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Stadiengerechte Therapie des Hämorrhoidalleidens
Abstract
Die Therapie des Hämorrhoidalleidens reicht von konservativen Maßnahmen bis hin zu chirurgischen Eingriffen, wobei sich diese nach dem Beschwerdebild des Patienten richten. Asymptomatische Hämorrhoiden bedürfen keinerlei Therapie. Anhand der Literatur sollen in diesem Beitrag eine stadiengerechte Therapie des Hämorrhoidalleidens definiert und Empfehlungen für die klinische Routine abgeleitet werden, wobei die gängigsten Methoden diskutiert werden. Die maßgeschneiderte Hämorrhoidenbehandlung je nach individuellem Fall ist wünschenswert, zumal die gängige Klassifikation nach Goligher nicht zwischen solitärem und zirkulärem Hämorrhoidalprolaps unterscheidet.
Abstract
Hemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy applied according to the patient’s complaints. The aim of this work was therefore to assess a stage-dependent approach for treatment of hemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of hemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent hemorrhoids. Tailored hemorrhoidectomy is preferable for individualized treatment with respect to solitary or circular hemorrhoidal prolapses.
... Symptomatic hemorrhoid disease has a large impact on quality of life, and can be managed with a multitude of surgical and nonsurgical treatments [8]. Treatment options comprise conservative and surgical therapy applied according to individual patient and clinical factors [9]. Continued symptoms despite conservative or minimally invasive measures usually require surgical intervention, and surgery is the initial treatment of choice in patients with symptomatic grade IV hemorrhoids or those with strangulated internal hemorrhoids [8]. ...
Background
Symptomatic hemorrhoids are one of the most common anorectal disorders. Many surgeons use tamponades after open hemorrhoidectomy to manage postoperative bleeding. The question of whether a tamponade is necessary and beneficial after hemorrhoidectomy has not yet been conclusively answered. A previously conducted single-center pilot trial included 100 patients after Milligan–Morgan hemorrhoidectomy. The data indicated that insertion of an anal tamponade after hemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. The findings of this pilot trial are now to be verified by means of a multicenter randomized clinical study called NoTamp.
Methods
We plan to include 953 patients after Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study. The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to postoperative bleeding, and that the patients report less pain. Primary endpoints of the trial are the maximum postoperative pain within 48 h and the incidence of severe postoperative bleeding that requires surgical revision within 7 days after the surgical procedure. Secondary endpoints of the study are the use of analgesics in the postoperative course, the lowest hemoglobin documented within 7 days, quality of life and patient satisfaction. Safety analysis includes all adverse and serious adverse events in relation to the study treatment. Further information can be found in the registration at the German Registry of Clinical Studies (DRKS00011590) and on the study webpage (https://notamp.de/en-GB/trial/main/setLocale/en_GB/). The study is financed by the HELIOS research funding.
Discussion
The study received full ethics committee approval. The first patient was enrolled on 3 May 2017. This trial will finally answer the question whether the insertion of a tamponade after open hemorrhoidectomy is necessary and beneficial.
Trial registration
German Clinical Trials Register (Deutsches Register Klinischer Studien (DRKS), DRKS00011590. Registered on 12 April 2017.
Hämorrhoiden werden als wohl häufigster Vorstellungsgrund in der proktologischen Sprechstunde angegeben. Dabei ist die Symptomatik unspezifisch und korreliert keineswegs eindeutig mit der objektivierbaren Befundgröße. Somit sind oftmals andere Ursachen für die angeführten Beschwerden – insbesondere bei der Angabe von Schmerzen – verantwortlich und müssen differenzialdiagnostisch abgegrenzt werden. Die Therapie sollte symptomorientiert und zunächst konservativ erfolgen. Lediglich bei unbefriedigendem Behandlungserfolg ist beschwerdeabhängig eine operative Intervention gerechtfertigt. Kein Operationsverfahren kann allen Befundsituationen gerecht werden, die Auswahl sollte neben dem Leitsymptom die segmentale oder zirkuläre Ausprägung der Stadien berücksichtigen und auf einen möglichst weitgehenden Anodermerhalt zielen. Eine operative Notfallindikation gibt es praktisch nicht.
Hemorrhoidal disease is one of the most common benign disorders of the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy and are still applied arbitrarily in accordance with the surgeon’s expertise. The aim of this chapter is therefore to assess a stage-dependent approach for treatment of hemorrhoidal disease in order to derive evidence-based recommendations for a clinical routine. The most common treatment methods are discussed with respect to hemorrhoidal disease in extraordinary conditions such as inflammatory bowel disease and recurrent hemorrhoids. Tailored hemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in segmental or circular hemorrhoidal prolapse.
