joint hospital surgical grand round updates on haemorrhoid management yvonne tsang department of...
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Joint Hospital Surgical Grand Round
Updates on haemorrhoid management
Yvonne TsangDepartment of SurgeryNorth District Hospital
Introduction
Haemorrhoids are very common, ~ 80% population
Formed by fibrovascular cushions
Fibrovascular cushions are part of NORMAL anatomy within anal canal
Important in maintaining continence
Anatomy and classification
Internal haemorrhoid found in right anterior (11), right posterior (7), left lateral (3)
Internal Originate from internal hemorrhoidal
plexus above dentate line
External Originate from external plexus below
dentate line
Grade I bleeding without prolapse Grade II prolaplse with spontaneous
reduction Grade III prolapse with manual
reduction Grade IV incarcerated, irreducible
prolapse
symptoms
bleeding Bright red blood per rectum, drip into toilet water Usually occurs with / after bowel movements Rarely leading to anaemia
Prolapse Occurs with bowel movements particularly straining Strangulation >> severe pain!!
Evaluation of rectal bleeding
Most commonly associated with haemorrhoid
? A harbinger of colorectal cancer Old age, family history, recent change in bo
wel habit >> need further investigations
Treatment
Guided by degree and severity of symptoms Varies from simple assurance to operation Three categories
Dietary and lifestyle modification Office procedures Operative procedures
Dietary and lifestyle modification
Prolonged attempts at defecation, either secondary to constipation or diarrhoea > development of haemorrhoids
Main goal Minimize straining at stool Minimize constipation in most circumstances
Micronized flavonoids Decrease capillary fragility Shown to be effective
Reducing haemorrhoidal bleeding Ho et al. Micronized purified flavonidic fraction compared favourably with rubber band
ligation and fiber alone in management of bleeding haemorrhoid. Dis Colon Rectum 2000;43(1):66-69
Recommended for acute haemorrhoidal bleeding prior to initiate clinical procedures
Office procedures Rubber banding ligation Sclerotherapy Infrared coagulation
Less pain than sclerotherapy More recurrence than RBL and sclerotherapy
Walker AJ et al. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhods. Int J Colorectal Dis 1990;5:113-6
Ambose NS et al. Prospective randomized comparison of photocaogulation and rubber band ligation in treatment of haemorrhoids. Br Med J 1983;286:1389-91
Bicap electrocoagulation Cryotherapy Anal stretch
Effective but 25% of patients had altered continence Konsten J. Haemorrhoidectomy vs Lord’s method. 17-year follow-up of a prospective, reand
omized trial. Dis Colon Rectum 2000;43(4):503-6
Rubber band ligation
Originally described by Barron in 1963 Barron J. Office ligation treatment of haemorrhoids. Dis Colon Rectum 1963;19:283-6
Most common method currently use for outpatient treatment
Identify origin of hemorrhoid and apply a band at its base > necrotic and slough off
Recommended for Grade I or Grade II Only applicable to internal haemorrhoids ab
ove dentate line
Individual ligation vs triple ligation Less discomfort and less vasovagal symptom
s Lee HH, Spencer et al. Multiple hemorrhoidal badning in a single session. Di
s Colon Rectum 1994; 37:37-41
Complications Bleeding Pain Thrombosis Rarely perineal sepsis but fatal
sclerotherapy
Phenol in oil, sodium morrhuate Injected into submucosa Decrese vascularity and increase fibrosis Leads to tissue necrosis Incorrect site injection
Pelvic infection and impotence
Rubber band vs sclerotherapy
Meta-analysis Johanson JF. Optimal nonsurgical treatment of hemorrhoids. Am J Gastro. 1992;
87(11):1600-6 MacRae HM. Comparison of hemorrhoidal treatment modalities. Dis of the Colo
n & Rectum.1995;38(7):687-94
Rubber band ligation Better in response in treatment Fewer patient required additional treatme
nt More pain
Operative procedures
Hemorrhoidectomy
Stapled hemorrhoidectomy
Hemorrhoidectomy
Various types Principles
Decreasing blood flow to the anorectal ring and removing redundant hemorrhoidal tissue.
Milligan Morgan Open technique UK
Ferguson Closed method Commonly performed in US
Open vs close
Successful day surgery No difference in pain, analgesic requirement, lengt
h of hospital stays Complete wound healing longer in closed group
Ho YH et al. Randomized controlled trial of opend and closed haemorroidectomy. Br J Surg 1997;84:1729-30
Carapeti EA et al. Randomized trail of open versus closed day-case haemorrhoidectomy. Br J Surg 1999;86:612-3
Prophylactic metronidazole reduces pain and increase patients’ satisfaction
Carapeti EA et al. Double-blind randomized controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet 1998;351:169-72
Alternate energy sources Ligasure
Palazzo FF et al. Randomized clinical trial of Ligasure versus open haemorrhoidectomy. Br J Surg 2002;89:154-57
Thorbeck CV et al. Haemorrhoidectomy: randomized controlled clinical trialk of Ligasure compared with Milligan Morgan operation. Eur J Surg 2002:168:482-4
Harmonic scalpel Yan JJY et al. Prospective, randomized trial comparing diathermy and hormonic s
calpel haemorrhoidectomy. Dis Colon Rectum 2001;44:67-679 Chung CC et al. Double-blinded randomized trail comparing hormonic scalpel hae
morridectomy, bipolar scissors haemorrhoidectomy and scissors excision. Dis Colon Rectum 2002;45:789-794
Electrocautery
Stapled Hemorrhoidectomy
Becoming more popular in recent 10 years
First describled by Pescatori et al and refined by Longo
Pescatori M et al. Trans anal staped excision of rectal mucosal prolapse. Tech Coloproct 1997;1:96-98
Longo A. Treatment of haemorrhoidal disease by reduction of mucosa and haemorrhoidal prolapse with circular stapling device: a new procedure – 6th World Congress of endoscopic Surgery. Mundozzi Editore 1998;777-84
Involves transanal, circular stapling of redundant anorectal mucosa with a standard circular stapling device
Literature review
Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy
Shalaby R., Desoky A. British Journal of Surgery 2001;88(8):1049-53
Largest number of patients recruited n=100 in both arms Clinical follow up in 1 year (90% in stapled, 85% in MM) Shorter operation time Less pain Shorter hospital stay Quicker return to work
advantages
Less pain Post-op and at first bowel motion
Shorter hospital stay Quicker return to normal function Shorter operation time
No difference
Ability to be done as day surgery Frequency of common post-operative
complication
However…
More expensive 5% risk of faecal urgency in first 30 postoper
ative days Increase reoperation rate for skin tag Rare but severe complications
Sepsis Molloy RG, Kingsmore D. Leif threatening sepsis after stapled haemorrhoidectomy. L
ancet 2000;355:810
Rectal perforation Wong et al. Dis Colon Rectum 2003;46:116-7 Ripetti et al. Dis Colon Rectum 2002;45:268-70
conclusions
Heamorrhoidal symptoms = hemorrhoids Treatment according to severity of symptom
s dietary, lifestyle modifcation > office procedu
res > operation Rubber band ligation for grade 1 to grade 2
haemorrhoids
Conventional or stapled haemorrhoidectomy??
Still too early to announce a recommendation
Follow up of studies is too short
The end
Thank you!