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

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

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

Grade I bleeding without prolapse Grade II prolaplse with spontaneous reduction Grade III prolapse with manual reduction Grade IV incarcerated, irreducible prolapse

symptoms bleeding Prolapse 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!!

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

Treatment Guided by degree and severity of symptoms Varies from simple assurance to operation Three categories Dietary and lifestyle modification Office procedures Operative procedures

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

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

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;286:1389-91 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

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

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

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

Rubber band vs sclerotherapy Meta-analysis Johanson JF. Optimal nonsurgical treatment of hemorrhoids. Am J Gastro. 1992;87(11):1600-6 MacRae HM. Comparison of hemorrhoidal treatment modalities. Dis of the Colon & Rectum.1995;38(7):687-94 Rubber band ligation Better in response in treatment Fewer patient required additional treatment More pain

Operative procedures Hemorrhoidectomy Stapled hemorrhoidectomy

Hemorrhoidectomy Various types Principles Decreasing blood flow to the anorectal ring and removing redundant hemorrhoidal tissue.

Milligan Morgan Ferguson Open technique UK Closed method Commonly performed in US

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;84:1729-30 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

Alternate energy sources Ligasure Palazzo FF et al. Randomized clinical trial of Ligasure versus open haemorrhoidectomy. Br J Surg 2002;89:154-57 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;44:67-679 Chung CC et al. Double-blinded randomized trail comparing hormonic scalpel haemorridectomy, bipolar scissors haemorrhoidectomy and scissors excision. Dis Colon Rectum 2002;45:789-794 Electrocautery

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 – 6th World Congress of endoscopic Surgery. Mundozzi Editore 1998;777-84

Involves transanal, circular stapling of redundant anorectal mucosa with a standard circular stapling device

Literature review Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy Shalaby R., Desoky A. British Journal of Surgery 2001;88(8):1049-53 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

advantages Less pain Shorter hospital stay Post-op and at first bowel motion Shorter hospital stay Quicker return to normal function Shorter operation time

No difference Ability to be done as day surgery Frequency of common post-operative complication

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

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

Conventional or stapled haemorrhoidectomy?? Still too early to announce a recommendation Follow up of studies is too short

The end Thank you!