5 Perioperative Management
Table 5.3 Postoperative instructions
Today, you underwent the following procedure:________________________________
During the recovery period, you should take the following medications in addition to your regular home
medications:
1.Docusate sodium 100mg: 1 pill to be taken twice daily. This is a stool softener to avoid constipation. It is
available over the counter.
2.Ibuprofen 200mg: 4 pills (800mg) to be taken three times per day for 5days, then up to three times per day
as needed after that. This is a pain medicine to help with anal discomfort. This should be taken with a small
snack to avoid stomach upset.
3.Hydrocodone/Acetaminophen 5/325mg: 1–2 pills every 6–8h as needed for pain. This is a narcotic, and
will cause constipation when used. A prescription will be sent home with you.
4.Additional new medications: _________________________
_________________________
Sitz baths should be performed three times per day, using warm water and soaking for 20min at a time. This will
decrease pain and help keep the wound clean. Epsom salts is not necessary. A bathtub can be used for the Sitz
baths, or a small plastic Sitz bath can be purchased from the pharmacy. Sitz baths can be performed more
frequently if desired
If unable to urinate, ll the bathtub above the waist with warm water to see if this allows you to void. If not, please
call the ofce immediately for further assistance
Some bleeding is normal after anal surgery. If the bleeding is copious or getting worse, please call the ofce for
assistance
It is essential that you keep your bowel movements soft and easy to pass. Hard or large stools will cause increased
discomfort and may traumatize your new wound. Please take the stool softeners as directed, drink plenty of water,
and maintain a high ber diet (20–25g/day). If hard stools persist, start taking polyethylene glycol 17g (one
capful) mixed in 8 ounces of water one to two times per day
An appointment has been made for you to follow up in the surgeon’s ofce on the following date:
____________________. Please call if you are unable to make that appointment, or if you wish to be seen sooner
Please call with any questions or concerns about your postoperative care. Your surgery team is available 24h per
day at the following number: ___________________________
93
Sitz Baths
To help with pain and wound care, patients often
undergo scheduled “Sitz baths” after anorectal surgery, which consists of soaking the anus in warm
water three to four times per day for 20–30min at a
time. It is typically recommended that the patients
utilize very warm water, but avoid temperatures that
can damage the wound. No additive agents are necessary, and the use of “Epsom salts” (Magnesium
Sulfate compounds) should be avoided. Patients can
use a bathtub, or can purchase a commercially
available plastic Sitz bath (Fig.5.1), which can be
easily found at local pharmacies and medical supply stores. Hospital wards can usually purchase Sitz
baths for less than $1, but they are typically in
excess of $15in retail locations [36, 37].
While utilization of the absorbable stula plug
for treatment of complex anal stulas is becoming
an increasingly rare procedure, the plug’s instructions should be read carefully, as Sitz baths are often
contraindicated in patients with indwelling plugs.
Fig. 5.1 Sitz bath. Photo courtesy of Sean Langenfeld,
MD
The evidence that Sitz baths reduce pain after
anorectal surgery is quite modest [38, 39], but they
are known to reduce intra-anal resting pressures
[40], which is of hypothetical benet to the patient.
In addition, the intervention is cheap and easy with
little known side effects, so it remains as a common element of most recovery algorithms.
94
S. J. Langenfeld
Wound Care
Wounds that exist within or above the anal canal do
not typically require postoperative care, and
attempts at special care may lead to unnecessary
wound trauma and patient discomfort. Open or
closed wounds at the anal verge or on the anal margin can typically be managed with Sitz baths alone,
or in conjunction with a gauze pad to control drainage. Special ointments to assist wound healing will
be discussed shortly, but are typically not necessary.
Antibiotic ointments for anorectal wounds have not
been well studied, and are generally unnecessary.
In general, serial or repeated packing of open
anal wounds causes signicant discomfort without patient benet. If packing is placed at surgery
to control bleeding or to stent the incision open,
this packing can be removed during the patient’s
rst Sitz bath, and does not require replacement.
