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Objectives: To study several factors affecting the postoperative healing with Ferguson technique for hemorrhoidectomy. Subjects and methods: 190 patients with third-degree and fourth-degree hemorrhoids underwent the Ferguson procedures at Vietnam-Germany Hospital from 01 Sep 2012 to 31 Dec 2013.
Journal of military pharmaco-medicine no2-2018 FACTORS AFFECTING THE POSTOPERATIVE HEALING IN FERGUSON TECHNIQUE FOR HEMORRHOIDECTOMY Phan Sy Thanh Ha*; Tran Minh Dao* Nguyen Xuan Hung*; Nguyen Van Xuyen** SUMMARY Objectives: To study several factors affecting the postoperative healing with Ferguson technique for hemorrhoidectomy Subjects and methods: 190 patients with third-degree and fourth-degree hemorrhoids underwent the Ferguson procedures at Vietnam-Germany Hospital from 01 Sep 2012 to 31 Dec 2013 Results: 82.1% had the incision wound healed in phase and 17.9% in phase There was a correlation between the duration of healing and the form of feces at the first postoperative bowel movement (p < 0.05) There was no correlation between the duration of healing and the degree of hemorrhoids and numbers of cut hemorrhoids (p > 0.05) Conclusion: Ferguson technique for hemorrhoidectomy is safe with good treatment outcome, rapid healing, simple postoperative care and patients soon return to normal life and work * Keywords: Hemorrhoids; Ferguson technique; Postoperative healing INTRODUCTION There are many methods of treatment for hemorrhoids, including adjustment of diets and sanitary care, procedure, surgery, oriental medicine, occidental medicine or combination of oriental and occidental medicine Surgical methods aim to cure hemorrhoids completely The Ferguson procedure was introduced in 1959 as an improvement of the Milligan-Morgan procedure and has been widely applied in the United States [1] The method is the most commonly indicated for hemorrhoids for its ability of good bleeding control, simple postoperative care, rapid healing, early return to normal life and work Some surgeons are still cautious to choose this method as the closure of skin and rectal mucous membranes by suturing may cause postoperative abscesses and infections In 2010, the first report by Nguyen Xuan Hung showed that Ferguson procedure was safe and effective with simple postoperative care so it should be applied [2] Some brief reports on this procedure were also available but they failed to clarify the postoperative treatment and care and factors affecting the healing process [1, 2, 3] Therefore, this article aimed: To study several factors affecting the postoperative healing in Ferguson technique for hemorrhoidectomy * 198 Hospital ** 103 Military Hospital Corresponding author: Phan Sy Thanh Ha (drha198@gmail.com) Date received: 14/11/2017 Date accepted: 22/01/2018 142 Journal of military pharmaco-medicine no2-2018 - Age, sex SUBJECTS AND METHODS - Healing: healing phase 1: - 10 days, phase 2: > 10 days Subjects 190 patients with third-degree and fourth-degree hemorrhoids underwent the Ferguson procedures at Vietnam-Germany Hospital from 01 September, 2012 to 31 December, 2013 Study of the correlation between the duration of healing: - Degrees of hemorrhoid (third-degree and fourth-degree hemorrhoids) - Numbers of hemorrhoidectomy, form of feces at the first postoperative bowel movement Methods A prospective descriptive study, clinical intervention and longitudinal study The data were processed using SPSS 22.0 * Research criteria: RESULTS Table 1: Age groups per sex Sex Male Female Total Age group n % n % n % ≤ 20 0.5 0.0 0.5 21 - 40 36 18.9 41 21.6 77 40.5 41 - 60 52 27.4 27 14.2 97 41.6 61 - 80 18 9.5 12 6.3 30 15.8 > 80 1.1 0.5 1.6 109 57.4% 81 42.6% 190 100% Total The most common age group was 21 - 60, accounting for 82.1%, the average age was 46.58 ± 14.72 years old The oldest patient was 83 years old and the youngest was 18 years old Male accounted for 57.4%, female 42.6% Table 2: Duration of healing per degree of hemorrhoids Degree Healing Third-degree Fourth-degree Total p n % n % n % Healing phase 113 81.9 43 82.7 156 82.1 Healing phase 25 18.1 17.3 34 17.9 138 100 52 100 190 100 Total 0.89 82.1% of the patients had their incisions healed in phase and 17.9% had wound dehiscence There was no correlation between the healing ratio and the degree of hemorrhoids 143 Journal of military pharmaco-medicine no2-2018 Table 3: Duration of healing per numbers of hemorrhoidectomy Number of hemorrhoidectomy hemorrhoid hemorrhoids hemorrhoids hemorrhoids Healing n % n % n % n % Healing phase 28 87.5 51 85.0 72 80.9 55.6 Healing phase 12.5 15.0 17 19.1 44.4 32 100 60 100 89 100 100 Total p 0.15 There was no correlation between