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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 16-19

Safety of prone jackknife position in ambulatory anorectal surgery


1 Montefiore Medical Center, Department of Surgery, Bronx, NY, USA
2 Drexel University College of Medicine, Department of Surgery, Philadelphia, PA, USA
3 Drexel University College of Medicine, Department of Anesthesia, Philadelphia, PA, USA

Date of Web Publication30-Aug-2018

Correspondence Address:
Juan Lucas Poggio
Department of Surgery, Drexel University College of Medicine, Mail Stop 413, 245 N, 15th Street, Philadelphia, PA 19102
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1941-8213.240255

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  Abstract 


Background and Objectives: The objectives of this study were to determine morbidity and mortality rates of ambulatory anorectal surgeries in prone jackknife position. Patients and Methods: Retrospective chart analysis on 210 patients undergoing ambulatory anorectal surgery in the prone jackknife position. The primary endpoint studied was mortality and complication rates. Other factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, American Society of Anesthesiologists physical status classification, current smoking status, mean pre- and post-operative mean arterial pressure (MAP), mean minimum intraoperative MAP, minimum intraoperative O2saturation, estimated blood loss, fluids given, anesthesia duration, antibiotic administration, and days to discharge and whether there were any readmissions within 30 days. To assess significant differences between pre-, intra-, and post-operative mean arterial pressure, one-way ANOVA was used. Results: There was no mortality within 30 days of surgery. Complication rate was 3.3% with urinary retention being the most common, comprising 42% of all complications. Thirty-day readmission rate from surgery was 1%. Mean pre- and post-operative MAP was 88.4 ± 11.4 and 90.6 ± 11.9, respectively. Mean minimum intraoperative MAP and O2saturation was 70.6 ± 9.5 and 98.7% ± 1.6%, respectively. Mean minimum intraoperative MAP was significantly decreased compared to mean pre- and post-operative MAP (P < 0.05). Conclusion: Prone jackknife position supports the chest while relaxing the abdomen by flexing at the hips. In ambulatory anorectal surgeries under general anesthesia, given the hemodynamic stability and lack of intra- and post-operative complications, prone jackknife position is a noninferior alternative to supine or lithotomy position.

Keywords: Ambulatory surgery, anesthesia, anorectal surgery, colorectal, prone jackknife


How to cite this article:
Cheema F, Lee S, Zebrower M, Poggio JL. Safety of prone jackknife position in ambulatory anorectal surgery. World J Colorectal Surg 2018;7:16-9

How to cite this URL:
Cheema F, Lee S, Zebrower M, Poggio JL. Safety of prone jackknife position in ambulatory anorectal surgery. World J Colorectal Surg [serial online] 2018 [cited 2019 Aug 18];7:16-9. Available from: http://www.wjcs.us.com/text.asp?2018/7/1/16/240255




  Introduction Top


The prone jackknife position has been used successfully by generations of colon and rectal surgeons for anorectal surgery and is considered the gold standard for anorectal surgical procedures.[1] It provides the best exposure to the surgeon for the majority of patients. Yet, there is limited literature on the use of the prone jackknife position and its safety in terms of anesthesia and hemodynamic changes, let alone when it comes to ambulatory anorectal surgery.[2],[3] Hatada et al. studied hemodynamic changes in 19 patients in the prone jackknife position undergoing ileoanal anastomosis and found a significant decrease in cardiac index when positioning from supine to prone jackknife. However, this did not pose a serious problem, and there were no complications experienced. Overall, the effects of prone jackknife position were comparable to other surgical positions and were believed to be manageable by experienced anesthesiologists.[4] In abdominoperineal resections, prone jackknife position provides better exposure with a lower complication rate compared to lithotomy position.[5] In addition, when compared to the Lloyd-Davies position, the rate of local recurrence after abdominoperineal excisions appears to be lower in the prone jackknife position.[6] Changes in patient position, however subtle, can cause significant changes and potential harm to the patient. For example, Akinci et al. found that in lumbar herniation surgery, compared to the prone position, the prone jackknife position led to decreased bleeding at the surgical site and decreased intra-abdominal pressures.[7] More recently, Kunitake and Poylin studied intraoperative and preoperative complications in anorectal surgery, concluding that anorectal surgery in the ambulatory setting is well tolerated, with the most common complications being bleeding, infection, and urinary retention.[8] However, the study did not mention the type of patient positioning that led to these complications.