If repeated packing is necessary to keep a wound
open after an incision and drainage of an anorectal abscess, it is likely that the surgeon made an
inadequate incision at the time of surgery.
The choice of suture for anorectal surgery is
left at the surgeon’s discretion, but this choice
does affect postoperative care. Absorbable suture
such as chromic or polyglycolic acid is preferred,
as postoperative suture removal is generally both
difcult and painful.
It is quite common for anal suture lines to
separate over time, which is normal and typically does not negatively impact surgical outcomes. If slower-absorbing sutures and running
suture lines are employed, patients may contact
or come to the ofce with complaints of hanging
sutures. Patients should be coached to avoid
pulling on these sutures in an attempt for
removal, and they should instead be instructed to
either ignore the strands, or gently cut them off
at the skin level.
When more complex anorectal surgeries are
performed, including sphincteroplasties, anoplasties, and endorectal advancement aps,
patients are often instructed to avoid sitting
directly on their incisions to help prevent wound
breakdown or ap disruption. While this seems
intuitive, the author is unaware of any literature
that supports or negates these recommendations.
Activity andWork Restrictions
There are no universal rules regarding whether or
not patients should limit their activities after anorectal surgery. For simpler procedures such as
sphincterotomy, stulotomy, and abscess drainage, patients can perform normal activities without restriction. For the more complex cases
including local excision of rectal tumors, sphincteroplasty, anoplasty, and endorectal advancement aps, it is reasonable to have the patient
avoid strenuous exercise and heavy lifting for
2–3weeks after surgery to prevent undue tension
on aps and suture lines.
Work restrictions are similarly vague, and
typically depend on the patient’s occupation and
the amount of anticipated postoperative pain.
Some patients will only require 1–2 days off
from work after surgery, while others will have
sufcient pain to warrant 1 or 2 weeks away
from work. Patients should be allowed up to
2weeks off of work if desired, especially if they
undergo hemorrhoidectomy or other procedures
known to be associated with signicant postoperative pain.
Diet
There are no meaningful data in support of a specic diet after anorectal surgery. High ber diets
are often recommended to help prevent postoperative constipation, but there are no specic
restrictions that require adherence. Once they are
voiding easily, it is also important that patients
drink plenty of water, as dehydration is common
in the postoperative period, which contributes to
fatigue and constipation.
Bowel Regimen
Constipation is common after anorectal surgery
for many reasons, including dehydration, narcotic intake, and the functional constipation that
occurs from the patient’s fear of a painful bowel
movement. Efforts should be made to avoid
postoperative constipation, as hard stools often
5 Perioperative Management
95
exacerbate pain and can put unnecessary stress
on surgical wounds.
No specic bowel regimen is superior, but
most surgeons recommend a combination of
increased ber intake, increased water intake,
and a scheduled stool softener such as Docusate
Sodium or Polyethylene Glycol to prevent large
or hard stools. Other stimulant laxatives such as
senna, bisacodyl, magnesium citrate, and milk of
magnesia may also be used temporarily as a rescue therapy, but they are often associated with
more diarrhea and cramping, can be habitforming, and should be avoided if possible in the
long term.
Pain Management
Anorectal surgery is often very painful, and poor
pain control can lead to a multitude of problems
including urinary retention, constipation, emergency room visits, and readmissions. ASCRS
guidelines recommend a multi-modal approach
to postoperative analgesia (Table 5.4) [2]. This
protocol begins in the operating room with the
use of local analgesia in the form of traditional or
long-acting (liposomal) bupivacaine, and also
includes the above-mentioned Sitz baths and
bowel regimens.
Oral andIV Analgesia
Most patients receive a prescription for an oral
narcotic such as hydrocodone or oxycodone
combined with acetaminophen. These compounds should be used with discretion, as consti-
Table 5.4 Elements of multi-modal postoperative
analgesia
Intraoperative:
Local injection of short or long-acting (liposomal)
bupivacaine
Intravenous Ketorolac
Postoperative:
Sitz baths
Oral narcotics in combination with acetaminophen
Ibuprofen or other NSAIDs
Topical agents (Metronidazole, Sucralfate)
Bowel regimen to avoid constipation
pation is nearly universal and dependence can
occur with prolonged use.
