[TDMC]- Haemorrhoids- New Solution to Old Problems

INTRODUCTION

Haemorrhoids are swollen, enlarged veins that form inside and outside the anus and rectum.

EPIDEMIOLOGY

• Age and sex: increased with age, equal both sexes. Female common during pregnancy and childbirth.

•  45 to 65 years of age^2,3.

•  Geographical distribution and race: Common in urban population and developed countries.

•  Diet: Higher in low fiber intake.

•  Socio-economic status: Higher with high socio-economic group.

•  Genetic predisposition: 50% have positive family history.

Clinical Features

• Haemorrhoids are presented clinically by a prolapsed lump which may require manual reduction or is constantly prolapsed.

• Painless bleeding.

• Perineal discomfort or discharge.

• Pruritis (Itchy skin).

• Soiling.

• Mass protruding from anus.

Goligher’s Classification

Depends on  the degree of prolapse into:

1.Anal cushions bleed without prolapse.

2.Anal cushions prolapse on straining but reduce spontaneously.

3.Anal cushions prolapse on straining or exertion and require manual reduction.

4.The prolapse is irreducible and remains out all the time.

Treatment:

Aim :

1.To reduce pain.

2.Improve quality of life.

3.To reduce the morbidity affecting daily living activities.

• Non operative versus operative procedures.

• Outpatient procedures /Day Care procedures.

Grade  1 and Grade 2

Conservative management.

1.) Life style modification.

   – Avoid prolonged straining.

   – Diet and bulk forming agents.

   – Increase oral fluids intake.

   – Improve anal hygiene.

2.) Oral medications

i) Micronized Purified Flavonoid Fraction is composed of 90% Diosmin and 10% Hesperidin (Dafflon).

     – Efficacy in the treatment.

     – Most common drug, phlebotonic activity.

     – Meta analysis of 14 RCTs, role of flavonoids concluded that limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects^9,10,11

ii) Calcium Dobesilate.

-It improves the response of symptomatic acute attacks.

3.) Topical treatment.

i) Topical preparations that contain low-dose local anesthetics, corticosteroids, keratolytic, protectants, or antiseptics.

Note: Chong et al¹², noted that well-designed studies have found no evidence to support the use of any of the myriad of over-the-counter topicals¹².

   – To relieve symptoms.

   – Long term usage of steroids is detrimental.

OUTPATIENT PROCEDURES

ASCRS Guidelines for Management of Haemorrhoids (2010)

    –  Evidence 1b, Grade 1,2 and 3 haemorrhoids  do not respond to conservative management but more to outpatient procedures.

Principles:

    – Decrease blood flow.

    – Reduce redundant tissue.

    – Fix haemorrhoid to the underlying tissue to reduce prolapse.

• 1.) Rubber Band ligation
•     2.) Sclerotherapy
•     3.) Infrared coagulation
•     4.)  Radiofrequency coagulation
•     5.) Cryosurgery
•     6.) Laser surgery

1.) Rubber Band Ligation (RBL)

A simple and quick means treating grades 1 and 2 haemorrhoids.

Method: place tight rubber band around prolapsing cushion to ligate the redundant rectal mucosa just above the internal hemorrhoids (at least 1.5 cm above dentate line) as many sites as required in a single session.

More than 1 band can be done and may need multiple sessions.

Band at dentate line & below: intense pain and need to remove the rubber band.

Warn patient that some bleeding can occur at 5-10 days.

Success rate: 80-89% with recurrence rate of 68% in 4-5 years¹³.

2.) Sclerotherapy

Formerly was the treatment of choice for grades 1 and 2 haemorrhoids.

Agent: 5% phenol in almond or arachis oil.

Uses long injecting needle and proctoscope with 3-5 ml of sclerosant agent into submucosa above dentate line at each haemorrhoid.

Aim: produce fibrosis and reduce degree of prolapse.

Inject too superficial: ulceration.

Inject too deep: ineffective, injury to prostate (painful erection), seminal vesicles (hemospermia) and perirectal sepsis.

Results: 30% had minor complications; 30% required further treatment in the 24 months after the initial procedure, and 8% were symptom-free at four years¹⁴.

3.)  Infrared Photocogulation

Applying a flat tip probe proximal to the hemorrhoidal tissue.

Giving 3 to 4 pulses of infrared energy to the normal mucosa to cause tissue destruction, protein coagulation, and inflammation, which then leads to scarring and tissue fixation.

May need several visits at monthly intervals as only one section of the haemorrhoids is treated per visit.

Advantages of infrared coagulation include being quick, painless, effective with a low rate of complications, and with a rapid return to work.

2 RCTs reported success rates of 67% and 96% of this procedure^15,16.

4.) Cryosurgery

Uses very low temperature to create water crystals within the cells resulting in destruction of the cell membrane and eventually the tissue.

