Stapled Hemorrhoidopexy : How to Avoid Complications 굿모닝대홍병원 이선칠

Complications after S.H Improper use of SH can lead to complications which include bleeding, urinary retention, stenosis, and thrombosis.

Tech Coloproctol (2012) Immediated (within 1 week) complications of stapled hemorrhoidectomy reported for 1107 patients treated in a 2-year period

Tech Coloproctol (2012) Late complications of stapled hemorrhoidectomy reported for 1107 patients treated in a 2-year period

Major Septic Complications Pelvic sepsis Intra-abdominal sepsis Fournier gangrene Rectovaginal fistula Rectal perforation : Related to technical errors inappropriate placement of purse-string (too deep or to cephalad in the rectum) Full thickness rectal anastomosis Dis Colon Rectum (2007)

Complications after S.H Literature review of complications after S.H in Korea

Post-operative pain Causes Staple line level(too close to the dentate line) Inclusion of muscle fibers 그 외, narrow anal canal , excessive sphincter tone, staple dehiscence, mucosal injury, thrombosis.

Smooth Muscle Including

Smooth Muscle Including

Early post operative bleeding (within 24hr) * Causes Staples did not achieve proper hemostasis Too much folded mucosa in the staple Taking larger bites of the mucosa in to the purse-string

Late post operative bleeding (after 24hr) Causes Suture line dehiscence, infection, necrosis.

Treatment of postoperative bleeding ① . Bed rest and supportive treatment ② . Anal packing ( Foley catheter, Gauze) ③ . Injection of Epinephrine ④ . Suture ligation

술 후 출혈을 예방하기 위한 Tips Pre Operative 1. 혈전용해제 복용유무 확인 2. 출혈에 영향을 주는 질환들 : Hemophila, DM, Hypertension, Liver cirrhosis, Leukemia 3. Prophylatic antibiotics

술 후 출혈을 예방하기 위한 Tips Intra operative 1. Purse-string suture시 mucosa and submucosa layer만 균일하게 6~8 stitches 2. SH firing 하기 전, 후 적어도 15초 이상 기다린다. 3. 수술시 Electrocautery 사용은 조심스럽게. : 나중 delayed local tissue necrosis 야기, 심하면 retroperitoneal sepsis 4. Pumping artery : Suture ligation Oozing : Compression or Electrocautery 5. 지혈제 사용. (Spongostan, Gelform, FloSeal, etc.)

술 후 출혈을 예방하기 위한 Tips Post operative 1. Antibiotics (Metronidazole, Cefa.) 2. Stool softening, 과도한 strain 금지.

Urinary Retention Etiology - higher spinal anesthesia level of C.H. - BPH in male, urinary bladder disorder in old female Incidence - In Korea : 9.4%(4 – 20%) urinary retention + catheterization

Rectal Stenosis / stricture Causes : residual sphincter hypertonia scar tissue retration In Korea 0.9% (0 – 3.2%) Management: Finger & Hega dilatation in OPD Surgical intervention Prevention Post-op. 3-4weeks : distal rectal exam if, ring-like diaphragm : finger fracture & dilatation 수술 시 staple line이 anal verge에서 항상 4cm 정도 되도록 한다

Postoperative Anal incontinence No complete anal incontinence after S.H Self-limiting Causes : Temporary sphincter dysfunction Dilation with anoscope Post-operative tissue edema Reduction in anal sensation Prevention Avoidance of over-stretching of internal sphincter

Recurrence Two major technical concerns Misapplication of purse-string suture (either too higher, too deep, or too superficial) 2. Inadequate control of the amount of rectal mucosa and submucosa to be excised double or spiral purse-string suture Higher recurrence of prolapsing hemorrhoids incomplete mucosal resection in grade Ⅳ volume of prolapsed tissue exceeds the volume of the stapler casing

Chang Gung Med J (2010)

* Complication (출혈, 협착으로 수술한 경우) In my clinic * Complication (출혈, 협착으로 수술한 경우)