Nonsteroidal anti-inammatory drugs
(NSAIDs) are typically used in the postoperative
period to improve analgesia and limit narcotic
consumption. Over-the-counter ibuprofen at a
dose of 600 or 800mg can be extremely effective
for analgesia. Ketorolac has also shown efcacy
with several methods of delivery, including intravenous, intramuscular, subcutaneous, and periincisional [41–44]. In general, patients without
contraindications will receive 30mg of IV ketorolac during the procedure to help with postoperative pain.
Oral metronidazole was previously discussed,
and no clear benet is known to routine postoperative administration.
Topical Analgesia
Many topical agents have been employed as
adjuncts for postoperative pain control; this discussion focuses on the most commonly used
medications.
Two small randomized controlled trials evaluated topical metronidazole cream (10%) for pain
relief after hemorrhoidectomy, both of which
concluded that there was a signicant reduction
in pain, but no change in narcotic consumption
[45, 46].
Topical sucralfate has been well studied for
alleviation of radiation proctitis, and has recently
earned the enthusiasm of a single group from
Nagpur, India. Dr. Prasad etal. published a randomized controlled trial in 2008 using sucralfate
7% ointment after hemorrhoidectomy [47], and
then a second study in 2011 focusing on stulotomy [48]. Both studies showed sucralfate
ointment to improve postoperative wound healing and decrease postoperative pain when compared to placebo.
Topical glyceryl trinitrate (GTN) and topical
calcium channel blockers (CCBs) are known to
reduce intra-anal pressures, and have long been
used for the conservative management of anal ssures. Since much of the pain after anorectal surgery is thought to be secondary to muscle spasm,
these agents have also been studied for the relief
of postoperative pain. Topical GTN has shown
96
S. J. Langenfeld
modest reductions in postoperative pain, but
headache is a common side effect, which limits
compliance [49]. Topical diltiazem has shown
similar modest benets in pain, but no reduction
in narcotic consumption [50].
In summary, topical agents can be used safely,
but the benets are modest, and most agents
require a visitation to a compounding pharmacy,
where cost can be a limiting factor.
Outpatient Follow-Up
In the early postoperative period, inspection of
the wound should typically be limited to an external exam, with digital rectal exam and anoscopy
reserved for the investigation of specic concerns. Otherwise, early invasive techniques will
result in a great deal of pain to the patient, and it
may lead to unnecessary wound trauma and
suture line disruption.
The interval between surgery and the rst follow up appointment is left to the discretion of the
surgeon, and is often based on individual and
institutional workows and practice patterns.
Typically, patients should be seen 2–6 weeks
after surgery to ensure they are recovering well
and ready to resume normal activity. Some surgeons advocate for the rst visit to be 4–6weeks
after surgery because at that time the pain will
generally have markedly decreased and the
patient is usually more satised with the surgical
outcome than they were at 2weeks.
Dismissal from clinic should be allowed once
the wounds have healed, and the patient’s underlying pathology has been adequately alleviated.
Certain conditions will require more long-term
follow up, including patients with complex anal
stulas, inammatory bowel disease, anal condyloma, anorectal neoplasia, and perianal Crohn’s
disease.
Ambulatory Surgery Outcomes
The move toward ambulatory anorectal surgery
came with many benets to both the patient and
surgeon. Surgeons often prefer the increased lev-
els of speed and efciency in the ambulatory setting, while patients appreciate many of the
mechanical benets that include more convenient
locations, easier scheduling, closer parking, and a
quicker return to a familiar home environment.
Ambulatory anorectal surgery has been shown
to be safe, with low rates of complications and
unplanned patient admissions. Patient outcomes
have been shown to be equivalent or better than
what can be achieved in the hospital setting [2,
51–55]. Ambulatory anorectal surgery has also
been shown to be cost-effective, with cost savings of 30–50% when compared to inpatient surgery [56, 57]. Of equal importance is patient
satisfaction, which has been very high in published surveys of ambulatory surgery [58]. A
2012 survey study looking specically ant ambulatory anorectal surgery showed very high scores
for postoperative quality of life and functional
outcomes, with an overall postoperative satisfaction rate of 92.4% [55].
