|Year : 2018 | Volume
| Issue : 1 | Page : 6-10
Day care coloproctology
Naresh T Row
One Day Surgery Centre, Mumbai, Maharashtra, India
|Date of Web Publication||17-Sep-2018|
Naresh T Row
One Day Surgery Centre, Sadgurusadan, Babulnath Road, Mumbai - 400 007, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The concept of day care surgery is fast catching on, with more and more surgeons practicing day care surgery. Here I discuss the feasibility of practicing day care surgery in coloproctology. Materials and Methods: Nearly 1664 (16.49%) cases of anorectal diseases (of a total of 10,089 cases) were operated at a single center over a 10 years' period from July 1, 2008 to June 30, 2018. Results: Two patients (0.12%) had complications in the form of bleeding requiring readmission. Both were managed conservatively and discharged on the next day. Conclusions: Day care coloproctology surgeries can be practiced safely and successfully in a select group of patients with specific indications.
Keywords: Colo-proctology, day care surgery, single day surgery
|How to cite this article:|
Row NT. Day care coloproctology. Indian J Colo-Rectal Surg 2018;1:6-10
| Introduction|| |
Day care surgery is a fast-growing concept of dispensing planned surgical care to select the group of patients. The past decade has seen a rapid and well-accepted increase in day care surgery and centers, specializing in its practice.
Definition of day care surgery is one wherein; the patient can be discharged on the same day of surgery or invasive procedure. These patients do need a few hours of observation and a fully equipped operation theater (OT) with all facilities. A surgical day case is a patient who is admitted for an operation on a planned nonresident basis and who nonetheless requires facilities for recovery. The whole procedure should not require an overnight stay in a hospital bed.
These do not include minor surgeries, office procedures, and endoscopies performed for diagnosis only. There are set protocols suggested by The Indian Association and The International Association for ambulatory surgery. These essentially addresses the pertinent issues such as which are for patient selection, patient preparation, type of surgeries, discharge criteria and minimal requirements for a day surgery center (DSC). These protocols are aimed at ensuring safety of patients and better efficiency of the surgical center.
Retrospective analysis of feasibility of benign ano-rectal diseases performed as day case, for the last 10 years, in a stand-alone, multispeciality DSC, utilizing protocols proposed by The International Association for Ambulatory Surgery and The Indian Association of Day Surgery.
| Materials and Methods|| |
Cases analyzed were from July 1, 2008 to June 30, 2018. Total number of cases performed at the center was 10,089, of which, anorectal diseases operated on were 1664. The details of the break-up of these cases are as given in [Table 1].
The protocols followed were as follows:
- Patient selection
- Age: more than 6 months
- Medically fit and stable patient (the American Society of Anesthesiologists [ASA] I, II, III (well controlled)
- Well motivated and psychologically/mentally stable
- Provision of toilet, transport, telephone, and responsible relative at home
- Body mass index: <35.
- Examination and diagnosis
- Routine investigations: hemogram, blood sugar, Triple H, urine, X-ray chest, electrocardiogram, and ultrasound sonography
- Liver and kidney function test if necessary. Any other test as per requirement
- Medical fitness (physician/cardiologist/diabetologist/anesthesiologist)
- Overnight fasting
- Bowel preparation, if necessary
- Preoperative instruction on medication, for example stop aspirin 3 days before surgery
- Use of anxiolytic or sedative for a good night's sleep
- Prophylactic antibiotic was given on admission.
- Local anesthesia: 2% lignocaine HCl with or without adrenaline, mixed with equal quantity of 0.5% bupivacaine, injected through a 27G needle. Sedation was given where required
- Blocks: Pudendal, ring, field
- Short general anesthesia: Inhalation or intravenous (IV)
- General anesthesia.
- The patient should be fully conscious
- Hemodynamically stable
- No giddiness on standing
- Able to walk without vomiting
- No or minimal pain
- Passed urine
- Responsible person is present to take patient home
- No surgical complications.
Advise on discharge
- Written instructions
- Verbal instructions
- Contact numbers of all our team, including the operating surgeons, in case of any questions and complications
- Instructions on how to look for complications and its management: Train the patient, relatives, staff, and family physician.
