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286 S. R. Brown
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•
If the patient wants intervention, the type of procedure should be tailored to
the stage of their haemorrhoids, their treatment priorities and views about postoperative pain.
•
Traditionally surgical options have been limited to a surgical haemorrhoidectomy;
this is almost always curative, has the most established evidence base but is
associated with short term significant pain.
•
Recently described operative options include the procedure for prolapsing haemorrhoids Doppler artery ligation, laser therapy and radiofrequency ablation; all
may be effective but are more expensive than haemorrhoidectomy and have a less
mature evidence base.
11.1 Introduction
Given the continued use of some haemorrhoid treatment methods, such as rubber
band ligation and haemorrhoidectomy, in some aspects the ‘modern’ management of haemorrhoidal disease has been the same for over 50 years. However,
in other aspects of treatment there are few areas of proctology where there has
been more innovation in the twenty-first century. A move to shared decision making and tailoring treatment to patient expectation and degree of disease has become
the vogue. A more conservative management regime has become standard. Even
when surgery is indicated, interventions such as Doppler guided ligation, circular
stapled excision, and application of various energy sources to destroy the haemorrhoid complex (e.g. electrotherapy, radiofrequency ablation, bipolar tissue sealing
devices) have been established with the aim to increase surgical efficacy whilst
improving the postoperative recovery experience. Even recovery after traditional
haemorrhoidectomy has been enhanced with the use of various adjuncts. The days
when a patient would spend 2–3 weeks in hospital after haemorrhoid surgery and
experience a miserable six weeks of recovery have disappeared. Nevertheless,
the treatment of haemorrhoids can still be challenging. Even an evidence-based
approach is difficult as the enormous literature base can be confusing and the
evidence conflicting.
The aim of this chapter is to summarise the current optimal management whilst
highlighting and critiquing areas of uncertainty and where further research is
required.
11.2 Pathogenesis and Classification
Internal haemorrhoids are caused by a pathological degeneration of the anal cushions that are normally present in humans. These cushions help maintain continence
and aid evacuation. They consist of a rich vascular plexus supported by a fibromuscular elastic scaffold. As such they provide a hermetic seal which, together
with the passive tone of the sphincter complex, avoids leakage of faecal content
and secretions. During evacuation the contraction of the scaffold squeezes blood
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from the cushions, enlarging the canal and allowing easier defaecation. If the ligaments of the scaffold rupture, the cushions become engorged and are prone to
bleed and prolapse [1]. In addition, the continence mechanism becomes compromised leading to faecal seepage. Irritation of the perianal skin can follow, leading
to pruritis. Profuse engorgement can ultimately result in thrombosis and pain [2].
There is an additional external haemorrhoidal plexus which lies below the
dentate line in the subcutaneous tissues of the anal verge. This plexus is normally not visible and appears to play no obvious physiological role. Nevertheless,
swelling can occur, often associated with internal haemorrhoids, and can contribute to symptoms, particularly pain associated with the overlying anoderm that
is squamous epithelium containing associated pain fibres [3].
Goligher’s classification of haemorrhoids has become the most universally
accepted classification system, despite inherent deficiencies [4]. These deficiencies
include, for instance, the fact that it only refers to internal haemorrhoids. In addition, there has been no assessment of validity or inter and intra-observer agreement.
Clinicians often misclassify based on perceived severity i.e. large haemorrhoids are
considered third degree, when in fact, if the patient does not have to replace them
manually they are technically large second degree (Fig. 11.1). Nevertheless, most
of the literature refers to this system when defining management strategies.