Complications After Anorectal Surgery
An in-depth discussion of complications after
anorectal surgery likely deserves its own chapter
or even its own textbook. However, this section
will summarize common problems that arise
after anorectal surgery. The two main categories
to consider are early/acute complications and
late/chronic complications.
Acute Complications
Infection
Infection after anorectal surgery can be difcult
to identify, as the symptoms of swelling, pain,
and foul-smelling drainage are very common and
considered to be a normal part of the recovery
process for many procedures. As mentioned earlier, major infection after anorectal surgery is rare
[22–25]. However, since the incidence is low, and
the symptoms are vague, the surgeon must maintain a high level of suspicion when evaluating
postoperative patient complaints.
5 Perioperative Management
97
One caveat is that pain and urinary retention
should not become progressively worse after
anorectal surgery, and such occurrences should
alert the treatment team to the possibility of pelvic sepsis. The triad of fever, worsening pain, and
the inability to urinate should lead to a prompt
examination by the surgeon, along with lab work
and a CT of the pelvis if the diagnosis remains in
question. If faced with pelvic sepsis, the next step
would be an emergent exam under anesthesia
with drainage of abscess, debridement of any
devitalized tissue, and consideration for fecal
diversion.
Urinary Retention
As mentioned earlier, urinary retention is very
common after anorectal surgery, with rates of
15–50% for male patients [27, 29, 59, 60]. When
urinary retention occurs despite the limitation of
uids and adequate pain control, the rst step is the
have the patient to lie waist-deep within a bathtub
of very warm water, with hopes that this will reduce
spasm and swelling and allow the patient to void. If
still unable to void, the next step is either an
indwelling urinary catheter or intermittent straight
catheterization, which often has to continue for
several days while the anorectal inammation
cools off. Most patients can have their urinary catheter removed in the ofce after 3–4days, at which
time their ability to void is improved. If problems
persist after the rst postoperative week, consultation with an urologist is appropriate.
Hemorrhage
Minor bleeding after anorectal surgery is nearly
universal, and patients are typically poor judges
of the true volume of blood experienced, especially when the toilet bowl water has been colored red. While signicant postoperative
hemorrhage is uncommon, it does occur in up
to 6% of anorectal surgeries, with the incidence being the highest after hemorrhoidectomy [61, 62].
When bleeding occurs, the treatment of choice
depends on the severity and location. Most bleeds
will resolve without intervention, and patients
can be placed in observation with serial exams
and serial hemoglobins. For anal margin bleed-
ing, bedside electrocautery or sutures can be used
for control. Anal canal bleeding is more problematic, and 15–33% of patients who bleed after
hemorrhoidectomy will require an unplanned
return to the operating room for surgical control
[63, 64].
Side Eects ofLocal Trauma
Constipation is common after surgery and has
been previously discussed. In addition, patients
may experience acute anal ssures and thrombosed external hemorrhoids as a result of their
recent surgery and the associated constipation.
These problems are typically self-limited and
should be treated with supportive care including
Sitz baths and topical ointments.
Chronic Complications
Fecal Incontinence
Postoperative fecal incontinence (FI) is often
multi-factorial. While uncommon, it can be devastating to the patient. A preoperative discussion
of risk, along with, when appropriate, a preoperative assessment of baseline fecal continence
using a validated instrument [65], are of utmost
importance.
Internal hemorrhoids provide 15% of the resting anal tone, and hemorrhoidectomy should be
avoided if possible in patients with pre-existing
fecal incontinence. Immediate and delayed
reductions in fecal continence can also occur
when sphincter muscle is intentionally divided.
Approximately 25% of patients with complex stulotomy and up to 8% of patients following
sphincterotomy will experience some degree of
FI [66–70]. In addition, unintentional sphincter
injuries can occur, including thermal trauma to
the sphincter. Thermal trauma can occur from
any source, but the surgeon should practice with
extreme caution when using energy devices for
hemorrhoidectomy, including ultrasonic shears,
as there is potential for lateral thermal spread.