Most commonly used material for local anesthesia in day-to-day surgery at our center was a combination of 2% lignocaine HCl (with or without adrenaline) and 0.5% bupivacaine. Mixed in equal quantity, dose can be calculated based on the patient's weight. Recommended dose for 2% lignocaine without adrenaline is 4.5 mg/kg body weight, maximum 300 mg, with 1:80,000 adrenaline 7 mg/kg body weight, maximum up to 500 mg. 0.5% bupivacaine can be given up to 175 mg in an adult, as a single dose. Injection for the block is administered with a 27G long needle. At the time of injection, the patient is sedated, with midazolam (1–2 mg) and pentazocine (15–30 mg). This avoids the pain felt while injecting.
Small doses of ketamine (10–25 mg) were sometimes used to achieve a complete sedation along with the regular sedatives.
Pudendal block anesthesia
All patients were operated under pudendal block. the pudendal nerve, which traverses the Pudendal canal, at the Ischial spine, on both sides, innervates the anal/perineal region. A 27G, 1 and half inch long needle was used to administer the block. A mixture of 2% lignocaine HCl, with or without adrenaline, and 0.5% bupivacaine, 15 ml each, to make up a diluted solution of 30 ml, was used.
In lithotomy position, the landmark on the surface is the ischial tuberosity and the anal verge. The needle is inserted midway between these two points, in the direction of the hip joint on the respected site. The injection site can be felt by a digital examination and the index finger is used as a guide to the ischial spine/pudendal nerve, as this is a blind procedure.
A volume of 10 ml of the anesthetic solution is injected in a fan-wise manner, moving the needle up and down to distribute evenly and as a safeguard against injection into the blood vessels. The procedure is repeated on the other side to complete the block. This is given by infiltrating 5-10 ml of anaesthetic solution in all four points: 12, 3,6 and 9 O clock position, as shown in [Figure 1] and [Figure 2].
Infiltrative anesthesia is used, with a using 27G long needle, 2 cm away from the sinus area, in a fan-wise manner, and covering all area to be excised [Figure 3].
- Piles: Hemorrhoidectomy: Milligan-Morgan procedure in all grades early 3 and above
- Fissure-in-ano: While, Acute fissures were managed conservatively patients with chronic fissures were subjected to Fissurectomy with lateral sphincterotomy. Acute fissures were managed conservatively
- Fistula-in-ano: Fistulectomy in most cases
- Pilonidal Sinus: Excision and primary closure was done. On table, methylene blue dye sinogram was done. Thereafter, a centric incision was taken excising the tract completely followed by obliteration of cavity
- Abscesses: An incision and drainage, followed by curettage and irrigation were done.
Usually, IV fluid is restricted to one that is started in the OT. Unless required, the patient is encouraged to start fluids orally, as soon as possible.
Mobilization is done as early as possible, first, on the bed, then out of bed. Care should be taken to support the patient or wait till giddiness is completely gone. Oral intake is initiated within 2 to 3 h. With water first and then followed by tea and biscuits. Unless it is necessary to be nil-by-mouth for a longer time.
Average hospital stay for a day surgery case is 6 h. Follow-up is after 48 h. Discharge protocols were followed in every patient.
Two patients presented with secondary bleeding on the same night of surgery from the fistulectomy group. They were readmitted and managed conservatively. They were discharged the following morning.
| Results|| |
Two out of 1664 patients operated at the center were readmitted. The reason for readmission was bleeding in both, which was managed conservatively. Therefore, present overall re-admission rates is calculated as: 0.12%.
| Discussion|| |
Perspective selection of cases for surgery in a specific category and its retrospective analysis has brought out, an equivocal result.
A true day case surgery is a major surgery, wherein, the patient is discharged on the same calendar day. However, these patients require a few hours of postoperative observation and a back-up of a fully equipped operating theater with qualified staff.
A DSC is a miniature hospital. It consists of OT, recovery area/rooms, staff duty rooms, reception, waiting rooms, and doctors changing room/lounge. In addition, pantry, store, linen, and autoclaving room. They are all very compact. For example, there may be one OT, ten recovery bays or rooms doubling as private rooms, etc.
There are three major types of DSCs, Incorporated: in the hospital building itself, like a separate ward with common dedicated OT or even separate OT and ward, but, same staff. These are self-contained units or wards in the hospital. Integrated: in the hospital complex, but, independent of the functioning of the hospital. They have separate staffing as well as accounting, but, situated in the hospital compound. Free standing or stand alone: center can be single or multispecialty. As the name suggests, they are outside of a hospital complex, that is, independent units. Like any existing nursing homes or small hospitals, they are self-sustaining units with all basic amenities.,
Among all these, the stand-alone model is the most efficient and economical. Probably, it utilizes all positive aspects of day surgery and reduces overhead costs.
