1. Update on the Management of Haemorrhoids Joint Hospital Surgical Grand Round 23 rd April 2016 Wong Ka Ming Candy United Christian Hospital

2. Introduction Fibrovascular cushions with subepithelial arteriovenous communications Normal anatomy of anal canal Functions: – Maintain continence – Subepithelial nerve ending to discriminate between solid, liquid and gas – Safe dilatation during defecation

3. Hemorrhoidal disease Hemorrhoids are considered pathological only when produce symptoms – Bleeding – Mucus secretion – Acute prolapse One of the most common ano-rectal disorders Reported prevalence 4.4% up to 36.4% Peak prevalence 45 to 65 years of age

4. “Sliding anal cushion theory” Repeated Stretching of the anal supporting tissue Fragmentation of supporting tissue Subsequent prolapse of the vascular cushions Thomson, W. H. F. (1975). The nature of haemorrhoids. British Journal of Surgery, 62(7), 542-552.

5. Classification Internal haemorrhoids Proximal to dentate line Covered by columnar epithelium “Internal-external haemorrhoids” when extend beyond dentate line External haemorrhoids Distal to dentate line Covered by anoderm / skin

6. Goligher Classification

7. Conservative management Lifestyle modification – Increase fibre and fluid intake – Behavior modification Topical treatment – Low dose local anesthetics – Steroids

8. Options of office procedure Rubber band ligation Sclerotherapy Infrared coagulation Electrotherapy AIM : Decrease blood flow to haemorrhoids Induce fibrosis at pedicles -> reduce prolapse tissue back into the anal canal AIM : Decrease blood flow to haemorrhoids Induce fibrosis at pedicles -> reduce prolapse tissue back into the anal canal Pedicle

9. Electrotherapy Probe with metal contact points placed at base of haemorrhoids above the dentate line Direct electric current is delivered Cause thrombosis of the feeding vessels -> Haemorrhoids shrink 2 approaches: Low amplitude direct electric current 8mA to 16mAOutpatient setting Higher amplitude direct electric current Up to 30mAUnder GA / SA http://www.ultroid-asia.com/ultroid-asiarevolutionary-procedure.html

10. NICE guideline 2014 Based on 6 RCT, 1 non-randomized comparative study and 2 case series (1989-2010) Some overviews : – 80-92% patient no bleeding recurrence after treatment – 93% went to work in 2 day (n=931 case series) – 20-70% patients experience mod to severe pain – Adverse effect: Bleeding (16%), rectal ulcer (14%), retention of urine (8%), vasovagal (0.08%)

11. NICE guideline 2014 recommendations on electrotherapy Adequate evidence (on efficacy and safety) to support use of electrotherapy for the treatment of grade I to II haemorrhoids Patient should be informed treatment not always successful and repeat procedures may be necessary

12. Operative treatment Excisional haemorrhoidectomyStapled haemorrhoidopexy Transanal haemorrhoidal Deartialization

13. Open (Milligan-Morgan haemorrhoidectomy) Close (Ferguson haemorrhoidectomy) Can be carried out with scissors, diathermy or energy device such as the LigaSure or Harmonic Excisional haemorrhoidectomy Open: Close:

14. Excisional haemorrhoidectomy Most effective treatment Lowest recurrence rate Disadvantages: – Most severe post op pain!!! – Acute urinary retention (2-36%) – Faecal incontinence (2-12%) – Anal stenosis (0-6%) – Post op bleeding (0.03-6%) – Infection(0.5-5.5%) Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17 full-text World J Gastroenterol. 2012 May 7;18(17):2009-17full-text

15. Stapled Haemorrhoidopexy Procedure for prolapsed haemorrhoids (PPH) Initially described by Pescatori for rectal internal mucosal prolapse and obstructed defaecation Further popularized by Longo in 1998

16. Stapled Haemorrhoidopexy Use of specially designed circular stapler Excise a complete ring of mucosa above the dentate line – Fix the haemorrhoids to the distal rectal muscular wall Transect the superior haemorrhoidal arteries – Reduce venous engorgement by transection of the feeding vessels Stapled mucosa anastomosis in the rectum above the dentate line