OriginalpublikationMoser K-H, Mosch C, Walgenbach M et al (2013) Efficacy and safety of sclerotherapy with polidocanol foam in comparison with fluid sclerosant in the treatment of first-grade haemorrhoidal disease: a randomised, controlled, single-blind, multicentre trial. Int J Colorectal Dis (publ. online) Fragestellung und HintergrundDie Sklerotherapie ist die Behandlung der Wahl bei einer Hämorrhoidalerkrankung 1. Grades. In zahlreichen Studien wurde nachgewiesen, dass zur Behandlung von Varizen die Sklerotherapie mit geschäumten Sklerosierungsmitteln wirksamer ist als mit flüssigen. Ziel dieser Studie war die Untersuchung der Wirksamkeit und Sicherheit von Polidocanolschaum im Vergleich zur flüssigen Form bei einer Hämorrhoidalerkrankung.Patienten und MethodikInsgesamt wurden 130 Patienten der Sklerotherapie mit Schaum (Polidocanol 3 %) oder Flüssigkeit zugeteilt. Patienten mit Hämorrhoiden 1. Grades wurden in die Studie eingeschlossen und gegenüber der Therapiezuteilung verblinde ...
Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hem-orrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiol-An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment , both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be man-plements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with vari-the results of the various anoplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
Dearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries.
Fifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated.
Haemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001).
This study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization.
The present study was conducted to compare operative time, postoperative course and outcome of LigaSure hemorrhoidectomy (LH), and conventional open hemorrhoidectomy (OH) for prolapsed hemorrhoids.
Eighty-four patients with grade III and IV hemorrhoids were randomized into two groups of 42 patients each; group 1 patients underwent LH whereas group 2 patients underwent OH. Data regarding patient demographics, operative details, postoperative pain score, amount of parenteral analgesics required, length of hospital stay, and time until return to work or normal physical activity were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. All patients had regular follow-ups every 2 weeks for the first 8 weeks postoperatively, and at 2-month intervals thereafter, for a total period of 12 months.
Patient demographics, clinical characteristics, and length of hospital stay were similar in both groups (P > 0.05). The mean operative time, postoperative pain score (up to 48 h), amount of parenteral analgesics required, time off work, and time needed for complete wound healing were significantly less in patients who underwent LH (P < 0.001). Both groups had similar postoperative complications except for delayed wound healing that was observed at 4 weeks postoperatively, in seven patients (16.67%) in the LH group compared to 17 patients (40.48%) in the OH group (chi(2) = 5.83, P = 0.016). Although hemorrhoid recurrence, at 1 year, was also lower among the LH group compared to the OH group (2.38 vs. 9.14%, respectively), the difference was not statistically significant (P = 0.167).
LH is a better alternative than conventional OH in treating prolapsed hemorrhoids (grades III and IV) since it reduces operating time, postoperative pain, and time off work, and allows surgical wounds to heal faster, with minimal comparable side effects and a low recurrence rate.
Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.
The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures.
The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%).
More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied.
DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.
The pathogenesis of hemorrhoidal disease is based mainly on the vascular hyperplasia theory. The aim of this study was to reassess the morphology and the functional mechanisms of the anorectal vascular plexus with regard to hemorrhoidal disease.
The anorectal vascular plexus was investigated in 17 anorectal and five hemorrhoidectomy specimens by means of conventional histology and immunohistochemistry. Vascular corrosion casts from two fresh rectal specimens were used for scanning electron microscopy. Transperineal color Doppler ultrasound (CDUS) with spectral wave analysis (SWA) was performed in 38 patients with hemorrhoidal disease and 20 healthy volunteers.
The anorectal vascular plexus was characterized by a network of submucosal vessels exhibiting multiple thickened venous vessels separated by distinct sphincter-like constrictions. CDUS and SWA showed significant flow differences in peak velocities (6.8 +/- 1.3 cm/s vs. 10.7 +/- 1.5 cm/s; P = 0.026) and acceleration velocities (51 +/- 4 ms vs. 94 +/- 11 ms; P = 0.001) of afferent vessels between the control group and patients with hemorrhoidal disease.
Coordinated filling and drainage of the anorectal vascular plexus is regulated by intrinsic vascular sphincter mechanisms. Both morphological and functional failure of this vascular system may contribute to the development of hemorrhoidal disease.
