1. Updates on the Treatment of Hemorrhoidal Disease
WH Chan
PYNEH
Joint Hospital Surgical Grand Round
April 2012

2. Hemorrhoids Diseased anal cushions
Due to long standing raised intra-abdominal pressure or aging
Internal vs external

3. Symptoms
Prolapse
Per rectal bleeding
Pain
Prevalence = 4.4 % - 30%

4. Goligher’s classification
Grade I
Bleeding without prolapse
Grade II
Prolapse on straining but spontaneous reduction
Grade III
Prolapse on straining need manual reduction
Grade IV
Irreducible prolapse
Objective description only. May not directly related to symptom

5. Management of hemorrhoids
Conservative
High fibre diet, Bulking agent, topical anaesthetic
Micronized purified flavonoids (Daflon)
Office procedures
Rubber band ligation, sclerotherapy
Infrared coagulation, cryotherapy, laser
Surgical procedures

6. Surgical Procedures Excisional hemorrhoidectomy
Stapled hemorrhoidopexy (PPH)
Transanal hemorrhoidal dearterialisation (THD)

7. Excisional hemorrhoidectomy
Milligan-Morgan technique
Open hemorrhoidectomy
Developed in UK in 1937
Excision of the hemorrhoids following transfixion at pedicles

8. Excisional hemorrhoidectomy
Ferguson technique
Closed hemorrhoidectomy
Developed in US in 1952
Excision of hemorrhoids
Mucosal defect closed with absorbable sutures to facilitate wound healing

9. Methods of hemorrhoidectomy
Open vs close
Comparable in complication rate, bleeding, post-operative pain and long-term recurrence rate
Closed vs Open Hemorrhoidectomy – Is there any difference?
Dis Colon Rectum 2000; 43: 31-34

10. Stapled hemorrhoidopexy
First described by an Italian surgeon Longo in 1998
Procedure for Prolapse and Hemorrhoids

11. Circumferential rectal mucosectomy 4-5cm above dentate line
Repositioning of the anal cushion (mucosal lifting)
No excision of hemorrhoids

12. Complications of PPH Common: Tenesmus (14-50%)1
Faecal or flatus incontinence (3-10%)1
Per rectal bleeding (4.3% readmission, 0.4% need surgical hemostasis)2
Pain (1.6% need readmission)2
Urinary retention (4.9%, none need permanent urinary catheterization)2
Postoperative complications after procedure for prolapsed hemorrhoids and stapled transanal rectal excision procedure
M. Pescatori, G. Gagliardi. Tech Coloproctol 2008: 12: 7-19
2. Experience of 3711 stapled haemorrhoidectomy operations
KH Ng, KS Ho, BS Ooi, CL Tang, KW Eu. British Journal of Surgery 2006; 93;

13. Rare complications of PPH
Rectal perforation
Pelvic sepsis
Anastomotic dehiscence
Rectovaginal fistula
Hemoperitoneum
Pneumoretroperitoneum

14. Doppler Guided Hemorrhoidal Artery Ligation
Transanal hemorrhoidal dearterialization
First described in 1995 by Morinaga

15. Doppler Guided Hemorrhoidal Artery Ligation
Use Doppler probe to locate the hemorrhoidal artery
Suture ligation to the hemorrhoidal artery

16. 1996 patients in 17 articles were analysed

17. Recurrence rate
For grade IV hemorrhoids:
59.3% has residual prolapse
26.7% relapse rate
excluded in many studies

18. Excisional hemorrhoidectomy vs PPH

19. Excisional hemorrhoidectomy vs PPH
25 randomized trials with 1918 procedures were reviewed (1991 to 2006)

20. Pain
Significantly less pain in PPH

21. Recovery
Earlier return to work and normal activities in PPH

22. Complete elimination of post operative wound care in PPH
Post excisional hemorrhoidectomy
Post PPH

23. Short term benefits of PPH
Less post operative pain
Earlier return of bowel function
Earlier return to work and normal activities
Similar complications
Complete elimination of post-operative wound care

24. 15 randomized trials with 1201 patients were included
Follow-up periods: 12 – 84 months

25. Prolapse recurrence rate is higher in PPH
Same recurrence rate for bleeding
Higher re-intervention rate in PPH

26. PPH vs THD

27. 3 randomized trials
80 patients in THD vs 70 patients in stapled hemorrhoidopexy

28. Significantly less pain in THD group

29. Similar complications

30. Similar recurrence rate

31. Summary Hemorrhoid is a benign disease
Treatment is for symptom relief and patient expectation

32. Grading of hemorrhoids
Depends on:
Main symptom
Patient expectation
Grading of hemorrhoids

33. Symptoms Prolapse: Bleeding: External component:
Excisional hemorrhoidectomy
Bleeding:
Excisional hemorrhoidectomy/PPH/THD
External component:

34. Patient expectation Less post-op pain, faster convalescene Safety:
PPH and THD
Safety:
Similar post-op complications
PPH associated with tenesmus
PPH associated with rare but potentially fatal complications

35. Management of hemorrhoids
Grade I and Grade II
Grade III and Grade IV
Bleeding only
Prolapse +/- bleeding
Conservative
Office Procedure
- Excisional hemorrohoidectomy
- PPH/THD (less pain, faster recovery)
Failed
Excisional hemorrhoidectomy
PPH/THD
Patient’s symptoms and expectation are more important 35

36. Conclusion Hemorrhoid is a benign disease
Management should aim at treating main symptoms and facilitate patient expectation
Need good pre-op communication in order to choose the best treatment and to achieve patient satisfaction

37. Thank you