Other patients may have new or recurrent anal
stulas with symptoms that mimic incontinence.
The workup of iatrogenic fecal incontinence is
similar to the approach to other causes of FI, and
98
S. J. Langenfeld
includes anorectal manometry and endorectal
ultrasound to better dene the injury. The
treatment algorithm is also similar to traditional
FI, and includes an initial trial of bulking agents
and low-dose anti-diarrheal agents. Biofeedback
may also be effective. When conservative treatment fails, these patients are candidates for sacral
neuromodulation or sphincteroplasty, but longterm outcomes in patients with non-obstetrical
trauma are not well known [71–73].
Anal Stenosis
Any trauma to the anal canal can result in scarring and long-term stenosis, which can cause difculty with evacuation, incontinence, anal
ssures, and severe pain with defecation. Patients
undergoing three-quadrant hemorrhoidectomy
are at an increased risk due to the large volume of
resected anoderm.
Once anal stenosis has been discovered, the
rst step is to ensure there is no underlying
malignancy. If an ofce exam is inadequate for
this, patients may require an exam under anesthesia, possibly with biopsy. Depending on the location and severity of stenosis, patients often benet
from serial ofce dilations. When these measures
fail, the surgeon may consider anoplasty to introduce healthy tissue into the anal canal.
Chronic Pain
Chronic pain after anorectal surgery is thankfully
uncommon. Causes are multiple, and include complications of surgery, such as stenosis, retained staples from a procedure for prolapsed hemorrhoids,
and persistence of the presenting pathology such
as residual ssures, abscesses, or stulas. Spasm
of the internal anal sphincter secondary to the
trauma of surgery may also contribute.
The rst step in the evaluation of chronic pain
is to ensure there is no untreated anorectal sepsis. Once this step has been completed, the focus
can shift to symptom control. Most chronic pain
will improve with time, and a combination of Sitz
baths, NSAIDs, low-dose antispasmodics, and
patient reassurance will be adequate. For patients
with persistent hypertonicity and anismus,
botulinum toxin injection can help to alleviate
symptoms [74]. For patients with retained staples
after PPH, exam under anesthesia with staple
removal can also be quite helpful [75]. Sacral
neuromodulation for chronic pelvic pain has also
been described in a small case series with promising results [76]. However, there is no USA FDA
labeling for this indication.
Summary
The perioperative management of the ambulatory
anorectal surgery patient has evolved over time,
and is currently supported by higher level evidence than was previously available. When surgeons take leadership in the perioperative care of
their patients, and invest time into the creation of
standardized treatment protocols, they can ensure
a successful surgery with a safe and expeditious
recovery. Complications after anorectal surgery
are typically minor, and can be easily managed
when identied in a timely manner.
References
1. Smith LE.Ambulatory surgery for anorectal diseases:
an update. South Med J. 1986;79(2):163–6.
2. Ternent CA, Fleming F, Welton ML, Buie WD,
Steele S, Rafferty J.Clinical practice guidelines for
ambulatory anorectal surgery. Dis Colon Rectum.
2015;58:915–22.
3. https://imis.fascrs.org/ASCRSIMIS/Members/Store/
StoreLayouts/Store.aspx. Accessed 4 Feb 2016.
4. ASA physical status classication system, last approved
by the ASA House of Delegates on October 15, 2014.
Available at: https://www.asahq.org/resources/clinical-
information/asa-physical-status-classication-system.
Accessed 21 June 2018.
5. Apfelbaum JL, Connis RT, Nickinovich DG,
et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society
of Anesthesiologists Task Force on Preanesthesia
Evaluation. Anesthesiology. 2012;116(3):
522–38.
6. Chung F, Yuan H, Yin L, Vairavanathan S, Wong
DT.Elimination of preoperative testing in ambulatory
surgery. Anesth Analg. 2009;108:467–75.