Despite an abundance of nonsurgical hemorrhoid therapies, none has been consistently more efficacious. By combining data from multiple clinical trials in a meta-analysis, the present study compared the efficacy and complications of infrared coagulation, injection sclerotherapy, and rubber band ligation to determine the optimal nonoperative hemorrhoid treatment. All published clinical trials comparing the three methods were identified by computer search and review of appropriate English language journals. Five trials studying 863 patients satisfied all inclusion criteria. Results demonstrated that similar numbers of patients were asymptomatic 12 months after treatment, regardless of initial therapy. However, significantly fewer patients undergoing rubber band ligation required additional treatment because symptoms had recurred. Although rubber band ligation demonstrated greater long-term efficacy, it was associated with a significantly higher incidence of posttreatment pain. In contrast, infrared coagulation was associated with both fewer and less severe complications. Thus, when all factors are considered, infrared coagulation may in fact be the optimal nonoperative hemorrhoid treatment.
Background:
Hemorrhoids are one of the most common anorectal disorders. The Milligan-Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized-controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day-case procedures potentially making it more economical
Objectives:
To compare the use of circular stapling devices and conventional excisional techniques in patients with symptomatic hemorrhoids.
Search strategy:
We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to May 2006.
Selection criteria:
All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries were included.
Data collection and analysis:
Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.
Main results:
Patients undergoing circular stapled hemorrhoidopexy (SH) were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those receiving conventional hemorrhoidectomy (CH) (7 trials, 537 patients, OR 3.85, CI 1.47-10.07, p=0.006). There were 23 recurrences out of 269 patients in the stapled group versus only 4 out of 268 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence(5 trials, 417 patients, OR 3.60, CI 1.24-10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (8 studies, 798 patients, OR 2.96, CI 1.33-6.58, p=0.008). In studies with follow up of greater than one year, the same significant outcome was found (6 studies, 628 patients, OR 2.68, CI 0.98-7.34, p=0.05). Non significant trends in favor of SH were seen in pain, pruritus ani, and fecal urgency. All other clinical parameters showed trends favoring CH AUTHORS' CONCLUSIONS: Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also likely to be associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the "gold standard" in the surgical treatment of internal hemorrhoids.
Haemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is eradication of symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of the disease: First-degree haemorrhoids are treated conservatively. In addition to high fibre diet, sclerotherapy is used. Haemorrhoids of the 2nd degree prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Third-degree haemorrhoids that prolapse during defecation have to be digitally reduced. The majority of these patients need surgery. For segmental disorders haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease Stapler haemorrhoidopexy is now the procedure of choice. Using a classification orientated therapeutical regime orientated to the classification of haemorrhoidal disease offers high healing rates with a low rate of complications and recurrences.
For thousands of years, anal complaints were treated symptomatically with ointments, suppositories and, in isolated cases, even surgically. Since the middle of the last century injection sclerotherapy has been by far the most widespread out-patient treatment for the very common haemorrhoidal disease. This is based on the notion that haemorrhoids are varicosities, and while this idea has been contested by the theory of a spongy body for over 200 years, it is nonetheless only in the last 40 years that the spongy body theory has become accepted, giving rise to further important functional investigations on the anal structures involved in bowel continence and to rational treatment for haemorrhoids. The conditions necessary for out-patient treatment of haemorrhoids and the options available are presented in this paper and discussed with reference to acceptance, inherent risks, and the possible complications. While diet and behavioural methods, and also anal dilatation and treatment with ointments, can be managed by the patient without any problems, regardless of how effective sclerotherapy and rubber band ligation are, these involve risks whose ramifications are often underestimated. One operative procedure that may well become established as an effective out-patient method in the future is Doppler-guided isolated haemorrhoidal artery ligation (HAL) after Morinaga. Traditionally, day surgery is not so well accepted for haemorrhoidectomy in Germany; unless the operation planned is not very extensive, in-patient treatment is still considered preferable.
The aim of this study was to compare the outcome of the hemorrhoidal artery ligation procedure for hemorrhoidal disease with and without use of the provided Doppler transducer.
Hemorrhoidal artery ligation, known as HAL (hemorrhoidal artery ligation) or THD (transanal hemorrhoidal dearterialization) procedure, is a common treatment modality for hemorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligated. It has been suggested that the use of the Doppler transducer does not contribute to the beneficial effect of these ligation procedures.
