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Update on the Management of Haemorrhoids

Update on the Management of Haemorrhoids. Joint Hospital Surgical Grand Round 23 rd April 2016 Wong Ka Ming Candy United Christian Hospital. Introduction. Fibrovascular cushions with subepithelial arteriovenous communications Normal anatomy of anal canal Functions: Maintain continence

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Update on the Management of Haemorrhoids

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  1. Update on the Management of Haemorrhoids Joint Hospital Surgical Grand Round 23rd April 2016 Wong Ka Ming Candy United Christian Hospital

  2. Introduction • Fibrovascular cushions with subepithelial arteriovenous communications • Normal anatomy of anal canal • Functions: • Maintain continence • Subepithelial nerve ending to discriminate between solid, liquid and gas • Safe dilatation during defecation

  3. Hemorrhoidal disease • Hemorrhoids are considered pathological only when produce symptoms • Bleeding • Mucus secretion • Acute prolapse • One of the most common ano-rectal disorders • Reported prevalence 4.4% up to 36.4% • Peak prevalence 45 to 65 years of age

  4. “Sliding anal cushion theory” Thomson, W. H. F. (1975). The nature of haemorrhoids. British Journal of Surgery, 62(7), 542-552.

  5. Classification

  6. Goligher Classification

  7. Conservative management • Lifestyle modification • Increase fibre and fluid intake • Behavior modification • Topical treatment • Low dose local anesthetics • Steroids

  8. Options of office procedure • Rubber band ligation • Sclerotherapy • Infrared coagulation • Electrotherapy Pedicle • AIM : • Decrease blood flow to haemorrhoids • Induce fibrosis at pedicles • -> reduce prolapse tissue back into the anal canal

  9. Electrotherapy • Probe with metal contact points placed at base of haemorrhoids above the dentate line • Direct electric current is delivered • Cause thrombosis of the feeding vessels -> Haemorrhoids shrink • 2 approaches: http://www.ultroid-asia.com/ultroid-asiarevolutionary-procedure.html

  10. NICE guideline 2014 • Based on 6 RCT, 1 non-randomized comparative study and 2 case series (1989-2010) • Some overviews : • 80-92% patient no bleeding recurrence after treatment • 93% went to work in 2 day (n=931 case series) • 20-70% patients experience mod to severe pain • Adverse effect: • Bleeding (16%) , rectal ulcer (14%) , retention of urine (8%), vasovagal (0.08%)

  11. NICE guideline 2014 recommendations on electrotherapy • Adequate evidence (on efficacy and safety) to support use of electrotherapy for the treatment of grade I to II haemorrhoids • Patient should be informed treatment not always successful and repeat procedures may be necessary

  12. Operative treatment

  13. Excisional haemorrhoidectomy • Open (Milligan-Morgan haemorrhoidectomy) • Close (Ferguson haemorrhoidectomy) • Can be carried out with scissors, diathermy or energy device such as the LigaSure or Harmonic Close: Open:

  14. Excisional haemorrhoidectomy • Most effective treatment • Lowest recurrence rate • Disadvantages: • Most severe post op pain!!! • Acute urinary retention (2-36%) • Faecal incontinence (2-12%) • Anal stenosis (0-6%) • Post op bleeding (0.03-6%) • Infection(0.5-5.5%) Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17full-text

  15. Stapled Haemorrhoidopexy • Procedure for prolapsed haemorrhoids (PPH) • Initially described by Pescatori for rectal internal mucosal prolapse and obstructed defaecation • Further popularized by Longo in 1998

  16. Stapled Haemorrhoidopexy • Use of specially designed circular stapler • Excise a complete ring of mucosa above the dentate line • Fix the haemorrhoids to the distal rectal muscular wall • Transect the superior haemorrhoidal arteries • Reduce venous engorgement by transection of the feeding vessels • Stapled mucosa anastomosis in the rectum above the dentate line

  17. Stapled HaemorrhoidopexyVSConventional Haemorrhoidectomy?

  18. Published in British Journal of Surgery 2008 • 29 RCT, n= 2056 • Patient follow up from 6 weeks to median of 62 months