When it comes to anorectal surgery, prone jackknife position is often done yet its mortality, and complication rates have not been adequately studied. The preclusion of such studies and concern for the airway has left room for doubt in some colorectal surgeons and anesthesiologists in their approach to anorectal surgery, occasionally leading to surgeons placing their patients in the lithotomy position instead. This is despite the point that the prone jackknife position makes the anorectal region more visible and easily accessible for the surgeon versus supine or left lateral position. The primary objective of this study was to determine the morbidity and mortality rates of ambulatory anorectal surgeries in the prone jackknife position.


  Patients and Methods Top


Patient charts were provided by the medical records department on all patients who underwent ambulatory surgery by two colorectal surgeons at a single urban academic tertiary-care institution between 2012 and 2014. Only patients undergoing surgery in the prone jackknife position were selected. Urinary retention is the most common complication after anorectal surgery regardless of position, with most studies reporting a value of around 15%.[9],[10],[11],[12] We predicted our study population would have at worst a urinary retention complication rate of around 8% as the study is narrowed to ambulatory procedures and not all anorectal procedures as a whole. A mortality rate of zero was also predicted. Therefore, to obtain results with a statistical power of at least 80%, it was calculated that a minimal sample size of 200 was required. Retrospective chart analysis was performed on 210 patients undergoing ambulatory anorectal surgery at this single urban academic tertiary-care hospital from 2012 to 2014. The primary endpoint studied was mortality and complication rates including urinary retention, fever, chest pain, and urinary tract infection. These were noted from the progress notes, discharge summaries, and clinic notes for each patient. Other factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, American Society of Anesthesiologists physical status classification, current smoking status, mean pre- and post-operative minimum arterial position (MAP), mean minimum intraoperative MAP, minimum intraoperative O2 saturation, estimated blood loss, fluids given, anesthesia duration, antibiotic administration, and days to discharge and whether there were any readmissions within 30 days. The mean preoperative MAP value is the average of blood pressures at clinic visits. The mean postoperative MAP value is the average of blood pressures first taken in the postanesthesia care unit. Electronic health records were reviewed, and patient clinic follow-up visits and/or hospital visits were reviewed to assess for any postoperative complications. Common complications, according to the literature, that were searched for in the medical charts include but not limited to urinary retention, intraoperative or acute postoperative hemorrhage, perianal thrombosis, fecal impaction, continence issues, fissures, fevers, perineal sepsis, drug hypersensitivities, and chest pain.[8],[13] All patients underwent general endotracheal anesthesia.

Data were collected from history and physical forms, operative notes, anesthesia flowsheets, and progress notes. The results were expressed as the mean and standard deviation for quantitative variables and as frequencies for categorical findings. To assess significant differences between pre-, intra-, and post-operative mean arterial pressure, one-way ANOVA was used and corrected for multiple comparisons. Mortality and complications were included only if they occurred within 30 days of surgery. Data were analyzed using the SPSS (Version 23) for Windows (SPSS Inc., Chicago, IL, USA) statistical package. Patient characteristics including age, gender, smoking status, and comorbidities are listed in [Table 1].
Table 1: Patient characteristics in the study population

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  Results Top


Of 210 patients undergoing ambulatory anorectal surgery, there was no mortality within 30 days of surgery. The complication rate was 3.3% with urinary retention being the most common at 43% of all complications. The other complications were two cases of postoperative fever, and one case each of a urinary tract infection and chest pain. Thirty-day readmission rate from surgery was 1%. This encompassed a case of rectal bleeding following excision and fulguration of anal condylomas and a case of bright red blood per rectum following hemorrhoid surgery. Almost 98% of patients were discharged the same day of surgery. All patients followed up postoperatively in clinic within 4 weeks of surgery and data were collected on those encounters in regard to morbidity or complications, specifically those injuries from positioning as they may not be recognized immediately after surgery, and these complaints are unlikely to present themselves to the emergency room (ER) or for readmission. However, none of these complications were noted to be found in these follow-up visits.