the duration of healing and the numbers of hemorrhoidectomy Table 4: Duration of healing per form of feces at the first postoperative bowel movement Healing Phase Phase Total p Form of feces n % n % n % Liquid 0.0 13 38.2 13 6.8 Mushy 49 31.4 20 58.8 69 36.3 Normal 99 63.5 2.9 100 52.6 Lumpy 5.1 0.0 4.2 156 100 34 100 190 100 Total 0.001 33/34 patients (97.1%) with liquid and mushy feces suffered from wound dehiscence The difference in the duration of healing and the form of feces at the first postoperative bowel movement was statistically significant DISCUSSION Postoperative complications of infections and abscesses in Ferguson technique for hemorrhoidectomy are always the special concern of the surgeons That is one of the reasons why so far only some Vietnamese surgeons have chosen this method to treat hemorrhoids 100% of patients in this article were found not to have postoperative abscesses and infections 156 patients had their incision healed in phase 1, accounting for 82.1%, phase 2: 17.9% (34 patients) Table and 144 showed that there was no correlation between the duration of healing and the degree of hemorrhoids and numbers of hemorrhoidectomy (p > 0.05) Table showed that 33/34 patients (97.1%) with liquid and mushy feces at the first postoperative bowel movement suffered from wound dehiscence The difference in the duration of healing and the form of feces at the first postoperative bowel movement was statistically significant (p < 0.05) This can be explained that liquid and mushy feces at the postoperative Journal of military pharmaco-medicine no2-2018 bowel movement moisten the anal area, cause the incision to have infections and wound dehiscence weeks after the procedure, all patients in the study had their incision completely healed Patients were always advised not to immerse their anus but always leave the anus dry Among 50 patients underwent the Ferguson procedure by Aziz A, 62% had their incision healed in the first week and 82% after weeks [4] In the study by Ho K.S, 33.3% of the patient suffered from wound dehiscence within the first weeks and after weeks this rate was 13.8% [5] Khubchandani I et al (2009) conducted a study on 3.247 patients, patients (0.22%) suffered from abscesses, of which patients (0.12%) did not require intervention patients (0.06%) required re-operation 163 patients (4.97%) suffered from partial wound dehiscence patients (0.06%) suffered from complete wound dehiscence In the study by Khanna R et al, 20 patients (14%) undergoing the Ferguson procedure suffered from wound dehiscence [7] In a study on 1,184 patients by Wesarachawit W (2007), patients suffered from wound dehiscence after weeks of procedure No new case of wound dehiscence was found after weeks, most patients had their incision healed with no stenosis According to Pattana-Arun J, 100 patients with third-degree and fourth-degree hemorrhoids might have complications, of which 46 cases were performed emergency operations and 54 patients were scheduled operations The author compared the outcomes of the two groups After weeks of the procedure, wound dehiscence occurred in patients (10.8%) from emergency operations and patients (11.7%) from scheduled operations; this difference was not significant (p = 0.12) No new case of wound dehiscence was found after weeks, all patients had their incision healed completely Pattana-arun J et al delivered the Ferguson procedure to 1,184 patients with third-degree and fourth-degree hemorrhoids Out of 416 emergency operations and 786 scheduled operations for treatment of prolapsing internal hemorrhoid, bleeding hemorrhoid and thrombosed external hemorrhoid, after weeks of operation, 24 patients suffered from wound dehiscence, accounting for 2.03% After weeks, all patients had their incision completely healed with no stenosis Among 130 patients undergoing the Ferguson procedure by Khalil-urRehman et al, 100% had their incision healed after weeks [6] Malik A.G (2009) delivered the Ferguson procedure to 30 patients and found that their healing process only took < weeks 3.03% of the patients in the study by Nguyen Sy Tuan Anh suffered from wound dehiscence and no case had infections and abscesses [1] 27.7% of the patients in the study by Nguyen Van Lam suffered from wound dehiscence, no case had infections and abscesses; according to this author, hemostasis in Ferguson procedure should be performed carefully and thoroughly to avoid hematoma which may cause infections and over-tight incision Coagulator may be used for effective hemostasis However, this device causes tissue damage around the edge of the incision and 145 Journal of military pharmaco-medicine no2-2018 impedes the healing process Do not remove too