Joint Hospital Surgical Grand Round

1. Joint Hospital Surgical Grand Round Updates on haemorrhoid management Yvonne Tsang Department of Surgery North District Hospital

2. 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

3. 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

4. Grade I bleeding without prolapse • Grade II prolaplse with spontaneous reduction • Grade III prolapse with manual reduction • Grade IV incarcerated, irreducible prolapse

5. 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!!

6. Evaluation of rectal bleeding • Most commonly associated with haemorrhoid • ? A harbinger of colorectal cancer • Old age, family history, recent change in bowel habit >> need further investigations

7. Treatment • Guided by degree and severity of symptoms • Varies from simple assurance to operation • Three categories • Dietary and lifestyle modification • Office procedures • Operative procedures

8. 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

9. 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

10. 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, reandomized trial. Dis Colon Rectum 2000;43(4):503-6

11. 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 above dentate line

12. Individual ligation vs triple ligation • Less discomfort and less vasovagal symptoms • Lee HH, Spencer et al. Multiple hemorrhoidal badning in a single session. Dis Colon Rectum 1994; 37:37-41 • Complications • Bleeding • Pain • Thrombosis • Rarely perineal sepsis but fatal

13. 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

14. 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 Colon & Rectum.1995;38(7):687-94 • Rubber band ligation • Better in response in treatment • Fewer patient required additional treatment • More pain

15. Operative procedures • Hemorrhoidectomy • Stapled hemorrhoidectomy

16. Hemorrhoidectomy • Various types • Principles • Decreasing blood flow to the anorectal ring and removing redundant hemorrhoidal tissue.

17. Milligan Morgan • Open technique • UK • Ferguson • Closed method • Commonly performed in US

18. Open vs close • Successful day surgery • No difference in pain, analgesic requirement, length 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

19. 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 scalpel haemorrhoidectomy. Dis Colon Rectum 2001;44:67-679 • Chung CC et al. Double-blinded randomized trail comparing hormonic scalpel haemorridectomy, bipolar scissors haemorrhoidectomy and scissors excision. Dis Colon Rectum 2002;45:789-794 • Electrocautery

20. 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

21. Involves transanal, circular stapling of redundant anorectal mucosa with a standard circular stapling device

22. 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

23. advantages • Less pain • Post-op and at first bowel motion • Shorter hospital stay • Quicker return to normal function • Shorter operation time

24. No difference • Ability to be done as day surgery • Frequency of common post-operative complication

25. However… • More expensive • 5% risk of faecal urgency in first 30 postoperative days • Increase reoperation rate for skin tag • Rare but severe complications • Sepsis • Molloy RG, Kingsmore D. Leif threatening sepsis after stapled haemorrhoidectomy. Lancet 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

26. conclusions • Heamorrhoidal symptoms = hemorrhoids • Treatment according to severity of symptoms • dietary, lifestyle modifcation > office procedures > operation • Rubber band ligation for grade 1 to grade 2 haemorrhoids

27. Conventional or stapled haemorrhoidectomy?? • Still too early to announce a recommendation • Follow up of studies is too short

28. The end Thank you!