Lead to less pain by freezing the sensory nerve ending.

Lengthy procedure, other disadvantages included profuse discharge, prolonged recovery, and late return to work⁵.

5.) Bipolar diathermy and direct-current electrotherapy

Local heat application to induce coagulation .

Success rates of both methods have been reported by several studies to be comparable to those of infrared coagulation with low rate complications¹⁶.

6.) Laser therapy/photocoagulation

Nd:YAG laser was first utilized in anorectal surgery in the 1960s.

Outcomes have improved later with the advent of the CO₂ laser and the development of the pulsed and the scanned laser.

Plapler et al, in their study of 350 patients treated with CO₂ laser open haemorrhoidectomy reported that laser therapy resulted in less postoperative pain and a better cosmetic scar when compared with conventional surgery¹⁷.

Grade 3 and 4 Haemorrhoids

Surgery

Indications:

• Haemorrhoids are severely prolapsed and require manual replacement.
• Patients fail to improve after multiple applications of nonoperative treatments.
• Haemorrhoids that are complicated by associated pathology, such as ulceration, fissure, fistula, large hypertrophied anal papilla, or extensive skin tags.
• Bleeding is the primary problem.

Treatment Options

Haemorrhoidectomy

Haemorrhoidectomy is considered to be the most effective treatment modality for hemorrhoids with the lowest recurrence rate as compared to other modalities.

Principle:

• Excision of prolapsing anal cushions (excise in the plane outside internal sphincter) while maintaining mucocutaneous continuity between area of excision.

• Marked post-operative pain.

• Post-operative pain may results from sphincter spasm, damage to nerve endings, insertion of hemostatic gauzes and damage to the mucosa. 

Conventional Haemorhoidectomy (CH).

 1.) Milligan–Morgan Procedure (Open)

 2.) Ferguson Technique (Closed)

LigaSure Haemorrhoidectomy

LigaSure vessel sealing system^® (Valleylab, Tyco Health Care Group) is a method that uses a bipolar electrothermal device for without the need for sutures.

(Sutureless haemorrhoidectomy)

Aim:

 – Avoid painful diathermy burns.

 -Allow better tissue adhesions at the wound site.

 – Decrease post operative haemmorhage.

Meta-analysis of articles published between January 2000 and September 2009, and RCTs showed superiority of LigaSure haemorrhoidectomy (LH) versus CH regarding operation time, the incidence of postoperative pain and urinary retention, as well as the time required to resume normal physical activity¹⁸

Harmonic scalpel haemorrhoidectomy

Harmonic scalpel^® (Johnson and Johnson Medical KK, Ethicon Endo-Surgery, Cincinnati, OH) is an ultrasonically-activated instrument, which vibrates at a rate of 55000 MHz per second. 

Ability to coagulate small- and medium-sized vessels by converting electrical energy to a mechanical one.

Submucosal haemorrhoidectomy (technique of Parks)

• Developed by Parks¹⁹, who published results and details of the technique in 1956. 
• Designed to reduce postoperative pain and avoid anal and rectal stenosis.
• Obsolete as complications are higher including longer surgical time, higher recurrence and increased post operative bleeding.

Hemorrhoidal Artery Ligation (HAL)

(HAL) with or without anopexy is a non-excisional procedure aiming at reduction of symptoms of haemorrhoidal disease by reducing the blood flow to the hemorrhoids.

Localization of the hemorrhoidal arteries may facilitated by using the Doppler probe.

Systematic review of 17 studies on 1996 patients with haemorrhoidal disease treated with HAL showed recurrence of bleeding and prolapse in 6.3% and 7.8% of patients respectively²⁰.

Stapled haemorrhoidopexy

In 1998, Longo²¹ proposed the use of a specially designed circular stapler (Ethicon Endo-Surgery, Inc) for treatment of grade III and grade IV haemorrhoids.

Aims at reducing the haemorrhoidal prolapse by excising a complete ring of mucosa above the dentate line and fixing the hemorrhoids to the distal rectal muscular wall leading to repositioning the hemorrhoids into the anal canal.

Transecting the superior haemorrhoidal arteries, which reduces the venous engorgement by transection of the feeding arteries resulting in reduction of the size of the hemorrhoids.

CONCLUSION

Haemorrhoid – it the most common Ano-rectal conditions.

Prepared by:

Dr. Vikneswaren Wera Singgam

Consultant General & Laparoscopic Surgeon

KMI Taman Desa Medical Centre

REFERENCES

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16.) Dennison A, Whiston RJ, Rooney S, Chadderton RD, Wherry DC, Morris DL. A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids. Dis Colon Rectum. 1990;33:32-34.

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