  19. Post op hemorrhage more common ( RR 1.57)

  20. More sphincter damageLess persistent wound discharge Less difficult defecation

  21. Less Pain Pain at 24hr : Pain at first bowel movement: Pain at 1-2 weeks after treatment:

  22. Shorter Hospital stayEarlier return to normal activity Hospital stay Return to normal activity

  23. Prolapse recurrent more common ( RR 2.29)

  24. Published in 2010 Total 22 RCT included Follow up periods 6-56 months ( median 12.3 months)

  25. Effects after intervention

  26. Conclusion from the 2 studies… Stapled Haemorrhoidopexy : • More advantages in short term outcome: • Less pain • Shorter hospital stay • Earlier return to normal activity • Disadvantages : • More bleeding post op • More recurrence in terms of prolapse • More additional procedure required

  27. Potential adverse effects with SH • Rectovaginal fistula • Staple line bleeding • Rectal stenosis • Severe pelvic sepsis • Fournier’s gangrene Petersen, Sven, et al. "Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids." BMC surgery 4.1 (2004): 1. Molloy RG, Kingsmore D .Life threatening pelvic sepsis after stapledhaemorrhoidectomy. Lancet. 2000 Mar 4;355(9206):810.

  28. Transanal Haemorrhoidal Dearterialization ( THD) • Also named haemorrhoidal artery ligation ( HAL) • Introduced in 1995 by Morinaga et al. and modified by Sohn et al. • Nonexisional selective ligation of arteries supplying blood to haemorrhoids using Doppler guidance • Venous outflow not disturbed • Usually performed under GA / SA

  29. Transanal Haemorrhoidal Dearterization ( THD) • Doppler probe was used to identify arterial waveforms at 6-8 circumferential points in the distal rectum. • Each vessel was then ligated with a deep suture placed per-anally. • Frequently modified to include mucopexy to treat associated prolapse

  30. Diseases of the Colon & Rectum. 52(9):1665-71, 2009 Sep

  31. Introduction • 17 studies, from 1995 to 2008 • 1996 patients • Piles grading: • 1st deg piles: 2% • 2nd deg piles 36.3% • 3rd deg piles : 57.4% • 4th deg piles : 14.6%

  32. Results • Average of 6 arteries ligated in each patient • Operation time : 5-50 min • Hospital stay • 1 day for most patient • Return to normal activities • 2-3 days in most cases

  33. Early post op outcomes Low overall complication rate

  34. Overall recurrence rate

  35. Transanal Haemorrhoidal DearterializationVS Stapled Haemorrhoidopexy?

  36. 3 RCT ( published in 2005, 2009 , 2011) 150 patients ( 80 THD, 70 SH)

  37. comparable treatment success rate, operation time , post op complication

  38. THD significantly less post op pain

  39. Conclusion for THD... • Safe and effective alternative • < 20% patients experience post op pain • Less pain than stapled haemorrhoidopexy • Very few significant complications • Quick recovery • < 10% recurrence rate • Limitations : • Only small scale comparative study • Larger studies with longer follow up required before definitive recommendations on this method

  40. Take home message • Treat only when symptomatic • Choice of treatment depends on symptomatology • Office procedures for mild grade haemorrhoids • Excisional haemorrhoidectomy • Remains standard surgical treatment especially for grade IV haemorrhoid • Stapled haemorrhoidopexy • Less pain , faster recovery but more recurrence • Transanal haemorrhoidal dearterialization • Safe and effective alternative • more comparative study required

