La mucoprolassectomia sec. Longo in Day Surgery

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Andrea Favara

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La mucoprolassectomia sec. Longo in Day Surgery

Unita’ Operativa di Chirurgia Generale laparoscopica e mininvasiva

UCP SICCR

Ospedale di Cantù (CO)

Dir. Marco Azzola Guicciardi

Azienda Ospedaliera Sant Anna Como

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Introduzione

La mucoprolassectomia è la tecnica di scelta nelle emorroidi di III grado sintomatiche

La nostra esperienza inizia nel 1998

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Treatment of Hemorrhoids in Day Surgery: StapledHemorrhoidopexy vs Milligan–Morgan Hemorrhoidectomy

Vito Maria Stolfi & Pierpaolo Sileri & Chiara Micossi &Isabella Carbonaro & Marco Venza & Paolo Gentileschi &Piero Rossi & Alessandro Falchetti & Achille Gaspari

Conclusions This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms,compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs

J Gastrointest Surg (2008)

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Evoluzione

Dopo un’ iniziale esperienza durante la quale gli interventi sono stati sempre condotti in anestesia generale o spinale e ricovero ordinario, le evidenza della letteratura e l’ esigenza di gestire al meglio le risorse aziendali ci hanno suggerito di modificare alcuni aspetti tecnici e organizzativi

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European Review for Medical and Pharmacological Sciences

Feasibility of stapled haemorrhoidopexy in Day Surgery

A. CAVIGLIA, A. DEL GRAMMASTRO, R. CROCETTA*, A. STRANIERO**,F. GIORGIANO***

Departmental Operative Unity of Colonproctology Policlinico Umberto I, “La Sapienza” University, Rome (Italy)

Stapled haemorrhoidopexy in day surgery may be a viable addition to the therapy for rectal prolapse with the advantages of an early discharge and a lower cost than a longer hospitalization. With this procedure, performed in a single day, we provided a value-added service to the patients with less cost and without a significant compromise on safety and efficacy.

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Local Anesthesia for StapledProlapsectomy in Day Surgery:Results of a Prospective Trial

Pierpaolo Mariani, M.D., Gianluca Arrigoni, M.D., Giorgio Quartierini, M.D.,Giovanni Dapri, M.D., Sara Leone, M.D., Matteo Barabino, M.D., Enrico Opocher, M.D.Dis Colon Rectum 2005;Department of General Surgery-UCP Seriate, Bolognini Hospital, Seriate, Bergamo, Italy

CONCLUSIONS: The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedureprovides good pain control and results in a minimalnumber of complications.

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Il nostro attuale orientamento

Utilizzo dell’ anestesia locale Dimissione in giornata Prericovero solo se

controindicazioni alla dimissione in giornata o all’ anestesia locale

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Day Surgery for Mucosal-Hemorrhoidal Prolapse Using a Circular Stapler andModified Regional Anesthesia

Francesco Gabrielli, M.D., Marco Chiarelli, M.D., Ugo Cioffi, M.D.,Angelo Guttadauro, M.D., Matilde De Simone, M.I)., Piero Di Mauro, M.D.,Alessandro Arriciati, M.D.

From the Department of General and Thoracic Surgery, University Milan, Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Maggiore Policlinico, Milan, Italy

CONCLUSION: Our study shows that, in selected cases, it is possible to perform day surgery for patients with hemorrhoidal disease using a circular stapler device when combined with regional anesthesia.

Dis Colon Rectum 2001;44:842-844.

Perianal Local Block for Stapled Anopexy

Roger Gerjy, M.D., Kristoffer Derwinger, M.D., Per-Olof Nystrom, M.D. Ph.D. Colorectal Surgery, Department of Surgery, Linkoping University Hospital, Linkoping, Sweden

CONCLUSIONS: A perianal local block is easy to apply and has a high degree of acceptance among patients. The operation time, postoperative pain, and success rates of the operation equaled those of stapled anopexy performed under general anesthesia. The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery.

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Anestesia tecnica

No premedicazione

20 ml ropivacaina 7% + 20 ml ropivacaina 2% (totale 190 mg)

Iniezione in 8 direzioni (5ml)

Lidocaina 10 ml sottomucosa prima di chiudere la stapler

Al bisogno eventuale midazolam ev

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Randomized clinical trial of stapled haemorrhoidopexyperformed under local perianal block versus general anaesthesia

R. Gerjy, A. Lindhoff-Larson, R. Sjo¨ dahl and P.-O. Nystrom

Colorectal Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden

Conclusion: Perianal local block is easy to apply with a high degree of acceptability among patients. Postoperative pain, restoration of anatomy and symptom resolution were similar to that of stapled haemorrhoidopexy performed under general anaesthesia.Paper accepted 16 July 2008

Local Perianal Block in Anal Surgery: The Disadvantage ofPain during Injection despite High Patient Satisfaction

Department of Surgery, Kyung Hee University School of Medicine, Seoul, Korea

Sun Jin Park, at, ar

J Korean Surg Soc 2010

Conclusion: Local perianal block is feasible for various anal operations and results in a high degree of satisfaction among patients. However, the pain associated with injection has an adverse effect on patient satisfaction.