Fig.11.1 Example of
probably grade III
haemorrhoids. However, if
these spontaneously reduce
they could be grade II
haemorrhoids. Alternatively,
if cannot be reduced they
would be classified as grade
IV
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11.3 Conservative Management
Haemorrhoids are very common, affecting as many as one in three of the population and as such represent a significant burden for both primary and secondary
care [5]. An assessment of a typical secondary care colorectal surgical practice
suggests that 1 in 5 of GP referrals will have haemorrhoids as the ultimate diagnosis (personal communication). Providing surgical treatment for every patient would
rapidly overwhelm resources. Therefore, it important to bear in mind that a substantial proportion of patients who present with symptoms due to haemorrhoids
are willing to tolerate their symptoms after reassurance that there is no indication
of an underlying sinister pathology [6]. Exclusion of such, combined with diet and
lifestyle advice is often sufficient management.
Fibre supplementation is an evidence-based recommendation [7]. Additional
advice on avoiding prolonged periods at defaecation and straining, increasing oral
fluids, exercise, weight loss is logical but not evidence based although one study
did identify prolonged time on the toilet as a predictor for haemorrhoids [1].
11.3.1 Drug Therapy
Many different topical agents are available without prescription and such medications remain an extremely profitable area for the pharmaceutical industry. They
typically contain various combinations of topical anaesthetic, steroids, antiseptics
and astringents [8]. Whilst they may bring temporary symptomatic relief there is
no evidence of overall effectiveness.
Conversely, there is some evidence for the effectiveness of venotonics (e.g.
TM
Daflon
ing venous capacity, and decreasing capillary permeability facilitating lymphatic
drainage. A large meta-analysis showed a positive effect particularly on bleeding,
pruritis and discharge [9]. Despite being incredibly popular in various countries,
they are rarely prescribed in the United Kingdom.
). These oral medications work by increasing vascular tone, reduc-
11.3.2 Outpatient Treatment
There have over the years been a plethora of outpatient treatments designed to
correct the underlying pathogenesis of haemorrhoidal disease. These all aim to
induce fibrosis around the haemorrhoid, leading shrinkage of the engorged element
and reduce the bleeding and prolapse tendency.
The perfect outpatient treatment should be easy and quick to carry out, well
tolerated without the need for anaesthetic, effective with minimal potential for
complications and should be cheap to implement. Some of the proposed outpatient
treatments have failed many of these criteria and have not gained universal uptake
[10–13]. For instance, cryotherapy can result in marked discharge post treatment
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and together with infrared coagulation requires expensive equipment and has a
more protracted learning curve than other techniques.
11.3.2.1 Rubber Band Ligation
One intervention that has stood the test of time and meets many of the requirements
for the optimal outpatient treatment is rubber band ligation. This is currently the
most popular non-surgical treatment, with 90% of surgeons offering the technique
as first line therapy for low grade haemorrhoids [14].
The procedure involves placing a small rubber band above the haemorrhoidal
plexus. This leads to necrosis of the tissue contained within the band resulting in
reduction of the vascular supply to the haemorrhoid. The resultant ulcer fibroses,
theoretically fixing and even drawing the prolapsed tissue back into the anal canal,
thus restoring normal anatomy and function.
There is substantial literature on efficacy which varies from 11 to over 50%
[15]. The variation probably reflects the poor definition of recurrence, length of
follow up and the variable degree of disease in these studies. Current recommendations suggest rubber band ligation is indicated in mainly grade II haemorrhoids
[16]. It may be trialled in grade III haemorrhoids but is less likely to work.
Nevertheless, efficacy can be improved with re-banding [17]. Indeed, some surgeons recommend a course of banding until resolution of symptoms in almost
all patients. This approach may be considered convenient by some patients and a
shared decision-making process is therefore essential.
If the patient elects for this procedure, it is important to warn them it is not
without risk. Pain may be an issue, especially if the bands encroach on the dentate line. Local anaesthetic infiltration may be used to negate the pain but this
makes the procedure more protracted [18]. Vasovagal symptoms can occur. Secondary haemorrhage is unusual but may be profuse. Banding should be avoided in
those on anticoagulants [19]. Finally, there have been very rare reports of severe
pelvic sepsis with a few instances leading to death [20]. Any immunocompromised
patient should have the procedure covered with antibiotics.