7. Czoski-Murray C, Lloyd Jones M, McCabe C, etal.
What is the value of routinely testing full blood count,
electrolytes, and urea, and pulmonary function tests
before elective surgery in patients with no apparent
clinical indication and in subgroups of patients with
common comorbidities: a systematic review of the
5 Perioperative Management
99
clinical and cost-effective literature. Health Technol
Assess. 2012;16:i–xvi,1.
8. Hyman NH, Cataldo PA, Trevisani GT, Burns BH,
Shackford SR. Tracking outcomes of anorectal surgery: the need for a disease-specic quality assessment tool. Dis Colon Rectum. 2008;51:1221–4.
9. Ansell GL, Montgomery JE. Outcomes of ASA III
patients undergoing day case surgery. Br J Anaesth.
2004;92(1):71–4.
10. Joshi GP, Chung F, Vann MA, etal. Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients
undergoing ambulatory surgery. Anesth Analg.
2010;111:L1378–87.
11. http://packageinserts.bms.com/pi/pi_glucophage.pdf.
Accessed 4 Feb 2016.
12. Albaladejo P, Marret E, Samama CM, et al. Noncardiac surgery in patients with coronary stents: the
RECO study. Heart. 2011;97:1566–72.
13. Fujikawa T, Tanaka A, Abe T, etal. Does antiplatelet
therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than
1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg. 2013;217(6):1044–53.
14. Sahebally SM, Healy D, Coffey JC, Walsh SR.Should
patients taking aspirin for secondary prevention continue or discontinue the medication prior to elective,
abdominal surgery? Best evidence topic (BET). In J
Surg. 2014;12(5):16–21.
15. Giannarini G, Mogorovich A, Valent F, et al.
Continuing or discontinuing low-dose aspirin before
transrectal prostate biopsy: results of a prospective
randomized trial. Urology. 2007;70(3):501–5.
16. Oscarsson A, Gupta A, Fredrikson M, etal. To continue or discontinue aspirin in the perioperative
period: a randomized, controlled clinical trial. Br J
Anaesth. 2010;104(3):305–12.
17. Burger W, Chemnitius JM, Kneissl GD, Rücker
G. Low-dose aspirin for secondary cardiovascular
prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med.
2005;257:399–414.
18. Gerstein NS, Schulman PM, Gerstein WH, Petersen
TR, Tawil I. Should more patients continue aspirin
therapy perioperatively? Clinical impact of aspirin
withdrawal syndrome. Ann Surg. 2012;255:811–9.
19. Devereaux PJ, Mrkobrada M, Sessler DI, etal. Aspirin
in patients undergoing noncardiac surgery. N Engl J
Med. 2014;370(16):1494–503.
20. Bailey HR, Snyder MJ.Selection, preoperative assessment, and education of the patient for ambulatory surgery. In: Ambulatory anorectal surgery. NewYork:
Springer; 2000. p.37–45.
21. Beck DE, Wexner SD.Preoperative and postoperative
management. In: Fundamentals of anorectal surgery.
2nd ed. NewYork: McGraw-Hill;1992; 50–56.
22. Bonardi RA, Rosin JD, Stonesifer GL Jr, Bauer
FW.Bacteremias associated with routine hemorrhoidectomies. Dis Colon Rectum. 1976;19:233–6.
23. Adami B, Eckardt VF, Suermann RB, Karbach U,
Ewe K. Bacteremia after proctoscopy and hemorrhoidal injection sclerotherapy. Dis Colon Rectum.
1981;24:373–4.
24. Nelson DW, Champagne BJ, Rivadeneira DE,
et al. Prophylactic antibiotics for hemorrhoidectomy: are they really needed? Dis Colon Rectum.
2014;57:365–9.
25. Khan KI, Akmal M, Wagas A, Mahmood S.Role of
prophylactic antibiotics in Milligan Morgan hemorrhoidectomy—a randomized control trial. Int J Surg.
2014;12(8):868–71.
26. Pannucci CJ, Shanks A, Moote MJ, etal. Identifying
patients at high risk for venous thromboembolism
requiring treatment after outpatient surgery. Ann
Surg. 2012;255(6):1093–9.