Analgesia perioperatoria

Preoperatorio 1 g paracetamolo per os

Postoperatorio Ketorolac 30 mg ev e

Paracetamolo al bisogno

Perianal Block for Ambulatory Hemorrhoidectomy, anEasy Technique for General Surgeon

Potchavit Aphinives MD*

* Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Conclusion: An easy technique of perianal block provides availability of performing ambulatory hemorrhoidectomy under general surgeons’ hands

J Med Assoc Thai 2009; 92 (2): 195-7

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Vantaggi

Semplificazione iter preoperatorio (unico accesso)

Utilizzo più razionale dei posti letto Costi ridotti Miglior programmazione attività

operatoria Minor disagio per il paziente

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Randomized clinical trial comparing day-care openhaemorrhoidectomy under local versus general anaesthesia

R. Kushwaha, W. Hutchings, C. Davies and N. G. Rao

Channel Day Surgery Unit, William Harvey Hospital, Ashford TN24 0LZ, UK

Conclusion: LH has similar tolerance and clinical outcome to GH, and is associated with a shorter journey time and lower cost.

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Stapled Hemorrhoidectomy With LocalAnesthesia can be Performed Safelyand Cost-Efficiently

Steven Esser, M.D., Indru Khubchandani, M.D., Mikhail Rakhmanine, M.D.Lehigh Valley Hospital, Allentown, Pennsylvania

CONCLUSIONS: Administration of general, spinal, or epidural anesthesia for the procedurefor prolapsing hemorrhoids is well described. This study suggests that the use of local anesthesia supplemented with conscious sedation for the procedure for prolapsing hemorrhoids yields results equivalent to those achieved with general or regional anesthesia without the attendant risks and additional costs. This study also suggests that the presenceof muscle fibers in the pathologic specimen does not seem to lead to increased pain or impaired continence, although it was not specific ally designed to address this issue.

Dis Colon Rectum 2004; 47: 1164–1169

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Selezione dei pazienti

Non vivere solo o lontano

dall’ ospedale Non comorbidità significative Età ? Assenza patologie psichiatriche

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Surg Endosc (2003)

Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the elderly

D. B. Johnson, M. R. DiSiena, R. D. FanelliResidency Program in General Surgery, Berkshire Medical Center, 725 North Street, Pittsfield, MA01201, USA

Conclusions: CMSP is a safe, effective, time-efficient procedure for patients with mucosal prolapse and prolapsing hemorrhoids that can be performed safely in the ambulatory surgery center setting. Age is not a limiting factor in selecting patients for this safe outpatient procedure.

Iter preoperatorio tradizionale

1)Visita proctologica

2) Secondo accesso per:

Ecg

Esami ematici

Rx torace

Valutazione anestesiologica

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Iter attuale

Visita generale proctologica ed anoscopia, (anamnesi, esame obiettivo, cartella e consenso informato)

Ecg preoperatorio sopra 45 anni

Percorso

Accesso in ospedale ed intervento al mattino, dimissione entro le 16

Contatto telefonico in 1 giornata Visita di controllo a una settimana e a un

mese

Criteri dimissibilità

Parametri vitali stabiliVigile e orientatoNon nausea o vomitoLibera assunzione per osDolore assente o leggeroNon sanguinamentoMinzione spontaneaCapace di camminareIstruzioni postoperatorie scrittePresenza di adulto responsabile

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Note di tecnica

Nessuna preparazione intestinale (peretta)

Nessuna tricotomia Profilassi antibiotica Posizione ginecologica Sempre punti di ‘emostasi’ Emostatico o garza nel canale anale Esame istologico

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Ambulatory stapled haemorrhoidectomy:a safe and feasible surgical technique

Conclusions. Stapled haemorrhoidectomy is a safe and effective operation for haemorrhoids. It is a feasible procedure to perform as day-surgery. The hospital stay can be significantly shortened, thus reducing the costs associated with inpatient care.

Hong Kong Med J Vol 9 No 2 April 2003

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Stapled anoplasty for haemorrhoids: a comparisonof ambulatory vs. in-patient procedures

R. J. Guy, Cho Eng Ng and Kong-Weng Eu

Department of Colorectal Surgery, Singapore General Hospital, Singapore April 2002

Conclusions Stapled anoplasty is suitable for use in day-case surgery as it is a quick and relatively painless procedure. The advantages, particularly financial, support the technique for use in an ambulatory setting, preferably in the morning, and provided detailed patient advice is given.

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ANZ J. Surg. 2005; 75 184–186

AMBULATORY CIRCULAR STAPLED HAEMORRHOIDECTOMY UNDERLOCAL ANAESTHESIA VERSUS CIRCULAR STAPLEDHAEMORRHOIDECTOMY UNDER REGIONAL ANAESTHESIA

CHIN HU ONG, et al.

Department of Surgery, Alexandra Hospital, Singapore

Conclusions: Circular stapled haemorrhoidectomy can be performed safely under local anaesthesia in an ambulatory care setting. The potential cost savings that may accrue would offset the cost of the stapler.

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Conclusioni I

1) Day surgery.

2) L’ anestesia locale:

meno ritenzioni urinarie

meno conversioni ricovero ordinario

Uguale numero emorragie postoperatorie

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Conclusioni II

Rigorosa selezione

Criteri generali

Fin dalla prima valutazione ambulatoriale

GRAZIE