The authors conducted a single-blinded randomized clinical trial and assigned a total of 82 patients with grade II and III hemorrhoidal disease to undergo either a HAL/THD procedure without use of the Doppler transducer (non-Doppler group, 40 patients) or a conventional HAL/THD procedure (Doppler group, 42 patients). Primary endpoint was improvement of self-reported clinical parameters after both 6 weeks and 6 months. This study is registered at trialregister.nl and carries the ID number: NTR2139.
After 6 weeks and 6 months in both the non-Doppler and the Doppler group, significant improvement was observed with regard to blood loss, pain, prolapse, and problems with defecation (P < 0.05). The improvement of symptoms between both groups did not differ significantly (P > 0.05), except for prolapse, which improved more in the non-Doppler group (P = 0.047). There were more complications and unscheduled postoperative events in the Doppler group (P < 0.0005). After 6 months, 31% of the patients in the non-Doppler group and 21% in the Doppler group reported completely complaint free (P = 0.313).
The authors' findings confirm that the hemorrhoidal artery ligation procedure significantly reduces signs and symptoms of hemorrhoidal disease. The authors' data also show that the Doppler transducer does not contribute to this beneficial effect.
Background:
Doppler-guided ligation of hemorrhoidal vessels is being proposed as a treatment of grade 2 and 3 hemorrhoids. Many researchers are coupling this procedure with mucopexy or lifting of hemorrhoids to control the prolapse more effectively. The present study was conducted in patients with 3rd-degree hemorrhoids to determine the usefulness of Doppler-guided hemorrhoidal artery ligation compared to mucopexy of prolapsing hemorrhoids and to compare it with mere mucopexy of the hemorrhoids.
Materials and methods:
A double-blind, randomized controlled study was conducted on 48 consecutive patients with grade III hemorrhoids requiring surgery. The patients were randomized into two groups. Half of them were treated with ligation and mucopexy [SL], while the remaining patients underwent a Doppler-guided hemorrhoidal artery ligation followed by ligation and mucopexy [DSL]. The patients were examined by a blinded independent observer at 2, 4, and 6 weeks and at the end of 1 year after the operation to evaluate postoperative pain scores, amount of analgesics consumed, and complications encountered. The observer also assessed recurrence of hemorrhoids after 1 year.
Results:
Operative time was significantly longer in the DSL group (31 min vs. 9 min P < 0.003). The postoperative pain score was significantly higher in the Doppler group [4.4 vs. 2.2, P < 0.002 (visual analogue scale)]. The mean total analgesic dose and duration of pain control using analgesics were greater and longer for the Doppler group than for the SL group (17 vs. 11 tablets, and 13 days vs. 9 days, respectively; P < 0. 01). Complications were similar in both the groups. At 1-year follow-up, the recurrence of hemorrhoids was not statistically significant in either group (4 patients in SL group and 3 patients in DSL group; P < 0.93).
Conclusions:
Suture ligation of hemorrhoids is a simple, cost-effective, and convenient modality for treating grade 3 hemorrhoids. Doppler assistance in ligating the hemorrhoidal vessels prior to hemorrhoidal mucopexy offers no advantage and is a time-consuming procedure.
Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure.
The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula.
Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0-50%, lateral sphincterotomy 0-45%, haemorrhoidal surgery 0-28%, lay open technique of anal fistula 0-64% and plastic repair of fistula 0-43%. Results vary considerably depending on what definition of "incontinence" was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum.
Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.
Doppler-guided transanal haemorrhoid dearterialization (THD) and stapler haemorrhoidopexy (SH) have been demonstrated to be less painful than the Milligan-Morgan procedure. The aim of this study was to compare the effectiveness of THD vs SH in the treatment of third-degree haemorrhoids in an equivalent trial.
One hundred and sixty-nine patients with third-degree haemorrhoids were randomized online to receive THD (n = 85) or SH (n = 84) in 10 Colorectal Units in which the staff were well trained in both techniques. The mean follow-up period was 17 (range 15-20) months.
Early minor postoperative complications occurred in 30.6% of patients in the THD group and in 32.1% of patients in the SH group. Milder spontaneous pain and pain on defecation were reported in the THD group in the first postoperative week, but this was not statistically significant. Late complications were significantly higher (P = 0.028) in the SH group. Residual haemorrhoids persisted in 12 patients in the THD group and in six patients in the SH group (P = 0.14). Six patients in the SH group and 10 in the THD group underwent further treatment of haemorrhoids (P = 0.34). No differences were found in postoperative incontinence. The obstructed defecation score (ODS) was significantly higher in the SH group (P < 0.02). Improvement in quality of life was similar in both groups. Postoperative in-hospital stay was 1.14 days in the THD group and 1.31 days in the SH group (P = 0.03).
