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

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Presentation on theme: "Joint Hospital Surgical Grand Round Updates on haemorrhoid management Yvonne Tsang Department of Surgery North District Hospital."— Presentation transcript:

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 IVincarcerated, 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:  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):  MacRae HM. Comparison of hemorrhoidal treatment modalities. Dis of the Colon & Rectum.1995;38(7):  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:  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:  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:  Chung CC et al. Double-blinded randomized trail comparing hormonic scalpel haemorridectomy, bipolar scissors haemorrhoidectomy and scissors excision. Dis Colon Rectum 2002;45:  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 – 6 th 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):  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!

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