  41. References • Sakr, Shao, W. J., Li, G. C., Zhang, Z. K., Yang, B. L., Sun, G. D., & Chen, Y. Q. (2008). Systematic review and meta‐analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. British Journal of Surgery, 95(2), 147-160. • Jayaraman S, Colquhoun PHD, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006 • Giordano, P., Overton, J., Madeddu, F., Zaman, S., & Gravante, G. (2009). Transanal hemorrhoidal dearterialization: a systematic review. Diseases of the Colon & Rectum, 52(9), 1665-1671. • M., & Saed, K. (2014). Recent advances in the management of hemorrhoids. World J Surg Proced, 4(3), 55-65. • Simillis, C., Thoukididou, S. N., Slesser, A. A. P., Rasheed, S., Tan, E., & Tekkis, P. P. (2015). Systematic review and network meta‐analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. British Journal of Surgery, 102(13), 1603-1618. • Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17 full-text • Petersen, Sven, et al. "Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids." BMC surgery 4.1 (2004): 1. • Molloy RG, Kingsmore D .Life threatening pelvic sepsis after stapled haemorrhoidectomy. Lancet. 2000 Mar 4;355(9206):810. • Tsang, Y. P., Fok, K. L. B., Cheung, Y. S. H., Li, K. W. M., & Tang, C. N. (2014). Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Techniques in coloproctology, 18(11), 1017-1022 • Thomson, W. H. F. (1975). The nature of haemorrhoids. British Journal of Surgery, 62(7), 542-552.

  42. Thank you

  43. THD local data • Retrospective study done in PYNEH comparing THD and SH • Paper published Jun 2014 • 40 THD vs 37 SH • FU at week 2, month 2, month 4 Tsang, Y. P., Fok, K. L. B., Cheung, Y. S. H., Li, K. W. M., & Tang, C. N. (2014). Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Techniques in coloproctology, 18(11), 1017-1022

  44. Results • THD: • Less pain (1.71 in THD vs 5 in SH, p=0.00) • Earlier return to normal daily activity ( 3.13 day in THD v 6.78 in SH , p = 0.001) • Recurrence at 4 months:

  45. Rubber band ligation • 60-80% effective • Multiple bandings associated with more adverse effect than single banding • pain and swelling (29% vs 4.5%) • urinary hesitancy and frequency ( 12.3% vs 0%) • Vasovagal symptoms (5.2% vs 0%) • 2-5% risk of secondary haemorrhage • Should be avoid in patients with coagulation disorder Dis Colon Rectum 1994 Jan;37(1):37

  46. Injection Sclerotherapy • 5% Phenol in almond oil / sodium tetradecyl sulphate • Injection around pedicles • local inflammation • Reduced blood flow to haemorrhoids • 70% effective • Risk of deep injections: • Perirectal fibrosis, infection , urethral irritation • Prostatic injection : intense pain, strong desire to void, haematuria, haemospermia

  47. Infrared coagulation • More commonly use for grade I or II haemorrhoids • Energy applied proximal to hemorrhoidal tissue • Causing tissue destruction , coagulation , inflammation, scaring and tissue fixation • Higher rates of recurrence compared to RBL Sakr, Mahmoud, and Khaled Saed. "Recent advances in the management of hemorrhoids." World J Surg Proced 4.3 (2014): 55-65.

  48. Electrotherapy mechanism • Application of the milliamperature current • Creates a unique biochemical reaction within the vascular feeding vessels at the intracellular level of water • causes the release of hydrogen ions (H2 gas) • foaming action concentrated at the point where the probe tips touch the base of the hemorrhoid • production of hydroxyl ions or OH- • Results in a strong basic environment around the probe • denaturation of proteins, a thrombosis of the capillary feeding vessels, and a chemical cauterization within the vascular feeding vessels of the hemorrhoid http://ultroid-asia.com/ultroid-asiarevolutionary-procedure.html

  49. SH vs conventional haemorrhoidectomy • systematic review of 15 randomized trials of low to moderate quality comparing stapled hemorrhoidopexy vs. conventional hemorrhoidectomy • N=1,210 • prolapse recurrence in 8.7% vs. 1.7% (p < 0.001, NNH 14) in analysis of 14 trials with 1,603 patients • recurrent bleeding in 9.7% vs. 8.5% (not significant) in analysis of 7 trials with 362 patients • additional operations in 7.5% vs. 4.1% (p < 0.03, NNH 29) in analysis of 10 trials with 824 patients Long-term Outcomes of Stapled Hemorrhoidopexy vs Conventional HemorrhoidectomyA Meta-analysis of Randomized Controlled Trials Arch Surg. 2009;144(3):266-272. doi:10.1001/archsurg.2008.591.

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