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Management of
Hemorrhoids
Ariane M. Abcarian, MD, and Herand Abcarian, MD
INTRODUCTION
Hemorrhoids are specialized vascular cushions in the anal canal or at
the anal verge. These cushions are composed of blood vessels, connective tissue, and smooth muscle fibers. Hemorrhoids are a normal
part of human anatomy and are responsible for 15% to 20% of anal
resting pressure. Hemorrhoids are typically paired and located in the
right posterior, right anterior, and left lateral locations. Internal hemorrhoids are positioned cephalad to the dentate line and are covered
with mucosa, and external hemorrhoids are located caudal to the
dentate line and are covered with anoderm, and most distally, skin.
(Fig. 1). Internal hemorrhoids are classified based on their degree of
prolapse (Table 1).
ETIOLOGY AND SYMPTOMS
Hemorrhoids are a normal part of human anatomy. Pathologic
hemorrhoids occur as such through increased abdominal pressure, usually caused by constipation, straining, and poor toileting
hygiene. Other causes for hemorrhoid enlargement and complications are diarrhea, pregnancy, chronic obstructive pulmonary
disease (COPD), and portal hypertension (PH). Approximately 10
million Americans are affected by symptomatic hemorrhoids, making it roughly 4.4% of the population affected. The majority of these
patients are over the age of 50.
Most patients with anorectal complaints will be labeled as having
“hemorrhoids.” It is imperative that the practitioner differentiate
hemorrhoidal symptoms from other benign or malignant anorectal
conditions. Patients with rectal bleeding from hemorrhoids will
describe bright red bleeding, usually with defecation. The blood can
be minor and seen on the paper with wiping, or can fill the toilet
bowl and include clots. Symptoms of constipation and straining or
diarrhea should be elicited, and documenting bowel and toileting
habits is a good place to start when evaluating these patients. Time
spent on the toilet should be noted, and it should be discerned if this
time is spent defecating, engaging in reading, and so on. It should
be documented if the patient feels a prolapse of tissue and whether
they need to manually reduce this. Hemorrhoidal prolapse should
be easily differentiated from true rectal prolapse by the absence of
circumferential folds and the presence of radial folds (Fig. 2). A family history of colon cancer, polyps, or inflammatory bowel disease
should be documented. Thorough examination of the anorectum
(externally, digitally, and with anoscopy) should be performed.
All patients with bleeding should have a discussion regarding
colonoscopy. Patients with symptomatic external hemorrhoids are
almost always suffering from thrombosis, and this may be solitary
or in conjunction with strangulated internal hemorrhoids (Fig. 3).
It may be difficult to examine these patients because of discomfort
and fear, and examination under anesthesia may be warranted. Skin
tags are common and asymptomatic but may contribute to hygiene
problems and pruritus ani.
TREATMENT
Dietary and Lifestyle Modifications
Once the patient has been diagnosed with symptomatic hemorrhoids
and other conditions fully ruled out, first-line treatment with conservative, nonoperative therapy should commence. The vast majority of
patients are started on a fiber supplement such as psyllium or methylcellulose and a stool softener such as docusate. Patients are encouraged to drink eight or more glasses of water per day, cut back on
caffeinated beverages, and increase dietary fiber. Patients should also
be advised on proper toileting hygiene as reducing pressure to the
pelvic floor by avoiding straining is imperative. Patients are encouraged to reduce time on the toilet to less than 3 minutes and not to sit
longer than necessary (no reading, cell phone, crossword puzzles).
In a large systematic review, these simple measures were sufficient
to decrease symptoms in the majority of patients with grade I and II
hemorrhoids. Warm sitz baths two to three times daily may also help
with symptom relief, as may application of cotton soaked with witch
hazel to reduce edema. Over-the-counter topical remedies usually
contain hydrocortisone or -caine analgesics and may provide temporary relief, but they do not help reduce symptoms in the long run.
