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SELF-MECHANICAL ANAL DILATION IN PATIENTS WITH PERSISTENT PAIN AND ANAL SPHINCTER SPASM AFTER HEMORRHOIDECTOMY WITH RADIOFREQUENCY
Chiara Eberspacher*1, Domenico Mascagni1, Lisa Fralleone1, Daniele Pironi1, Domenico Di Nardo1, Pavlos Antypas1, Stefano Pontone1, Pietro Mascagni2, Marco G. Muzi1
1 "Sapienza" University of Rome, Rome, Italy; 2Università di Roma Tor Vergata, Rome, Italy
Background: The most hateful complication after a radiofrequency excisional treatment of grade III-IV hemorrhoids is the persistent postoperative pain associated with anal sphincter spasm that can even develop into a chronic anal stenosis; this occurs in approximately 4 % of patients, but the percentage increases when three or more piles are removed. Patients complain of pain (persistent > 20 days), difficult defecation, increase of stool frequency with narrow stools. Early use of an anal dilator can reduce the spasm, gently dilate the lumen, minimize the trauma of defecation and allow an elastic and soft healing of the tissues.
Methods: Between January 2016 and June 2017 we enrolled 85 patients treated with radiofrequency hemorrhoidectomy with a minimum of three piles removed. We checked every patient at one week, three weeks and forty days. Postoperative (PO) pain assessment was accomplished by using the VAS (Visual Analog Scale) Pain Score; overall satisfaction was evaluated after 40 days with a score 1 to 10. In 35 patients (41%) we found, after three weeks, a persistent pain with a mean VAS score of 8 (6-10) and an evident spasm during the digital rectal examination. We gave all these patients stool softeners and analgesic therapy; in 19 patients (Group A) we associated the use of self-mechanical anal dilation; the other 16 patients (Group B) are the control group. Every patient performed the dilation in Sims positon, for three minutes a day, preferably before defecation, with a little size dilator (20 mm) for the first week, then with the medium (23 mm) for two weeks and for the last two weeks with the larger size (27 mm)(total time of application 35 days).
Results: There were no complications with the dilator. In Group A, the pain with the insertion of the dilatator decreased very quickly with a mean VAS of 5 after three days and a mean VAS of 2 after 14 days of dilation. In the Group B the mean VAS was persistently higher with a mean VAS of 6 after four weeks and in 4/16 cases (25%) a VAS higher than 5 forty days after the operation. We observed a complete resolution of symptoms in a mean period of 18 days in the Group A, with a good satisfaction of all the patients (mean 9/10), while in the Group B there was the persistence of symptoms in 7/16 (43,7%) of patients after forty days with an overall satisfaction lower (mean 7/10). The digital examination after 40 days revealed a soft and elastic healing in Group A and a persistent reduction of the lumen with fibrosis in 4 (25%) Group B patients.
Conclusion: Early self-mechanical anal dilation can be a useful, conservative, easy and not expensive procedure to reduce persistent pain and to prevent a possible anal stenosis, after radiofrequency radical hemorrhoidectomy. The anal dilation can guarantee a better late operative course and can minimize the risk of consolidated anal stenosis.
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