title: Stapled hemorrhoidectomy with local anesthesia can be performed safely and cost-efficiently.
abstract: OBJECTIVE
  This prospective study was designed to assess the feasibility of performing the procedure for prolapsing hemorrhoids, or stapled hemorrhoidectomy, under local anesthesia supplemented with conscious sedation.
  
  
  METHODS
  Seventy consecutive patients (mean age, 56 years; 37 males) with Grade 3 or 4 hemorrhoids underwent the procedure for prolapsing hemorrhoids after perianal infiltration of 0.5 percent lidocaine with 1:200,000 epinephrine and supplemental conscious sedation. The procedure was performed in an outpatient setting, with the patient being discharged within two hours of checking into the ambulatory facility. All patients were assessed the following day by telephone, and then in the office at three weeks and two months for degree of postoperative pain, bleeding, continence, and time back to work or social activities. Additionally, all excised mucosal anastomotic rings were analyzed for presence or absence of muscle.
  
  
  RESULTS
  Each patient rated the pain as minimal or none. Five patients complained of mild, transient perineal pressure, and three complained of fecal urgency and seepage before their first office visit; one complained of external skin tags at the second office visit. All subjects were back to work or social activities within three to four days-most within 48 hours. Complications included urinary retention in five patients, two of whom had a concomitant urinary tract infection, and one had urosepsis requiring hospitalization. One patient required immediate reoperation for bleeding from the staple line. Another patient was admitted for postoperative bleeding and packed with a hemostatic agent the evening of surgery. Muscularis propria fibers were identified in 68 of 70 pathologic specimens.
  
  
  CONCLUSIONS
  Administration of general, spinal, or epidural anesthesia for the procedure for 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 presence of muscle fibers in the pathologic specimen does not seem to lead to increased pain or impaired continence, although it was not specifically designed to address this issue.
authors.affiliation: Lehigh Valley Hospital, Allentown, Pennsylvania, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Esser
authors.forename: Indru
authors.initials: I
authors.lastname: Khubchandani
authors.forename: Mikhail
authors.initials: M
authors.lastname: Rakhmanine
mesh_terms: D000556:Ambulatory Surgical Procedures / Q000191:economics; D000772:Anesthesia, Local; D016292:Procedural Sedation; D003362:Cost-Benefit Analysis; D005240:Feasibility Studies; D005260:Female; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000209:etiology; D011446:Prospective Studies; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D017792:Surgical Stapling / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation*; D016896:Treatment Outcome