The use of phlebotonics including the natural plant extract flavonoids are thought to improve hemorrhoids through an unknown
mechanism of action. Studies report increased venous drainage and
decreased hemorrhoidal inflammation. Patients report less bleeding,
less pruritus, and overall symptom improvement. Long-term data do
not exist to support durability at this time.
Some patients will fail conservative treatment and require procedural intervention. Office-based procedures include rubber band
ligation (RBL), sclerotherapy, infrared coagulation (IRC), and use of
the HET bipolar system. Operative procedures are also included in
the algorithm of treatment and may be employed as more conservative treatments fail.
Office-Based Procedures
Rubber Band Ligation
RBL is the most common office-based procedure for symptomatic
hemorrhoids. It is appropriate for use on grade I, II, or III hemorrhoids and requires no anesthetic or bowel preparation. Patients who
are on anticoagulation, on antiplatelet therapy, or are allergic to latex
287
288 MANAGEMENT OF HEMORRHOIDS
Left lateral
xus)
Mixed hemorrhoid
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Usual position of internal
hemorrhoids, or anal cushions
Right
posterior
Right
anterior
Internal hemorrhoidal plexus
Dentate line
External hemorrhoidal plexus
Types of hemorrhoids
Origin below
dentate line
(external plexus)
FIG. 1 Location and types of hemorrhoids.
External hemorrhoid
TABLE 1 Classification of Internal Hemorrhoids
Grade Location Symptoms
1 Bulge into anal canal Painless bleeding
2 Prolapse, reduce
spontaneously
3 Prolapse, require manual
reduction
4 Prolapse, cannot be
reduced
delayed bleeding. Patients are asked to abstain from aspirin-containing products at home for 7 days before the procedure. They are placed
in the left lateral decubitus or prone jack-knife (preferred) position
on a procto table. Anoscopy is performed, and the hemorrhoids are
Bleeding, pressure, itching
Bleeding, pressure,
mucoid drainage
Pain, bleeding, pressure,
mucoid drainage
Origin above
dentate line
(internal plexus)
Internal hemorrhoid
Origin above
and below
dentate line
(internal and
external ple
visualized. The largest or most excoriated hemorrhoid is addressed
at the first session. The rubber band is placed approximately 2 cm
above the dentate line at the apex of the hemorrhoid (Fig. 4). There
is no somatic pain sensation at this level, and many patients report
dull pelvic pressure.
There are several types of rubber band ligators available; our
preference is shown. Suction ligators have the benefit of not needing
an assistant. RBL helps reduce hemorrhoid size by reducing blood
flow to the hemorrhoidal cushion and by removing a small portion
of rectal mucosa. Over time, fibrosis and scarring occur, which help
pull the hemorrhoid cephalad and further reduce size and prolapse
symptoms. Hemorrhoid banding has a high success rate of over 90%.
Many patients may need a series of bandings to fully address symptoms; these should be scheduled roughly 3 to 4 weeks apart. Our
preference is to band one hemorrhoid at the first occasion and up
to two thereafter. We avoid banding all three hemorrhoidal columns
to reduce pelvic pressure and pain. The band will slough in approximately 1 week, causing some minor bleeding. Again, it is this part
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of the procedure that makes it unsuitable for those on anticoagulants
or aspirin. For those who can stop anticoagulation 1 week before and
after, banding is a good option. For those who cannot, sclerotherapy
can be offered.
RBL is safe, and its most common complications are pain, bleeding, vasovagal symptoms, or thrombosis of the contiguous external
hemorrhoid. Severe pain immediately after banding indicates the
band was placed too low, and band removal is required either in
the operating room or with a band-removing tool in the office.
Rarely, pelvic sepsis can occur with fever, increasing and severe
pain, and urinary retention. It is a rare but serious complication and
requires immediate operative intervention to control sepsis with
wide debridement of necrotic tissue.