17. Stapled Haemorrhoidopexy VS Conventional Haemorrhoidectomy?

18. Published in British Journal of Surgery 2008 29 RCT, n= 2056 Patient follow up from 6 weeks to median of 62 months

19. Post op hemorrhage more common ( RR 1.57)

20. More sphincter damage Less persistent wound discharge Less difficult defecation OutcomeRR ( 95% C.I.)P valueFavours Additional procedure for haemorrhage 1.13 (0.64-2.01)0.667CV Sphincter damage2.52 ( 1.91 – 5.32)0.016CV Total complication rate1.08 (0.80 – 1.45)0.631CV Anal stenosis1.00 (0.58-1.71)1 Persistent wound discharge0.13 (0.06 – 0.27)<0.001SH Acute urinary retention0.91 ( 0.67-1.24)0.562SH Difficult defecation0.47 (0.27 – 0.82)0.009SH Incontinence0.71 (0.38 – 1.35)0.298SH

21. Less Pain Pain at 24hr : Pain at first bowel movement: Pain at 1-2 weeks after treatment:

22. Shorter Hospital stay Earlier return to normal activity Hospital stay Return to normal activity

23. Prolapse recurrent more common ( RR 2.29)

24. Published in 2010 Total 22 RCT included Follow up periods 6-56 months ( median 12.3 months)

25. Effects after intervention No of trials No. of patients ORCIP value Favour group Bleeding1310061.130.80-1.610.48CH Prolapse1311912.651.45-4.850.002CH Pruritis75061.190.75-1.860.46CH Faecal urgency 53731.260.75-2.110.38CH Pain118230.790.50-1.240.31SH Haemorrhoid recurrence 129553.221.59-6.510.001CH Anal stenosis1015360.680.34-1.350.27SH Additional operations 85532.751.31-5.770.008CH

26. Conclusion from the 2 studies… Stapled Haemorrhoidopexy : More advantages in short term outcome: – Less pain – Shorter hospital stay – Earlier return to normal activity Disadvantages : – More bleeding post op – More recurrence in terms of prolapse – More additional procedure required

27. Potential adverse effects with SH Rectovaginal fistula Staple line bleeding Rectal stenosis Severe pelvic sepsis Fournier’s gangrene Petersen, Sven, et al. "Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids." BMC surgery 4.1 (2004): 1. Molloy RG, Kingsmore D.Life threatening pelvic sepsis after stapled haemorrhoidectomy. Lancet. 2000 Mar 4;355(9206):810.

28. Transanal Haemorrhoidal Dearterialization ( THD) Also named haemorrhoidal artery ligation ( HAL) Introduced in 1995 by Morinaga et al. and modified by Sohn et al. Nonexisional selective ligation of arteries supplying blood to haemorrhoids using Doppler guidance Venous outflow not disturbed Usually performed under GA / SA

29. Transanal Haemorrhoidal Dearterization ( THD) Doppler probe was used to identify arterial waveforms at 6-8 circumferential points in the distal rectum. Each vessel was then ligated with a deep suture placed per-anally. Frequently modified to include mucopexy to treat associated prolapse

30. Diseases of the Colon & Rectum. 52(9):1665-71, 2009 Sep

31. Introduction 17 studies, from 1995 to 2008 1996 patients Piles grading: – 1 st deg piles: 2% – 2 nd deg piles 36.3% – 3 rd deg piles : 57.4% – 4 th deg piles : 14.6%

32. Results Average of 6 arteries ligated in each patient Operation time : 5-50 min Hospital stay – 1 day for most patient Return to normal activities – 2-3 days in most cases

33. Early post op outcomes Low overall complication rate

34. Overall recurrence rate

35. Transanal Haemorrhoidal Dearterialization VS Stapled Haemorrhoidopexy?

36. 3 RCT ( published in 2005, 2009, 2011) 150 patients ( 80 THD, 70 SH)

37. comparable treatment success rate, operation time, post op complication

38. THD significantly less post op pain

39. Conclusion for THD... Safe and effective alternative – < 20% patients experience post op pain – Less pain than stapled haemorrhoidopexy – Very few significant complications – Quick recovery – < 10% recurrence rate Limitations : – Only small scale comparative study – Larger studies with longer follow up required before definitive recommendations on this method

40. Take home message Treat only when symptomatic Choice of treatment depends on symptomatology Office procedures for mild grade haemorrhoids Excisional haemorrhoidectomy – Remains standard surgical treatment especially for grade IV haemorrhoid Stapled haemorrhoidopexy – Less pain, faster recovery but more recurrence Transanal haemorrhoidal dearterialization – Safe and effective alternative – more comparative study required