Mean pre- and post-operative MAP was 88.4 ± 11.4 and 90.6 ± 11.9, respectively. Mean minimum intraoperative MAP and O2 saturation was 70.6 ± 9.5 and 98.7% ± 1.6%, respectively. one-way ANOVA was performed to determine significant differences between the three MAPs. As shown in [Figure 1], mean minimum intraoperative MAP was significantly decreased compared to mean pre- and post-operative MAP (P < 0.05).
Figure 1: Mean preoperative, intraoperative, and postoperative mean arterial pressures (P < 0.05)

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The most common clinical diagnoses were anal condylomas and anal dysplasia (35.2%), hemorrhoids (14.8%), and pilonidal cysts (12.4%). The most common procedures, therefore, were excision and fulguration, hemorrhoidal surgery, and pilonidal cyst excision. Because of the rare number of complications, there were no comorbidities that could be significantly correlated to having a complication postoperatively. As mentioned in the methods, all patients underwent general endotracheal anesthesia. Antibiotics were not administered in 68.1% of the cases in total. However, they were administered in all cases of colostomy reversals, hernia repairs, generator implantations, penile lesion excisions, and anoscopies. A full summary of the results can be found in [Table 2] and [Table 3].
Table 2: Summary of results including means and frequencies

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Table 3: Most common diagnoses and procedures

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  Discussion Top


Patient positioning is a subject of prime importance to the anesthesiologist and surgeon. However, as the anesthesiologist's primary concern is maintaining hemodynamic stability, the surgeon is focused on achieving optimal anatomical access, causing potential friction between the two specialty's objectives. Poor positioning may lead to serious complications such as pressure sores, vascular compression, and increased intra-abdominal and intrathoracic pressure.[7] No study has addressed these concerns in the past regarding patients undergoing ambulatory anorectal surgeries in the prone jackknife position.

This study focused on resolving such a potential conflict when it comes to the prone jackknife position done in elective outpatient anorectal procedures. Prone jackknife position supports the chest while relaxing the abdomen by flexing at the hips. In this study, we show that in ambulatory anorectal surgeries under general anesthesia, this position provides enhanced exposure and is a safe procedure with no mortality and minimal morbidity.

The total complication rate was 3.3%; urinary retention is the most common. Other common complications, according to the literature, that were also searched for in the medical charts include intraoperative or acute postoperative hemorrhage, perianal thrombosis, fecal impaction, continence issues, fissures, fevers, perineal sepsis, drug hypersensitivities, and chest pain.[8],[13] Recent literature reports concerns regarding MAP in noncardiac surgeries below 55 mmHg, when acute kidney injury and myocardial injury become common.[14] The average minimum intraoperative MAP of 70.64 in this study is well above the threshold of 55 mmHg and thus considered hemodynamically stable. As with any surgical procedure, this decrease is most likely due to general vasodilatory effects of anesthesia rather than due to a shift in position from supine to prone jackknife.

There are some limitations when it comes to assessing the applicability of this study to the general population. For instance, our study population is specific to a single-center, urban environment with high rates of HPV and HIV/AIDS in the general population. This skews the type of surgical procedures performed toward issues related to the previously mentioned comorbidities. Furthermore, we were unable to have a comparison group, either from having patients placed in an alternative position or from inpatient groups. This is due to the limited sample size in ambulatory anorectal surgeries performed in positions other than the prone jackknife position. Moreover, all cases were done under general anesthesia, and there is no data on anesthetic administration. Cases under local anesthesia or sedation are common and the cases usually most affected by patient positioning.

Furthermore, data were dependent on the accuracy of flowsheets and the dependence on completed fields. Thirty-day readmissions only included those to the same hospital. Thus, it precludes readmissions to any hospital, and also any ER visits in the same time period. However, nearly, all patients were followed up postoperatively in the office, and data were collected on those encounters in regard to morbidity, of which there were none. Given the small sample size, rare complications, such as nerve injuries and death, may have been missed.