11.3.2.2 Injection Sclerotherapy
Another intervention that has been used for many years and is still carried out
by some is injection sclerotherapy, usually with phenol in almond oil as the sclerosant. The principle is the same as for rubber band ligation. Namely the injection
of 2–3 mls of sclerosant per haemorrhoid causes an inflammatory response in
the area above the haemorrhoidal plexus resulting in reduced blood flow to the
haemorrhoid and a fibrotic reaction. Complications such as bleeding may occur,
but the mechanism of action is such that bleeding is less likely than after rubber
band ligation in patients who are taking anticoagulants;-there is usually no ulcer
formed. In males care should be taken to not inject too deeply anteriorly as prostatic inflammation, epididymitis and even prostatic abscess formation can occur
[21].
Whilst the evidence base is not perfect, the general consensus is that injection
sclerotherapy is not as effective as rubber band ligation and as such has become
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less commonly used in most countries [22] although the possibility of utilising
the technique endoscopically has led to some resurrection of the technique by
gastroenterologists. In addition, advocates of the use of polidocanol foam as a
sclerosant report superior results to phenol and even rubber band ligation [23].
11.3.2.3 Combination Therapy
There have been descriptions of combination outpatient therapies [24, 25] purporting improved efficacy. Data is not sufficient to be totally convincing, but the
concept of a combination of rubber band ligation with sclerotherapy applied to
the tissue distal to the band is appealing as a ‘fail safe’ in case the band slips.
In addition, the consequent swelling of the distal tissue with sclerosant makes the
band less likely to slip.
11.3.3 ‘Walk in Walk Out’ Therapy
Certain interventions fall between true surgical procedures (done in a theatre
environment usually with an anaesthetic) and outpatient interventions. Whilst traditionally an outpatient therapy, an increasing number of surgeons offer rubber
band ligation in the theatre environment. They argue that good lighting and a supporting team provide the best environment for delivery of the intervention and that
appropriate pre-assessment and consent is possible, with aftercare available for
the small proportion of patients who suffer with complications such as vaso-vagal
events. Critics point to the cost and capacity issues arising from such a policy.
11.3.3.1 Radiofrequency Ablation
This involves the application of radiofrequency energy to the haemorrhoidal tissue, again reducing the vascular supply to the pile and inducing fibrosis. The ‘cold’
energy source results in less potential damage to the surrounding tissues and therefore theoretically reduces pain. Delivery can be carried out under local anaesthetic
and the procedure is well tolerated and easy to administer with rapid recovery.
Despite a lack of quality evidence [26], the technique is rapidly gaining traction
in the surgical community of some countries including the UK. Whether the procedure is as effective as the current sparse literature indicates will be answered in
the forthcoming ORION trial [27].
11.3.3.2 Direc t Current Electrotherapy
This method delivers direct current into the haemorrhoid via a probe attached to a
generator. It does not require any form of anaesthetic and has been proposed as a
treatment for haemorrhoids. The procedure is protracted, requiring the probe to be
applied to each haemorrhoidal pedicle for several minutes. Comparative data are
lacking despite the procedure being available for several years. The low-quality
comparative data that does exist suggests it is as effective as rubber band ligation
but takes much longer to carry out [28]. Given the cost of the generator it is not
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likely to be cost effective compared with rubber band ligation for low grade haemorrhoids. It is hard to believe it will be effective for higher grade haemorrhoids
although some poor-quality data suggest it is [29].
11.4 Surgical Therapy
11.4.1 Haemorrhoidectomy
The concept of haemorrhoidectomy is simple. The swollen haemorrhoidal tissue is
excised with preservation of the anal sphincter and sufficient mucosa and anoderm
to maintain anal canal function. There are 2 current methods of doing this. The
Milligan-Morgan haemorrhoidectomy is the most popular method in the United
Kingdom and Europe. It leaves the wounds open to heal by secondary intention.
The Ferguson closed method is popular in the USA and aims to preserve the
mucosa overlying the haemorrhoid and close the wound. General consensus is that
the choice of open or closed haemorrhoidectomy is a matter of surgeon preference.