Sclerotherapy
Sclerotherapy is an office-based procedure used for grade I and II
hemorrhoids and is a viable option for patients on anticoagulants
and antiplatelet agents. A sclerosant is injected into the hemorrhoid,
resulting in shrinkage, fibrosis, scarring, and fixation. Sclerosing
agents include 5% phenol (suspended in almond oil), hypertonic
saline, or ethanolamine. Anoscopy is performed and, using a
25-gauge needle, the surgeon injects the sclerosant 1 cm above
the dentate line in the submucosa of the hemorrhoid. The volume
injected varies based on the sclerosant but is typically 2 to 3 mL
when using phenol and 1 mL when using ethanolamine, and all three
hemorrhoids can be treated in one session. Digital pressure is used
to control needle site bleeding in patients who are anticoagulated.
Sclerotherapy, like RBL, can be repeated to achieve the desired effect.
Complications are similar to RBL and arise usually from injecting the
sclerosant into the muscle or mucosa, which leads to pain, ulceration,
and eventual sloughing of the mucosa.
Other Office-Based Procedures
IRC and bipolar diathermy are also utilized for grade I and II hemorrhoids. Like sclerotherapy, both can treat all hemorrhoid columns
in one setting. In IRC, the tip of the infrared coagulator (IRC 2100,
Redfield Corporation) is placed at the apex of the hemorrhoid.
A 1- to 1.5-second pulse is applied, resulting in a 4-mm
coagulation. This creates a 2.5-mm-deep ulcer. Typically three to
four applications are made on each hemorrhoid. The overall effect
is thrombosis and tissue destruction, which leads to shrinkage, scarring, and fixation of the hemorrhoid. IRC is well tolerated and has
similar side effects to RBL and sclerotherapy (Fig. 5).
The HET system (HET bipolar system, Covidien) is also used
in the office setting. Using specialized forceps, the hemorrhoid is
grasped, and bipolar energy is applied. HET is well tolerated and has
similar side effects to RBL and sclerotherapy.
2
focus of
FIG. 2 Prolapsed external and internal hemorrhoids.
Operative Treatment
Operative treatment is indicated for patients with grade III and
grade IV hemorrhoids and for those who have persistent symptoms
A B
FIG. 3 (A) An acute, thrombosed external hemorrhoid. (B) Prolapsed and strangulated internal hemorrhoids with an external component.
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despite conservative and office-based procedures. Some patients are
suitable to go directly to an operation in the nonurgent setting. Only
about 5% to 10% of patients with symptomatic hemorrhoids will
require an operation. Surgery is superior to office-based procedures
A
B
C
FIG. 4 Rubber band ligation of internal hemorrhoids. (A) A rubber
band is placed onto a banding gun. (B) The hemorrhoid is grasped 2 cm
above the dentate line, and the band is advanced over the hemorrhoid.
(C) The band is shown in the correct position after ligation.
in terms of durability but has more potential complications including pain, urinary retention, bleeding, anal stenosis, infection, and
changes in continence. Use of long-acting injectable anesthetics is
helpful. Detailed postoperative instructions including pain management, local wound care, controlling constipation, and return
precautions are important for patient satisfaction and comfort in the
postoperative period.
Acute Hemorrhoidal Crisis
The term acute hemorrhoidal crisis is attributed to Dr. Eugene
Salvati, whose robust practice of over 50 years focused heavily on
proctology. Acute hemorrhoidal crisis refers to circumferential
prolapsed, thrombosed, and incarcerated internal and external
hemorrhoids, with or without necrosis. In the absence of necrosis,
the patient can be treated definitively or temporized with the use
of an injected mixture of 1% lidocaine with epinephrine, normal
saline, and hyaluronidase. The mixture is injected into all edematous
tissues. The area is massaged, and a pressure dressing is applied. We
typically have the patient sit on a roll of kerlix. The procedure can
be repeated (Fig. 6). With necrosis present, this should be managed
operatively with hemorrhoidectomy. Before incision, the hyaluronidase mixture can be injected and the hemorrhoids reduced to better
delineate the tissues that are necessary for excision and reduce the
chances for overexcision of anoderm. Single-column thrombosis
can be excised and the wound left open to granulate. This is best
done within the first 72 hours of thrombosis, and patients should be
counseled that pain and drainage will be present after the procedure
(Fig. 7).
