The Levels of Evidence (I–III) are defined at the end of the "Major Recommendations" field.
Ambulatory Facilities
Anorectal Surgery May Be Safely and Cost-Effectively Performed in an Ambulatory Surgery Center.
Level of evidence - Class III. It has been estimated that 90 percent of anorectal cases may be suitable for ambulatory surgery. A wide variety of anorectal conditions including condylomata, fissures, abscesses, fistulas, tumors, hemorrhoids, pilonidal disease, and various miscellaneous conditions have been shown to be amenable to surgery on an outpatient basis. An admission rate of 2 percent has been reported. A reduction in hospital charges of 25 to 50 percent has also been noted.
Patients With American Society of Anesthesiology (ASA) Classifications I and II Are Generally Considered Suitable Candidates for Outpatient Anorectal Surgery (refer to Appendix B in the original guideline document).
Level of evidence - Class III. Multiple factors must be considered in determining the appropriateness of performing anorectal surgery in the ambulatory setting. The ASA physical status classification is useful to determine the risk of anesthesia. The magnitude of the proposed surgery, type of anesthesia, availability of appropriate instrumentation, ability of the patient to follow instructions, distance of the patient's home from the surgical center, and home support structure all need to be considered.
Selected ASA Category III Patients May Also Be Appropriate Candidates.
Preoperative Evaluation
Preoperative Investigations (e.g., Laboratory Studies and Electrocardiograms) Should Be Dictated by History and Physical Examination.
Level of evidence - Class III. Multiple studies have documented that patient history and physical examination are the key elements of an appropriate preoperative evaluation. Routine preoperative investigations that are not warranted on the basis of history and physical seem to provide little further information. There is clear evidence that nonselective preoperative screening yields few abnormal results.
Intraoperative Considerations
Most Anorectal Surgery May Be Safely and Cost-Effectively Performed Under Local Anesthesia; Regional or General Anesthesia May Be Used Depending Upon Patient or Physician Preference.
Level of evidence - III. The use of local anesthetics such as monitored anesthetic care for anorectal surgery is safer and has fewer complications than other anesthetic techniques. Perianal infiltration of local anesthetics is a simple procedure that is easily learned. Injection of the local anesthetics can be accomplished in less than five minutes and the operation begun immediately. However, the anesthetic technique used for any procedure should be the one that provides for maximal safety and efficacy.
Postoperative Considerations
Anorectal Surgery Patients May Safely Be Discharged From the Postanesthesia Care Unit.
Level of evidence - II. The time course for recovery from anesthesia includes early recovery, intermediate recovery, and late recovery. Early recovery is the time interval for anesthesia emergence and recovery of protective reflexes and motor activity. The Aldrete score has been used for 30 years to determine release from phase 1 (early) recovery to a hospital bed or phase 2 (intermediate) recovery. Intermediate recovery is the period during which coordination and physiology normalize to an extent that the patient can be discharged from phase 2 recovery in a state of "home readiness" and be able to return home in the care of a responsible adult. The Post-Anesthetic Discharge Scoring System has been shown to be efficacious for discharge.
Multiple Modalities May Be Used to Achieve Adequate Postoperative Pain Control.
Level of evidence - II. If local anesthetics are not used as the primary anesthetic technique, their use will provide prolonged postoperative analgesia. Oral narcotics may be used as primary postoperative analgesia. The use of nonsteroidal anti-inflammatory drugs, particularly intramuscular or intravenous Toradol® (Roche Pharmaceuticals, Nutley, NJ) or sulindac suppositories, has also shown improved analgesia, lower narcotic usage, and lower rates of urinary retention. Although the effect is unknown, oral metronidazole shows improved postoperative pain control.
Postoperative Urinary Retention Can Be Reduced by Limiting Perioperative Fluid Intake.
Level of evidence - III. Multiple studies have shown that limiting perioperative fluid lowers the incidence of postoperative urinary retention. These same studies show conflicting evidence over the relationship between gender, age, and the quantity of narcotic medication and urinary retention. Hemorrhoidectomy and the performance of multiple anorectal procedures have higher rates of urinary retention.
Postoperative Education Should Include Recommendations for Sitz Baths, Fluid Intake, and Activity Limitations.
Level of evidence - III. Textbooks of anorectal surgery advocate consistent instructions before discharge from ambulatory surgery. Although derived from common sense, scientific justification does not exist. With appropriate communication, ambulatory anorectal surgery may be performed with a high degree of patient satisfaction.
Definitions:
Levels of Evidence
Level I
Evidence from properly conducted randomized, controlled trials
Level II
Evidence from controlled trials without randomization, or cohort or case-control studies, or multiple times series, dramatic uncontrolled experiments
Level III
Descriptive case series or opinions of expert panels