Both THD and SH techniques are effective for the treatment of third-degree haemorrhoids in the medium term. THD has a better cost-effective ratio and lower (not significant) pain compared with SH. Postoperative pain and recurrence did not differ significantly between the two groups.
To evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation (DGHAL).
Operative and follow-up patients' data were prospectively collected for patients undergoing either SH or DGHAL by a single surgeon during a 2-year period. A retrospective comparison between patients' outcome operated by one of the two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6 weeks, 6, 12, and 18 months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by a standardized questionnaire that was conducted during the last visit 18 months postoperatively.
A total of 63 patients underwent SH (aged 52 ± 3.2 years) and 51 patients underwent DGHAL (aged 50 ± 7.3 years). DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1 ± 1.4 vs. 5.5 ± 1.9 for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH patients reported greater satisfaction compared with DGHAL patients at 1 year postoperatively.
Both SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids. DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence rates and lower satisfaction rates compared with SH.
Stapled hemorrhoidopexy was introduced in 1998 as a new technique for treating advanced hemorrhoidal disease. Despite a clear perioperative advantage regarding pain and patient comfort, literature reviews indicate a higher recurrence rate for stapled hemorrhoidopexy than for conventional techniques.
Our aim was to present long-term on the use of this technique.
Observational study.
Consecutive patients with hemorrhoid prolapse treated at a regional surgical center from May 27, 1999, through December 31, 2003.
Stapled hemorrhoidopexy with accompanying resection of residual hemorrhoidal nodules if necessary.
Standardized patient questionnaire regarding satisfaction, resolution of symptoms, and performance of further interventions.
Of 257 patients (82 female, 175 male, mean age 53 ± 13 years) undergoing stapled hemorrhoidopexy, follow-up data were available for 224 patients (87.2%) with a mean duration of 6.3 ± 1.2 years. Of these, 195 patients (87.1%) were satisfied or very satisfied with the operation outcome; 19 patients (8.5%) were moderately satisfied; and 10 (4.5%) were not satisfied. Regarding preoperative anal symptoms, complete relief was observed in 179 patients (80.6%) for prolapse, 172 (77.5%) for bleeding, 139 (85.3%) for mucus discharge, 139 (78.5%) for burning sensation, and 115 (75.5%) for itching. Considering all recorded symptoms, 194 patients (86.6%) reported absence and or an improvement at follow-up. Twelve patients (5.4%) reported newly developed incontinence in the sense of urge symptoms; 42 patients out of 51 patients (82.4%) with preexisting incontinence reported an improvement. Local or topical retreatment (ointment, suppositories, sclerotherapy) was performed in 48 patients (21.4%). Reoperation for residual or newly developed hemorrhoidal nodules was needed in 8 patients (3.6%).
Lack of a comparative group.
Our long-term results show that this strategy for stapled hemorrhoidopexy can achieve a high level of patient satisfaction and symptom control, with a low rate of reoperation for recurrent hemorrhoidal symptoms.
Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external-genital organs. It is secondary to polymicrobial infection by aerobic and anaerobic bacteria with a synergistic action. The aetiology is identified in 95% of cases. The source of infection is either cutaneous, urogenital or colorectal. Predisposing factors, such as age, diabetes and immunodepression, are often present in affected patients. Urgent and aggressive treatment is essential to ensure the patient's survival. Treatment consists of restoration of the fluid and electrolyte balance and broad-spectrum antibiotic therapy rapidly followed by surgical debridement. However, the mortality remains high, about 20 to 80%, frequently, due to delayed diagnosis and management. Patients who survive the infection require reconstructive surgery with sometimes marked sequelae related to the extent of fasciitis and debridement.
An anatomical and clinical study aimed at uncovering factors likely to be helpful in understanding the true nature of haemorrhoids is described. The main finding was of specialized 'cushions' of submucosal tissue lining the anal canal; it is argued that piles are merely the result of their displacement.