27. Petros JG, Bradley TM. Factors inuencing postoperative urinary retention in patients undergoing
surgery for benign anorectal disease. Am J Surg.
1990;159:374–6.
28. Prasad ML, Abcarian H.Urinary retention following
operations for benign anorectal diseases. Dis Colon
Rectum. 1978;21:490–2.
29. Zaheer S, Reilly WT, Pemberton JH, Ilstrup
D. Urinary retention after operations for benign
anorectal diseases. Dis Colon Rectum. 1998;41:
696–704.
30. Bailey HR, Ferguson JA.Prevention of urinary retention by uid restriction following anorectal operations. Dis Colon Rectum. 1976;19:250–2.
31. Hoff SD, Bailey HR, Butts DR, et al. Ambulatory
surgical hemorrhoidectomy—a solution to postoperative urinary retention? Dis Colon Rectum.
1994;37(12):1242–4.
32. Sozener U, Gedik E, Kessaf Aslar A, etal. Does
adjuvant antibiotic treatment after drainage of
anorectal abscess prevent development of anal
stulas? A randomized, placebo-controlled, double- blind, multicenter study. Dis Colon Rectum.
2011;54(8):923–9.
33. Carapeti EA, Kamm MA, McDonald PJ, Phillips
RK. Double-blind randomised controlled trial of
effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet. 1998;351:169–72.
34. 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.
2002;45(9):1186–90.
35. Hosseini SV, Sabet B, Nouri Amirkolaee M,
Bolandparvaz S. A randomized clinical trial on the
effect of oral metronidazole on wound healing and
pain after anal sphincterotomy and ssurectomy. Arch
Iran Med. 2008;11(5):550–2.
36. http://www.cardinalhealth.com/en/consumer-prod-
ucts/home-healthcare-solutions/Daily-Living-Aids/
Sitz-Bath.html. Accessed 3 Feb 2016.
37. http://www.cvs.com/shop/home-health-care/other-
daily-living-aids/bath-body-products/cvs-sitz-bathskuid-741742. Accessed 4 Feb 2016.
100
S. J. Langenfeld
38. Gupta PJ. Effects of warm water sitz bath on symptoms in post-anal sphincterotomy in chronic anal
ssure—a randomized and controlled study. World J
Surg. 2007;31(7):1480–4.
39. Gupta PJ.Warm sitz bath does not reduce symptoms
in posthaemorrhoidectomy period: a randomized,
controlled study. ANZ J Surg. 2008;78(5):398–401.
40. Dodi G, Bogoni F, Infantino A, Pianon P,
Mortellaro LM, Lise M. Hot or cold in anal
pain? A study of the changes in internal anal
sphincter pressure profiles. Dis Colon Rectum.
1986;29(4):248–51.
41. Richman IM.Use of Toradol in anorectal surgery. Dis
Colon Rectum. 1993;36(3):295–6.
42. Place RJ, Coloma M, White PF, Huber PJ, Van
Vlymen J, Simmang CL.Ketorolac improves recovery after outpatient anorectal surgery. Dis Colon
Rectum. 2000;43(6):804–8.
43. O’Donovan S, Ferrara A, Larach S, Williamson
P. Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy. Dis Colon Rectum.
1994;37(8):793–9.
44. De Oliveira GS, Agarwal D, Benzon HT.Perioperative
single dose ketorolac to prevent postoperative pain:
a meta-analysis of randomized trials. Anesth Analg.
2012;114(2):424–33.
45. Nicholson TJ, Armstrong D. Topical metronidazole (10 percent) decreases posthemorrhoidectomy
pain and improves healing. Dis Colon Rectum.
2004;47(5):711–6.
46. Ala S, Saeedi M, Eshghi F, Mirzabeygi P. Topical
metronidazole can reduce pain after surgery and pain
on defecation in postoperative hemorrhoidectomy.
Dis Colon Rectum. 2008;51(2):235–8.
47. Gupta PJ, Heda PS, Kalaskar S, Tamaskar VP.Topical
sucralfate decreases pain after hemorrhoidectomy and
improves healing: a randomized, blinded, controlled
study. Dis Colon Rectum. 2008;51(2):231–4.
