Elective surgery for hemorrhoidal complaints: The decision to operate
Section snippets
Elective surgery for hemorrhoidal complaints
There are several complex factors that affect discussions with patients regarding hemorrhoidal concerns and about the decision of whether or not to address their hemorrhoids surgically. Such discussions often have significant tension due to recent dramatic changes in three areas: how doctors relate to patients, how patients access information about healthcare, and how quality in healthcare is measured. To effectively manage hemorrhoidal disease, the surgeon needs to be cognizant of these
The evolving doctor–patient relationship
A number of events occurred at the end of the last century that radically changed the doctor–patient relationship. In 2001, the Institute of Medicine's report on quality in healthcare, “Crossing the Quality Chasm,” identified six key elements to quality. One of these elements was patient-centered care.1 Patient-centered healthcare is based on the obligation to care for the patient on their own terms within their social context. There is also the expectation that the patient will be listened to,
Patient information and the Internet
Shortly prior to its 2001 publication on quality in healthcare, the Institute of Medicine published another report, “To Err Is Human,” that focused intense scrutiny on the occurrence of medical errors.3 The identification of almost 100,000 in-hospital deaths per year initiated a serious dialog regarding patient safety. However, it also eroded public confidence in the healthcare system. In so far as medicine's contract with society is based on societal expectations that physicians are competent,
Quality measurement
The third area of change that impacts how doctors and patients interact comes out of a melding of the Institute of Medicine's inclusion of patient-centered care as a key factor in healthcare quality with what is commonly referred to as the healthcare crisis—the crisis being that the current escalations in cost for healthcare are unsustainable. As a consequence, the Centers for Medicare and Medicaid Services is starting to develop and pilot accountable care models. Physician payment models are
How to say no
So how do these changes in patient expectations and quality measurement affect the surgeon when confronted with a patient request that is inappropriate? The clinician can take three approaches to saying no. The first approach is to simply deny the request. In the doctor-centric medicine of the 20th century, this might have worked. A second approach might involve getting more information, which could take the form of additional diagnostic testing to confirm a clinically apparent situation. This
Pre-operative counseling and the recovery process
Once the surgeon and the patient have decided to proceed with a hemorrhoidectomy, the informed-counseling phase of the pre-operative evaluation can begin. The pre-operative counseling session is an opportunity to provide the patient with realistic expectations of the events that will occur the night before surgery, the day of surgery, and in the early and late post-operative phases. The night before surgery, the patient may undergo a gentle bowel preparation, employing the aid of suppositories
Indications for urgent or emergent hemorroidectomy
Although the choice to undergo elective hemorrhoidectomy should be a decision arrived at by the patient after having an informed discussion, the decision to operate emergently is made by the surgeon. The majority of these cases involve strangulated hemorrhoids, which are prolapsed third- or fourth-degree hemorrhoids and have become incarcerated because of the associated swelling. Untreated, strangulation can progress to ulceration and necrosis. Strangulated hemorrhoids with necrosis are an
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Hemorrhoids
2014, New England Journal of MedicineCitation Excerpt :The primary goals of office-based procedures, which are less costly than excisional therapies, are to decrease the amount of redundant tissue, reduce vascularity, and affix the hemorrhoidal cushions to the rectal wall.5 Before such procedures are performed, it is important to inform patients about any external components that will not be addressed by the procedure — for example, residual skin or skin tags that will not be excised or anal contouring that will not be restored.21 Rubber-band ligation involves identifying a hemorrhoidal complex, using forceps or suction to elevate the cushions, and placing one or more rubber bands around the base of each cushion while taking care to avoid impinging any muscle tissue (Figure 3).