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

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

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

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

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

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

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

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

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

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

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

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; 226-230

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

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

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

1996 patients in 17 articles were analysed

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

Excisional hemorrhoidectomy vs PPH

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

Pain Significantly less pain in PPH

Recovery Earlier return to work and normal activities in PPH

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

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

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

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

PPH vs THD

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

Significantly less pain in THD group

Similar complications

Similar recurrence rate

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

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

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

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

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

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

Thank you