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

2. 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

3. 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

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

5. 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!!

6. 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

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

8. 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

9. 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

10. 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:
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

11. 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

12. 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

13. 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

14. 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

15. Operative procedures
Hemorrhoidectomy
Stapled hemorrhoidectomy

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

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

18. 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:
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

19. 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:
Electrocautery

20. 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

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

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

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

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

25. 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

26. 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

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

28. The end
Thank you!