Whilst there have been numerous studies comparing the two methods, there are
methodological issues with almost all the literature. The open technique is certainly quicker. The closed technique may reduce the potential for post operative
bleeding and quicken healing [30, 31].
Numerous devices have been described for the excisional component of the
procedure, whether open or closed techniques are used. These include scissors,
diathermy and more recently ultrasonic devices [32], bipolar tissue sealing devices
(Ligasure) [33], laser [34] and radiofrequency devices [35]. Whilst there have been
reports that these energy devices reduce postoperative pain and allow more rapid
recovery, the only convincing data is for Ligasure haemorrhoidectomy [33]. The
technique is similar to a conventional Milligan-Morgan technique, but with the
Ligasure device used to seal the anal mucosa and haemorrhoidal pedicle (not the
anal skin). Various meta-analyses, including a Cochrane review have suggested
short term outcomes including operative time and pain are reduced compared with
other interventions [33, 36]. However, this must be offset against the additional
cost. Whilst not evidence based, it makes sense to reserve Ligasure for haemorrhoidectomy cases where there are particularly protuberant grade 3 haemorrhoids
with wide pedicles. The Ligasure instrument can be easily and safely manipulated
to seal the pedicle, theoretically reducing the potential for bleeding and pain.
Haemorrhoidectomy is notorious for the potential for complications, particularly pain. Evidence from a high-quality multicentre trial looking at VAS scores
[37] describes the typical pattern of this pain. The VAS score more than doubles
on average in the first week after surgery. It then declines to baseline levels by 3
weeks and below baseline after 6 weeks (see Fig. 11.2).
Various adjuncts have been proposed to reduce this pain. Preoperative laxatives were proposed over 40 years ago and shown to reduce the pain for the
first few days after surgery [38]. Intra-operatively there is a strong suggestion that
diathermy rather than ligation of the pedicle reduces pain [39]. Local anaesthetic
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Fig.11.2 Typical pain
profile after
haemorrhoidectomy
illustrated by a visual
analogue scale (VAS) (taken
from the Ethos trial [37])
6
4
2
0
Baseline 1 week 3 weeks 6 weeks
VAS
should be utilised, but there seems to be no difference to either local delivery
of the anaesthetic or a formal pudendal nerve block [39]. Postoperatively various
medications have been proposed. Probably the medication with largest evidence
base is Metronidazole. This may reduce pain by limiting the potential for microabscess formation. Two meta-analyses have suggested a benefit of treatment for a
few days after surgery [40, 41]. GTN ointment may also be used but side effects,
especially headache, reduce tolerance [42]. In addition, the ointment may cause
irritation when applied to open wounds. Other adjuncts (mechanical bowel preparation, prophylactic intravenous antibiotics, topical diltiazem, botulinum toxin,
anal dilator) have been trialled but evidence is currently negative or insufficient to
recommend incorporating into practice [39]. A lateral sphincterotomy is effective
in reducing pain but increases the incidence of incontinence and cannot therefore
be recommended [39].
Bleeding is another complication and can occur either immediately postoperatively, when it is related to inadequate intraoperative haemostasis, or as a
secondary type of haemorrhage. Adequate pressure will stop the bleeding, but
this may be challenging. Submucosal injection of adrenaline can be trialled [43].
Tranexamic acid and metronidazole are used by some. Otherwise, a return to
theatre for haemostasis is required.
Urinary retention is probably due to reflex spasm of the urinary sphincter in
response to pain. It is obviously more common in those with pre-existing outlet issues and hence seen more frequently in males. There are factors related to
the anaesthetic that can reduce the incidence of retention including avoidance of
long duration spinal anaesthesia, intraoperative opiates, high volume IV fluids and
reducing the time to mobilisation [44, 45]. It is important to warn the patient of
this potential complication, especially if they have pre-existing urinary outflow
issues.
