Update on the Management of Haemorrhoids: Joint Hospital Surgical Grand Round 23rd April 2016 by Wong Ka Ming Candy at U

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

44. 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

45. 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:

46. 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

47. 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

48. 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.

49. 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

50. 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.