There are several strengths to this study. First, the noninferiority of prone jackknife position from a surgical and anesthesiological approach can be established given the large sample size showing no mortality and minimal complication rates in ambulatory anorectal procedures. As mentioned earlier, with a power of 80%, this study collected enough sample size to detect statistically significant urinary retention complication rates. Second, this study provides informative epidemiological data regarding age, sex, common procedures, diagnoses, comorbidities, and smoking rates in our urban ambulatory anorectal surgical population. Third, the data provided in this study can be used for subsequent studies to validate the safety of prone jackknife position by comparing mortality and complication rates directly with alternative surgical positions.


  Conclusion Top


The authors of this study endorse the noninferiority of prone jackknife position in ambulatory anorectal surgeries. From a surgical standpoint, the anatomy is subjectively better exposed, decreasing the chances of blood loss and complications. From an anesthesia standpoint, an adequate airway, pulmonary compliance, and duration under anesthesia need to be ensured. In this study, given the hemodynamic stability (MAP >55) and lack of intra- and post-operative complications, prone jackknife position is a noninferior alternative to supine or lithotomy position in patients undergoing elective anorectal ambulatory surgery under general anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bailey HR, Snyder MJ. Ambulatory Anorectal Surgery. New York, NY: Springer Science; 1999.  Back to cited text no. 1
    
2.
Smith RH, Gramlig Z, Volpitto PR. Problems related to the prone position for surgical operations. Anesthesiology 1961;22:189-93.  Back to cited text no. 2
    
3.
DePasse JM, Palumbo MA, Haque M, Eberson CP, Daniels AH. Complications associated with prone positioning in elective spinal surgery. World J Orthop 2015;6:351-9.  Back to cited text no. 3
    
4.
Hatada T, Kusunoki M, Sakiyama T, Sakanoue Y, Yamamura T, Okutani R, et al. Hemodynamics in the prone jackknife position during surgery. Am J Surg 1991;162:55-8.  Back to cited text no. 4
    
5.
Liu P, Bao H, Zhang X, Zhang J, Ma L, Wang Y, et al. Better operative outcomes achieved with the prone jackknife vs. Lithotomy position during abdominoperineal resection in patients with low rectal cancer. World J Surg Oncol 2015;13:39.  Back to cited text no. 5
    
6.
Tayyab M, Sharma A, Ragg JL, Macdonald AW, Gunn J, Hartley JE, et al. Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum. Dis Colon Rectum 2012;55:316-21.  Back to cited text no. 6
    
7.
Akinci IO, Tunali U, Kyzy AA, Guresti E, Sencer A, Karasu A, et al. Effects of prone and jackknife positioning on lumbar disc herniation surgery. J Neurosurg Anesthesiol 2011;23:318-22.  Back to cited text no. 7
    
8.
Kunitake H, Poylin V. Complications following anorectal surgery. Clin Colon Rectal Surg 2016;29:14-21.  Back to cited text no. 8
    
9.
Petros JG, Bradley TM. Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease. Am J Surg 1990;159:374-6.  Back to cited text no. 9
    
10.
Bowers FJ, Hartmann R, Khanduja KS, Hardy TG Jr., Aguilar PS, Stewart WR, et al. Urecholine prophylaxis for urinary retention in anorectal surgery. Dis Colon Rectum 1987;30:41-2.  Back to cited text no. 10
    
11.
Zaheer S, Reilly WT, Pemberton JH, Ilstrup D. Urinary retention after operations for benign anorectal diseases. Dis Colon Rectum 1998;41:696-704.  Back to cited text no. 11
    
12.
Toyonaga T, Matsushima M, Sogawa N, Jiang SF, Matsumura N, Shimojima Y, et al. Postoperative urinary retention after surgery for benign anorectal disease: Potential risk factors and strategy for prevention. Int J Colorectal Dis 2006;21:676-82.  Back to cited text no. 12
    
13.
Gupta PJ. Ambulatory proctology surgery – An Indian experience. Eur Rev Med Pharmacol Sci 2006;10:257-62.  Back to cited text no. 13
    
14.
Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A, Rodseth RN, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: Toward an empirical definition of hypotension. Anesthesiology 2013;119:507-15.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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