Other complications are rare. Submucosal infection is not surprisingly more
common with a Ferguson type closed procedure. Fulminant infection has been
described, usually in immunocompromised patients and an increased index of suspicion and aggressive management is required in such a patient who presents with
pyrexia, increasing pain and difficulty passing urine post operatively [46]. Avoidable complications include anal stenosis if there is a failure to maintain adequate
mucosal skin bridges and faecal incontinence if the sphincter complex is damaged.
In terms of incidence no anal stenosis or faecal incontinence was seen in around
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Table 11.1 Patient reported recurrence of haemorrhoidal disease 1 year after various interventions
Intervention Self reported recurrence at 1 year (%)
Haemorrhoidectomy 14
Doppler guided haemorrhoidal artery ligation 30
Stapled haemorrhoidopexy 32
Rubber band ligation 49
Data taken from references [37, 54]
400 patients undergoing ‘traditional’ haemorrhoidectomy from multiple centres
contributing to the Ethos trial [37].
With this list of potential complications, one might question why the procedure
remains part of mainstream practice and is currently the treatment of choice for
third- and fourth-degree haemorrhoids and second-degree haemorrhoids that have
failed outpatient treatment [16]. The reason is that haemorrhoidectomy give the
greatest chance of long-term cure (see Table 11.1). Data varies concerning recurrence after haemorrhoidectomy, but the Ethos trial is perhaps indicative. At one
year over 85% of patients reported their symptoms had not come back [37]. This
is likely to be substantially better than any other intervention. In addition, haemorrhoidectomy is the only procedure that directly tackles any external component to
haemorrhoidal disease. The paradox of ‘more pain but more gain’ should be discussed with any patient who wishes surgical intervention for their haemorrhoids
as part of a shared decision-making process.
Day case haemorrhoidectomy has become the standard of care if the patient
fits the criteria for safe same day discharge and is given a package of care that
includes appropriate non-constipatory analgesia, metronidazole, and advice about
perianal hygiene. The use of local anaesthetic or pudendal nerve block is essential
[45]. In one large cohort study the same rate of readmission was seen in matched
cohorts of those kept in hospital and those discharged on the day [47].
11.4.2 Procedure for Prolapsed Haemorrhoids
In contrast to other excisional techniques, the PPH procedure only excises the
rectal mucosa/wall. Avoidance of excision of the sensitive anoderm theoretically
reduces post-operative pain. The technique utilises a circular stapler and various
adjuncts that allow access to the mucosa above the haemorrhoidal disease. A purse
string is placed into this mucosa which allows the tissue to be incorporated in
the stapler mechanism. Resultant firing resects a doughnut of tissue thereby disrupting the haemorrhoidal blood supply and drawing the haemorrhoids into their
normal anatomical position. Numerous comparative trials have confirmed that pain
is reduced compared with conventional excisional haemorrhoidectomy. However,
the long-term recurrence rate and quality of life is inferior to haemorrhoidectomy
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with self reported recurrence rates over 30% at one year [37]. Whilst complications
such as bleeding, discomfort and urinary retention are as frequent as other procedures, there are some rare serious events that have been recorded. These include
rectovaginal fistulae, rectal perforation, and retroperitoneal sepsis [48]. A unique
syndrome of rectal pain, urgency and tenesmus has also been highlighted [49]. The
syndrome is probably rare. It was never seen in the cohort of 400 patients from
the Ethos trial. It may relate to technical issues but seems to respond to topical
nifedipine if it occurs [50].
Cost is also an issue, with the expense related to the device making it not cost
effective compared with conventional haemorrhoidectomy. Interestingly, it is likely
to be more cost effective than Doppler guided haemorrhoidal artery ligation [51].
Because of long term recurrence and complication issues, the technique has
fallen out of favour in many countries including the United Kingdom. However, it
may be indicated in the case of the patient with circumferential prolapsing third
or even forth degree haemorrhoids where it is difficult to carry out a conventional
haemorrhoidectomy and remove all haemorrhoidal tissue whilst maintain adequate
mucosal skin bridges.
