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486 Effective Management of Posthemorrhoidectomy Secondary Hemorrhage Using Rectal Irrigation [2002년 2월 DCR] 2011-11-17 1848
 
Hong Hwa Chen, M.D., Jeng-Yi Wang, M.D., Chung Rong Changchien, M.D., Chien-Yuh Yeh, M.D.
From the Colorectal Sections, Chang Gung Memorial Hospital, Kao-Hsiung, Taiwan, and Chang Gung
Memorial Hospital, Linkou, Taiwan
PURPOSE: How to manage posthemorrhoidectomy secondary hemorrhage, a rare but serious complication, effectively remains controversial. This study evaluated the effectiveness of using rectal irrigation as an initial treatment for posthemorrhoidectomy secondary hemorrhage.
METHODS: Among 4,880 patients on whom elective closed hemorrhoidectomy for symptomatic hemorrhoidal disease was performed, 45 (0.9 percent) developed posthemorrhoidectomy secondary hemorrhage. The 45 patients were divided into two groups based on the initial treatment in the stoma
therapy room (n = 25) or in the operating room (n = 20). Patients in the stoma therapy room group were treated with rectal irrigation, whereas those in the operating room group were examined under anesthesia and the bleeding point (if any) was under-run using a suture. The two groups were then compared with respect to the cost-effectiveness of treatment, rehospitalization stay, and satisfaction with treatment.
RESULTS: The two groups (stoma therapy room vs. operating room groups) were comparable with respect to the mean age of patients (44 vs. 38 years), interval of hemorrhage (9.4 vs. 7.8 days), and estimated amount of blood loss (560 vs. 520 ml). Bleeding effectively stopped in 22 (88 percent) patients in the stoma therapy room group but only in 12 (60 percent) patients in the operating room group (P = 0.010). The rehospitalization stay was three days in the stoma therapy room and 4.9 days in the operating room group (P = 0.016). In addition, the stoma therapy room group had a greater satisfaction rate than the operating room group did (80 vs. 10 percent, P = 0.001). Moreover, the average cost of treatment in the operating room group was six-fold higher than that in the stoma therapy room group. CONCLUSIONS: Our data suggest that rectal irrigation is an effective initial treatment for posthemorrhoidectomy secondary hemorrhage and offers a high rate of patient satisfaction with a reduced hospital cost.
Posthemorrhoidectomy secondary hemorrhage (PHSH) is a rare but widely recognized postoperative
complication of hemorrhoidectomy. Occurring several days after operation in 0.6 to 5.4 percent of cases, if undetected or not promptly treated, it may be life-threatening because of cardiovascular decompensation with circulatory collapse. The treatment of PHSH is controversial.
In 1922 Burrows and
Burrows first described using a rectal packing to stop the bleeding. Since then, other rectal compression
devices, such as a rectal pack,9 plug,10 or Gelfoam® (Pharmacia & Upjohn, Kalamazoo, MI), have also
been advocated. These obstructing devices are painful, and an extended hospital stay is necessary for
closer observation. More recently, some authors suggest to examine these patients under anesthesia
(EUA) in the operation room (OR) as an initial treatment. After removing the clotted blood by irrigation
with saline, the bleeding point(s) can be observed using a anoscope and under-run by a suture with or
without coagulation. Nevertheless, the above-mentioned remedies have their limitations. In a related
study 15 percent of these patients developed late complications and needed reoperation from either the
initial suture-ligation or rectal packing.
Having found rectal irrigation to be a tolerable and effective alternative management of PHSH in a preliminary report, we initiated this prospective study to compare rectal irrigation to EUA as an initial treatment for PHSH with respect to effectiveness and patient satisfaction.
DISCUSSION
The treatment of PHSH remains controversial. Our current data confirm the report of Farrer that nearly
one-half of their cases ceased bleeding spontaneously without any treatment other than bed rest. However, treatment with bed rest only will delay the timing for checking bleeding in the remaining 40 to 50 percent of patients, who require suture of the bleeding point. Moreover, if the blood and clots inside the rectum are not evacuated, most patients may feel urgency, defecate blood intermittently, and complain of persistent hemorrhage from the anus.
Various obstructive devices have been developed to control the bleeding. Rosen et al. suggested a
rigid sigmoidoscopic examination to remove all blood and clots, followed by anal packing of Gelfoam®
wrapped by a topical hemostat to stop bleeding, 7 (35 percent) patients having complications and 15 percent of patients requiring a reoperation. Basso claimed that all patients treated using tamponade with
an inflated Foley catheter stopped bleeding instantaneously, and no secondary hemorrhage was inflicted
by this procedure. The patients treated by these modalities require prolonged hospitalization, bed rest,
and a considerable amount of medication to relieve pain from the impacted foreign body.
Turell proposed examination under anesthesia in the OR and suture ligation to manage PHSH effectively. Using this treatment modality, we and other authors12 observe a discernible bleeding point in only less than one-half of the patients who were sent to the OR for EUA.