In a study conducted in a government hospital, up to 50% of reduction in the cost of surgical care has been shown by the use of day care surgery.
One Day Surgery Centre is one of its kind Day Care Centre and has been certified by the Quality Control of India as “Optimum”. The SOPs and the Protocols followed at the One Day Surgery Centre are as per the recommendations by The Indian Association and The International Association for Ambulatory Surgery.
An analysis of outcome of Day Care Surgery performed over the years have been encouraging. Besides the number of cases being performed as Day Care Surgery has been increasing each day. The number of cases in the 'Major' category had markedly risen, indicating the increasing acceptance of day surgery.
There are several classifications of cases in a DSC, most commonly used are major ambulatory surgery, minor ambulatory surgery, day case, day care, 23 h stay, short stay, etc. We have used major ambulatory surgery and short stay for cases up to 48 h and beyond. The first proposal for a unified terminology was put forward by Roberts and Wardenin 1998.
Outpatient department cases are not true day surgery and hence should not be included. They are merely indicative of the percentage of cases performed at the center.
Medical protocols are strictly followed and implemented. Patient selection was broadly based on the fact that infants and children below 6 months would require monitoring and can go into dehydration very fast, therefore, not ideal for day surgery. ASA have classified patients on the basis of their physical condition, therefore, ASA I and II were usually chosen for day surgery. In some cases, a well-controlled ASA III class of patient can be taken for day surgery.
Patient preparation would mean examination, investigation, and surgery. This scheme of management can be applied to all categories of patients. Investigations were done with relevance to the type of surgery. Medical fitness wherever required. Advice regarding overnight fasting and peroperative medication is self-evident.
Pre-operative counselling of the patients, with regards to the various aspects of surgery to be performed including its complication is an important aspect of the pre-operative work up. Not only is it necessary for the patients understand that they will be discharged on the same day, it would also mean to be able to accept conscious anesthesia. They have to be advised regarding the disadvantage as well as advantages of day care surgery. It is best to be counseled by the operating surgeon, to have proper impact.
Advantages of day surgery
- Reduces hospital stay, and thus, hospital-acquired infection
- Early ambulation and return to work
- Reduction of overall cost
- Reduces anxiety of surgery
- Recovery in familiar surroundings
- Risks and side effects of general anesthesia and spinal anesthesia are reduced
- Less postoperative starving
- Less in convenience to relatives and family
- Reduces waitlist and congestion in a large hospital.
- Poor patient acceptance
- Poor compliance to instructions/preoperative medication
- Inadequate facilities at home
- Lack of responsible person at home
- Lack of facility near home in case of an emergency.
Contraindication to surgery, as illustrated, they are self-explanatory, medically unfit patients would need to be monitored postoperatively. Patients who have some form of mental retardation or who are psychologically unstable would require hospitalization for better care. Long distance from any medical aid-like hospital or primary care center, or even a medical professional, will make it difficult to decide if to send the patient home as day case. Overall, these contraindications will vary from case to case.
Discharge protocols help you make double sure that the patient has completely recovered from the surgery and anesthesia. That they have understood the implications of going home and fully understood how to look after themselves and communicate on their own or with the help of their relatives, with a medical practitioner, if necessary. We must make sure that all instructions are written down and explained to the patient and their relative present, and further make sure that it has been understood, any query from the patient is answered. This requires training of the staff for this purpose.
In the hospital, we make sure that the patient is fully conscious, oriented, able to walk, take orally and having passed urine, in relevant cases. Further, we need to ensure does not have any complication, and then, they are fit to be discharged. The presence of a responsible person is a must to take the patient home. Driving by the patient on the day of discharge is not encouraged. A phone call is made on the next day of discharge, to confirm the well -being of the patient. In the UK, over a 100 years ago, in 1909, an article was published on day surgery, of 7392 children, operated in Glasgow.
Concurrently, another large series of simple excision and primary closure showed excellent results and the researchers concluded that the natal cleft is flattened and the incision scar and the incision line is transferred from the midline to the lateral side by performing the asymmetric excision and primary closure, and thus, the essential cause of pilonidal sinus is eliminated. The procedure is simple, the complications and recurrences are very low, and it is seen to be an excellent procedure in the surgical treatment of uncomplicated pilonidal sinus disease.
| Conclusions|| |
Results of the past 10 years, with a minimal complication rate, are due to the meticulous following the protocols proposed for day surgery. We can ensure the patient safety and overall success of the day surgery, in selected patients, with proper counseling, as modality of dispensing surgical treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]