11.4.3 Doppler Guided Haemorrhoidal Artery Ligation
Variously known as trans-anal haemorrhoidal dearterialization or haemorrhoidal
artery ligation, this procedure utilises a proctoscope with a Doppler probe to sense
the vessels supplying the haemorrhoids in the rectal mucosa, allowing targeted
suture obliteration of the vessel. In addition, a running suture down any prolapsing tissue (mucopexy) enables reduction of any prolapse. The procedure makes
theoretical sense as there is preservation of tissue and a potential restoration of
normal anatomy and physiological function of the anal cushions [52].
The procedure was introduced with substantial media hype suggesting it was a
painless way of treating haemorrhoidal disease and was taken up on the back of
astounding evidence of efficacy [53, 54]. Subsequent higher quality evidence has
questioned the ‘painless’ label as well as the efficacy [55].
Pain is undoubtedly an issue for some and is probably related to the number of
sutures and the mucopexy element of the procedure [56]. Care must be taken to
avoid the sensitive anoderm. Nevertheless, pain is certainly less than other excisional procedures [57] but not rubber band ligation [55]. Bleeding is also more
likely than after rubber band ligation although probably a safe option in patients
who are on anticoagulants, negating the need for temporary cessation [58].
Regarding efficacy, the Hubble trial utilising a simple patient reported dichotomous outcome of recurrence suggested at one year 30% of patients with grade
2 and early grade 3 haemorrhoids would have symptoms that were the same or
worse than before surgery. Efficacy was equivalent to a course of rubber band
ligation [55]. Both the Hubble trial and the Liga Longo trial highlight the costeffectiveness of the procedure, suggesting it is not cost effective compared with
rubber band ligation or even stapled haemorrhoidopexy [51, 55]. It may be that the
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procedure is reserved for patients with lower grade haemorrhoids who have failed
rubber band ligation and who want to avoid haemorrhoidectomy [59].
Recently the need for the Doppler element of the procedure has been questioned
[60–62]. A consistent theme from each of the trials on this topic, totalling 170
patients, is that the Doppler probe does not significantly reduce recurrence. It may
lead to a longer operation and more post-operative pain, presumably because more
suturing is carried out. Suture mucopexy alone therefore seems effective and would
certainly reduce cost.
11.4.4 Laser
The use of laser treatment for haemorrhoids has been described for many years.
Recently the procedure has been combined with Doppler identification of the
haemorrhoidal vessels allowing rapid and accurate ‘dearterialisation’ without the
need for suturing. The HeLp procedure (haemorrhoidal laser procedure) has been
compared with other procedures with apparently superior results in terms of operative time, recovery, and recurrence [63]. The results of this small single centre
trial need to be confirmed in larger multicentre trials, but the cost of equipment
make this procedure unlikely to become mainstream unless shown to be truly
markedly superior to established interventions. This seems unlikely although the
avoidance of sutures, which probably contribute to the pain some patients suffer
after conventional haemorrhoidal artery ligation, is appealing.
11.5 Special Situations
11.5.1 Thrombosed External Haemorrhoids
Often conservative management is recommended for this condition. Ice packs, sitz
baths and the application of sugar or salt to create a hyperosmolar environment
can bring symptomatic relief and possibly enhance recovery by reducing oedema.
The ‘iced finger’ technique may help with delivery of the local anal hypothermia
[64]. The author finds the injection of hyaluronidase (1500u) plus local anaesthetic
extremely effective [65]. Hyaluronidase is freely available in plastics theatres and
the solution is injected directly into the oedematous tissue. If surgery is contemplated, then excision of the major component of the thrombosed piles alone is
recommended [66] (Fig. 11.3).
11.5.2 Perianal Haematoma
A perianal haematoma is caused by a rupture of a vessel on or near the anal verge.
It presents typically as a firm pea sized swelling that can be exquisitely tender
(Fig. 11.4). It doesn’t tend to extend far into the anal canal and hence is usually
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