much skin and mucous membranes of the anal canal in the procedure which may cause the sutures to over-tight and lead to wound dehiscence All of these factors contribute to the occurrence of wound dehiscence Numerous clinical trials comparing the outcomes of the hemorrhoidectomy using Milligan-Morgan and Ferguson techniques of international authors have concluded that the duration of healing in Ferguson procedure is significantly shorter than that in Milligan-Morgan procedure despite the risk of wound dehiscence Thus, from these outcomes, we can completely trust the Ferguson technique for hemorrhoidectomy incase the principles of surgery, those of treatment and patient care must be strictly followed * Postoperative treatment and care: After transferring the patient from the operating room to the treatment room Inject 1,000 mL solution of 500 mL ringer’s lactate solution + 500 mL glucose 5% Pain relief after pain assessment: Efferalgan g IV x vials/day each hours for the first day Severe pain may be treated with opioid Paracetamol 0.5 g x tablets/day for the following days Antibiotics: flagyl 0.5 g IV x bottles/day for the first day, flagyl 250 mg x tablets/2 times (morning and afternoon) /day for the following - days Laxatives should be used to avoid fecal stagnation in the rectum which may cause irritation and prolong pain Place proctolog suppositories into the anus from the 7th day after surgery when the incision was physiologically healed and a slight shrink 146 may cause mild stenosis; which is a very effective treatment for stenosis Patients were fed porridge 12 hours after the surgery and could eat regular diets with more fiber and water, avoid alcoholic stimulants, tobaco, spicy and hot food * Wound care: Change wound dressing 24 hours after the surgery and using betadine 10% daily * Guide the patient to perform wound care: - Keep the incision clean (clean the anus after bowel movement and dry by permeable materials) - Do not perform anal dilation without medical advice and not immerse the anus Always keep the anus dry If the patient has no bowel movement for days after the surgery, take a bottle of fleet phospho-soda or a bag of fortran g to avoid fecal stagnation in the rectum which may cause irritation, prolonged pain and incision infections Monitor the patient’s pulse, temperature, blood pressure and perception Urinary retention, incision status: postoperative bleeding, infections and abscesses Hospital discharge standards: no fever, minor pain in the incision, no urinary retention, no bleeding, no infection, no abscess at the incision Postoperative visit: or 14 days afterward CONCLUSION Ferguson technique for hemorrhoidectomy has the advantages of safety, good outcome, rapid healing, simple postoperative care The incision rate was 82.1% Do not soak and squeez the anus everyday Patients Journal of military pharmaco-medicine no2-2018 soon return to normal life, average time 2.41 ± 0.76 days and quikly return to work, average time back to work was 13.63 ± 4.29 days Aziz A, Ali I, Alam S.N et al Open hemorrhoidectomy versus closed hemorrhoidetomy: The choice should be clear Pakistan Journal of Surgery 2008, 24 (4), pp.254-257 REFERENCES Ho K.S, Ho Y.H Prospective randomized trial comparing stapled hemorrhoidopexy versus closed Ferguson hemorrhoidectomy Techniques in Coloproctology 2006, 10 (3), pp.193-197 Nguyễn Sỹ Tuấn Anh Kết điều trị bệnh trĩ phẫu thuật Ferguson Bệnh viện Việt Đức Luận án Tiến sỹ Y học Đại học Y Hà Nội 2011 Nguyễn Xuân Hùng, Mark Helbraun, Phạm Đức Huân CS Phẫu thuật Ferguson điều trị trĩ Tạp chí Đại tràng 2010, 5, tr.9-13 Khalil-ur-Rehman, Hasan A, Taimur M et al A comparison between open and closed hemorrhoidectomy J Ayub Med Coll Abbottabad 2011, 23 (1), pp.114-116 Nguyễn Văn Lâm, Mai Văn Đợi Đánh giá kết phẫu thuật Ferguson điều trị bệnh trĩ Bệnh viện Trường Đại học Y Dược Cần Thơ Tạp chí Y Dược học 2014, 421 (1), tr.12-15 Khanna R, Khanna S, Bhadani S et al Comparison of ligasure hemorrhoidectomy with conventional Ferguson’s hemorrhoidectomy Indian Journal of Surgery 2010, 72 (4), pp.294-297 147 ... Urinary retention, incision status: postoperative bleeding, infections and abscesses Hospital discharge standards: no fever, minor pain in the incision, no urinary retention, no bleeding, no infection,... liquid and mushy feces at the first postoperative bowel movement suffered from wound dehiscence The difference in the duration of healing and the form of feces at the first postoperative bowel movement... underwent the Ferguson procedure by Aziz A, 62% had their incision healed in the first week and 82% after weeks [4] In the study by Ho K.S, 33.3% of the patient suffered from wound dehiscence within the