Hemorrhoid Surgery in Older Adults: Not a 'Minor' Procedure

Jake Remaly

June 03, 2021

Many older adults who undergo hemorrhoid surgery experience complications in the 30 days after the procedure, including infections and cardiovascular or pulmonary problems, and a substantial proportion die during the year after surgery, according to a Medicare claims study.

In addition, data from nursing home residents indicate a possibility of worsening fecal continence after hemorrhoid surgery. These risks may have implications for treatment decisions and patient counseling, a researcher suggested at the virtual American Geriatrics Society (AGS) 2021 Annual Scientific Meeting.

Whether hemorrhoid surgery is appropriate for a given patient depends on the person and the case, said study author Alexis Colley, MD.

"But I think it is important that we are counseling our patients and thinking about the high rates of complications and even mortality for our frail nursing home patients when we evaluate them for potential hemorrhoidectomy," said Colley, a resident in general surgery at the University of California, San Francisco (UCSF).

Michael Steinman, MD, who is a member of the faculty in the UCSF Division of Geriatrics and is affiliated with the San Francisco VA Medical Center, agreed. He was not involved in the study.

"This may cause us to reevaluate when we would recommend surgery for hemorrhoids for a highly vulnerable older adult in a nursing home setting and to have a frank discussion of the potential risks of this procedure," Steinman told Medscape Medical News.

Hemorrhoids can typically be treated effectively with nonoperative approaches, but some refractory or high-grade cases require surgical intervention, Colley said. Some studies have suggested that age may not affect hemorrhoidectomy outcomes, but studies that focus on older adults and frail older adults have been lacking, Colley and coauthors note.

To fill this knowledge gap, they analyzed outcomes for 3664 patients aged 65 years and older who underwent hemorrhoid surgery between 2014 and 2016, using data from Medicare claims and the Minimum Data Set for Nursing Home Residents.

Their analysis included 916 nursing home residents who were matched in a 1:3 ratio with community-dwelling older adults on the basis of age, sex, race, and comorbidities. The average age of the patients was 81 years.

The nursing home residents had a significantly greater risk for adverse events, compared with matched adults who lived in the community. The study also showed high rates of 30-day complications and 1-year mortality overall, Colley said.

Compared with the matched community-dwelling older adults, nursing home residents were more likely to experience 30-day complications (53% vs 33%; risk ratio [RR], 1.59). They also had an increased risk for 1-year mortality (25% vs 16%; RR, 1.54).

In a subset of nursing home residents for whom more information was available, the researchers found that 32% experienced worsening fecal continence after hemorrhoid surgery.

The relatively increased risk for poor outcomes among nursing home residents "is understandable based on the degree of frailty that our patients in the nursing home tend to have," Colley said. "Frailty has been associated with worse outcomes after all types of surgery."

In future studies, the researchers plan to examine changes in patients' quality of life and mental and functional status. They also plan to stratify the data by frailty status and the type of surgical procedure. Surgical treatment for hemorrhoids can include rubber band ligation, sclerotherapy, and hemorrhoidectomy.

"Doctors often think of hemorrhoidal surgery as a minor procedure and thus of minor consequence, including for older adults," Steinman said. "But the data suggest that harms from this procedure in vulnerable, older nursing home residents can be substantial."

Colley has disclosed no relevant financial relationships. Steinman has coauthored chapters for UpToDate.

American Geriatrics Society (AGS) 2021 Annual Scientific Meeting: P-25. Presented May 14, 2021.

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