41. References 1.Sakr, Shao, W. J., Li, G. C., Zhang, Z. K., Yang, B. L., Sun, G. D., & Chen, Y. Q. (2008). Systematic review and meta‐analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. British Journal of Surgery, 95(2), 147-160. 2.Jayaraman S, Colquhoun PHD, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006 3.Giordano, P., Overton, J., Madeddu, F., Zaman, S., & Gravante, G. (2009). Transanal hemorrhoidal dearterialization: a systematic review. Diseases of the Colon & Rectum, 52(9), 1665-1671. 4.M., & Saed, K. (2014). Recent advances in the management of hemorrhoids. World J Surg Proced, 4(3), 55-65. 5.Simillis, C., Thoukididou, S. N., Slesser, A. A. P., Rasheed, S., Tan, E., & Tekkis, P. P. (2015). Systematic review and network meta‐analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. British Journal of Surgery, 102(13), 1603-1618. 6.Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17 full-text 7.Petersen, Sven, et al. "Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids." BMC surgery 4.1 (2004): 1. 8.Molloy RG, Kingsmore D.Life threatening pelvic sepsis after stapled haemorrhoidectomy. Lancet. 2000 Mar 4;355(9206):810. 9.Tsang, Y. P., Fok, K. L. B., Cheung, Y. S. H., Li, K. W. M., & Tang, C. N. (2014). Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Techniques in coloproctology, 18(11), 1017-1022 10.Thomson, W. H. F. (1975). The nature of haemorrhoids. British Journal of Surgery, 62(7), 542-55 2.

42. Thank you

44. THD local data Retrospective study done in PYNEH comparing THD and SH Paper published Jun 2014 40 THD vs 37 SH FU at week 2, month 2, month 4 Tsang, Y. P., Fok, K. L. B., Cheung, Y. S. H., Li, K. W. M., & Tang, C. N. (2014). Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Techniques in coloproctology, 18(11), 1017-1022

45. Results THD: – Less pain (1.71 in THD vs 5 in SH, p=0.00) – Earlier return to normal daily activity ( 3.13 day in THD v 6.78 in SH, p = 0.001) – Recurrence at 4 months: THDSHP value Bleeding1/40 ( 2.5%)2/37 (5.4%)- Prolapse3/40 (7.5%)7/37 (18.9%)- Recurrence4/30 (10.26%)9/37 (24.32%)0.306

46. 60-80% effective Multiple bandings associated with more adverse effect than single banding – pain and swelling (29% vs 4.5%) – urinary hesitancy and frequency ( 12.3% vs 0%) – Vasovagal symptoms (5.2% vs 0%) 2-5% risk of secondary haemorrhage Should be avoid in patients with coagulation disorder Rubber band ligation Dis Colon Rectum 1994 Jan;37(1):37

47. Injection Sclerotherapy 5% Phenol in almond oil / sodium tetradecyl sulphate Injection around pedicles  local inflammation  Reduced blood flow to haemorrhoids 70% effective Risk of deep injections: Perirectal fibrosis, infection, urethral irritation Prostatic injection : intense pain, strong desire to void, haematuria, haemospermia

48. Infrared coagulation More commonly use for grade I or II haemorrhoids Energy applied proximal to hemorrhoidal tissue Causing tissue destruction, coagulation, inflammation, scaring and tissue fixation Higher rates of recurrence compared to RBL Sakr, Mahmoud, and Khaled Saed. "Recent advances in the management of hemorrhoids." World J Surg Proced 4.3 (2014): 55-65.

49. Electrotherapy mechanism Application of the milliamperature current Creates a unique biochemical reaction within the vascular feeding vessels at the intracellular level of water – causes the release of hydrogen ions (H2 gas) foaming action concentrated at the point where the probe tips touch the base of the hemorrhoid – production of hydroxyl ions or OH- Results in a strong basic environment around the probe denaturation of proteins, a thrombosis of the capillary feeding vessels, and a chemical cauterization within the vascular feeding vessels of the hemorrhoid http://ultroid-asia.com/ultroid-asiarevolutionary-procedure.html

50. SH vs conventional haemorrhoidectomy systematic review of 15 randomized trials of low to moderate quality comparing stapled hemorrhoidopexy vs. conventional hemorrhoidectomy N=1,210 – prolapse recurrence in 8.7% vs. 1.7% (p < 0.001, NNH 14) in analysis of 14 trials with 1,603 patients – recurrent bleeding in 9.7% vs. 8.5% (not significant) in analysis of 7 trials with 362 patients – additional operations in 7.5% vs. 4.1% (p < 0.03, NNH 29) in analysis of 10 trials with 824 patients Long-term Outcomes of Stapled Hemorrhoidopexy vs Conventional HemorrhoidectomyA Meta-analysis of Randomized Controlled Trials Arch Surg. 2009;144(3):266-272. doi:10.1001/archsurg.2008.591.