48. Gupta PJ, Heda PS, Shrirao SA, Kalaskar SS.Topical
sucralfate treatment of anal stulotomy wounds:
a randomized placebo-controlled trial. Dis Colon
Rectum. 2011;54(6):699–704.
49. Ratnasingham K, Uzzaman M, Andreani SM, Light
D, Patel B.Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing. Int J Surg.
2010;8(8):606–11.
50. Silverman R, Bendick PJ, Wasvary HJ.A randomized,
prospective, double-blind, placebo-controlled trial of
the effect of a calcium channel blocker ointment on
pain after hemorrhoidectomy. Dis Colon Rectum.
2005;48(10):1913–6.
51. Faiz OD, Brown TJ, Colucci G, Grover M, Clark
SK. Trends in colorectal day case surgery in
NHS Trusts between 1998 and 2005. Color Dis.
2008;10:935–42.
52. Lohsiriwat D, Lohsiriwat V.Outpatient hemorrhoidectomy under perianal anesthetics inltration. J Med
Assoc Thail. 2005;88:1821–4.
53. Hidalgo Grau LA, Heredia Budó A, Llorca Cardeñosa
S, etal. Day case stapled anopexy for the treatment of
haemorrhoids and rectal mucosal prolapse. Color Dis.
2012;14:765–8.
54. Chan PY, Lee MP, Cheung HY, Chung CC, Li
MK. Unplanned admission after day-case haemorrhoidectomy: a retrospective study. Asian J Surg.
2010;33:203–7.
55. Grucela A, Gurland B, Kiran RP. Functional outcomes and quality of life after anorectal surgery. Am
Surg. 2012;78:952–6.
56. Stephenson SV.Ambulatory surgical centers. JAMA.
1985;253(3):342–3.
57. Lacerda-Filho A, Cunha-Melo JR.Outpatient haemorrhoidectomy under local anaesthesia. Eur J Surg.
1997;163:935–40.
58. Tong D, Chung F, Wong D. Predictive factors in
global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology. 1997;87:856–64.
59. Toyonaga T, Matsushima M, Sogawa N, et al.
Postoperative urinary retention after surgery for benign
anorectal disease: potential risk factors and strategy
for prevention. Int J Color Dis. 2006;21(7):676–82.
60. Baldini G, Bagry H, Aprikian A, Carli F.Postoperative
urinary retention: anesthetic and perioperative considerations. Anesthesiology. 2009;110(5):1139–57.
61. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis
Colon Rectum. 1995;38(7):687–94.
62. Rosen L, Sipe P, Stasik JJ, Riether RD, Trimpi
HD. Outcome of delayed hemorrhage following
surgical hemorrhoidectomy. Dis Colon Rectum.
1993;36(8):743–6.
63. Nisar PJ, Acheson AG, Neal KR, Scholeeld
JH. Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of
randomized, controlled trials. Dis Colon Rectum.
2004;47(11):1837–45.
64. Chen HH, Wang JY, Changchien CR, Yeh CY, Tsai
WS, Tang R. Effective management of posthemorrhoidectomy secondary hemorrhage using rectal irrigation. Dis Colon Rectum. 2002;45(2):234–8.
65. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum.
1993;36(1):77–97.
66. Roig JV, Jordán J, García-Armengol J, Esclapez P,
Solana A. Changes in anorectal morphologic and
functional parameters after stula-in-ano surgery. Dis
Colon Rectum. 2009;52(8):1462–9.
67. Visscher AP, Schuur D, Roos R, Van der Mijnsbrugge
GJ, Meijerink WJ, Felt-Bersma RJ. Long-term follow-up after surgery for simple and complex cryptoglandular stulas: fecal incontinence and impact
on quality of life. Dis Colon Rectum. 2015;58(5):
533–9.
68. Jordán J, Roig JV, García-Armengol J, GarcíaGranero E, Solana A, Lledó S.Risk factors for recurrence and incontinence after anal stula surgery.
Color Dis. 2010;12(3):254–60.