A prospective randomized controlled trial was carried out on the effects of Daflon 500 mg (a micronized flavonidic fraction containing diosmin 450 mg and hesperidin 50 mg) on bleeding after haemorrhoidectomy. In all, 228 consecutive patients with prolapsed irreducible piles were recruited. Elective haemorrhoidectomy was performed with a standardized diathermy excision method. Some 114 patients were randomized to receive Daflon 500 mg for 1 week after operation (group 1), and there were 114 controls (group 2). Postoperative analgesia and laxative prescription as well as hospital stay were otherwise the same. One patient (0.9 per cent) from group 1 and seven (6.1 per cent) from group 2 had postoperative bleeding (P = 0.03). All bleeding occurred from 6 to 15 days after haemorrhoidectomy. There were no side-effects from the use of Daflon 500 mg. The risk of secondary bleeding from haemorrhoidectomy is reduced with postoperative Daflon.
In 1995, Morinaga reported a new technique for the treatment of hemorrhoids, hemorrhoidal artery ligation (HAL), which uses a specially designed proctoscope coupled with a Doppler transducer for identification and ligation of hemorrhoidal arteries.
Because the arteries carrying the blood inflow are ligated, internal pressure of the plexus hemorrhoidalis is decreased.
We report the results of the first 308 patients (189 male and 119 female; median age 50.1 years) who have been treated at our department since 2002 and followed-up for a median period of 18 months. Eighty-nine patients had grade II, 192 patients had grade III, and 27 patients had grade IV hemorrhoids. The acute symptoms of hemorrhoids were treated immediately by performing HAL.
Our study showed that HAL is painless, effective, and has a low rate of complications. It can be applied in an outpatient setting and is an good alternative to all other hemorrhoid treatment methods.
This study was undertaken to determine the incidence of and risk factors for urinary retention after surgery for benign anorectal disease.
We reviewed 2,011 consecutive surgeries performed under spinal anesthesia for benign anorectal disease from January through June 2003 to identify potential risk factors for postoperative urinary retention. In addition, we prospectively investigated the preventive effect of perioperative fluid restriction and pain control by prophylactic analgesics on postoperative urinary retention.
The number of procedures and the urinary retention rates were as follows: hemorrhoidectomy, 1,243, 21.9%; fistulectomy, 349, 6.3%; incision/drainage, 177, 2.3%; and sliding skin graft/lateral subcutaneous internal sphincterotomy, 64, 17.2%. The overall urinary retention rate was 16.7%. With hemorrhoidectomy, female sex, presence of preoperative urinary symptoms, diabetes mellitus, need for postoperative analgesics, and more than three hemorrhoids resected were independent risk factors for urinary retention as assessed by multivariate analysis. With fistulectomy, female sex, diabetes mellitus, and intravenous fluids >1,000 ml were independent risk factors for urinary retention. Perioperative fluid restriction, including limiting the administration of intravenous fluids, significantly decreased the incidence of urinary retention (7.9 vs 16.7%, P<0.0001). Furthermore, prophylactic analgesic treatment significantly decreased the incidence of urinary retention (7.9 vs 25.6%, P=0.0005).
Urinary retention is a common complication after anorectal surgery. It is linked to several risk factors, including increased intravenous fluids and postoperative pain. Perioperative fluid restriction and adequate pain relief appear to be effective in preventing urinary retention in a significant number of patients after anorectal surgery.
Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy.
A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale.
Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047).
Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.
Eine neue Methode zur Behandlung von Hämorrhoiden mit Hilfe eines Zirkularstaplers
- S N Koblandin
- J L Schalkow
Koblandin SN, Schalkow JL (1981)
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von Hämorrhoiden mit Hilfe eines
Zirkularstaplers. Wissenschaftliches
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Hemorrhoidal artery ligation procedure with or without Doppler transducer in grade II and III hemorrhoidal disease. A blinded randomized clinical trial
- Jp Schuurman
- Ihm Borel Rinkes
- Pm Go
Schuurman JP, Borel Rinkes IHM, Go
PM (2012) Hemorrhoidal artery ligation procedure with or without
Doppler transducer in grade II and III
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Revised morphology and hemodynamics of the anorectal vascular plexus: impact on the course of hemorrhoidal disease
- F Aigner
- H Gruber
- F Conrad
- Aigner
Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared, rubber band ligation and injection sclerotherapy
- J F Johanson
- Johanson
Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids
- A Infantino
- D F Altomare
- C Bottini
- Infantino
Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy
- G E Theodoropoulos
- N Sevrisarianos
- J Papaconstantinou
- Theodoropoulos
Doppler-guided hemorrhoidal artery ligation
- M Scheyer
- E Antonietti
- G Rollinger
- Scheyer