Ferguson Hemorrhoidectomy
The Ferguson or “closed” hemorrhoidectomy is the most common
hemorrhoid operation performed in the United States and offers
a durable solution to hemorrhoidal symptoms. It involves excision
of the hemorrhoidal tissue (internal and external) with ligation of
the hemorrhoid pedicle and closure of the mucosal defect and skin.
Our preference is to perform this operation under spinal anesthesia
with the patient in the prone jack-knife position. The hemorrhoid
is marked for excision at the anoderm. It is injected with an equal
mixture of lidocaine with epinephrine and bupivacaine. A V-shaped
incision is made in the perianal skin, and the hemorrhoid is elevated
off the external and internal sphincter as the dissection is carried
cephalad. The sphincter muscles should be clearly identified in
situ as the incision is continued onto the mucosa. The apex of the
hemorrhoid is identified, and the vascular pedicle is clamped before
excision of the hemorrhoid. The pedicle is suture ligated (we use 2-0
Vicryl on a tapered needle), and the defect is then closed using a
locking running suture until reaching the skin, where simple running
sutures complete the closure. The last few millimeters are left open to
drain (Fig. 8). The procedure can also be performed using a bipolar
FIG. 5 Infrared coagulation of
internal hemorrhoids. (A) The
applicator is applied to the apex of the
hemorrhoid. (B) The IRC 2100 device
(Redfield Corporation).
AB
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FIG. 6 Acute hemorrhoidal crisis. (A) Thrombosed internal and external hemorrhoids with severe edema before injection. (B) After hyaluronidase
mixture injection and massage. Note the absence of edema.
AB
FIG. 7 Acute thrombosed external hemorrhoid. (A) Single thrombosed external hemorrhoid. (B) Clot excised with overlying.
sealing device (LigaSure or Harmonic). Careful identification of the
internal sphincter is mandatory to proceed safely with this technology, and caution must be used to prevent overexcision of anoderm
with resultant anal stenosis. Using an energy device will also signifi-
Milligan-Morgan Hemorrhoidectomy
The Milligan-Morgan, or “open” hemorrhoidectomy, is performed
most commonly in Europe and the United Kingdom. The procedure is identical to the Ferguson hemorrhoidectomy, but after
excision the wound is left open to heal by secondary intention.
292 MANAGEMENT OF HEMORRHOIDS
Excision technique for mixed hemorrhoids
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FIG. 8 Ferguson hemorrhoidectomy.
External
sphincter
Internal
sphincter
Hemorrhoid grasped
and pulled down
Deep suture
ligation of
vascular
pedicle
Dead space closed
with suture incorporating
skin edges and muscle
External
sphincter
External hemorrhoid dissected
free; dissection carried cephalad
to free internal portion
Outcomes and overall durability are similar, but wound healing is
much longer.
Stapled Hemorrhoidopexy
Stapled hemorrhoidopexy (or procedure for prolapsed hemorrhoids
[PPH]) is usually offered to patients with grades I to III circumferential internal hemorrhoids without a bulky external component. It was
developed as an alternative to excisional hemorrhoidectomy because
of the associated postoperative pain. The technique uses a specialized circular end-to-end anastomosis (EEA) stapler that removes
a circumferential band of mucosa and submucosa proximal to the
hemorrhoids. It does not remove the hemorrhoids, but flattens them
with tension and disruption of the vascular pedicle and helps reposition them back to their normal anatomic position in the anal canal.
There are no external wounds, and the staple line is cephalad to the
dentate line, thus reducing pain compared with traditional excisional
hemorrhoidectomy. PPH can help flatten external disease, but it will
not completely address large external hemorrhoids.
Stapled hemorrhoidopexy is also performed under spinal anesthesia in the prone jack-knife position. The hemorrhoidopexy kit
contains a dilator, a clear plastic anoscope, an operating anoscope,
and stapler (Fig. 9). The dilator is placed in the anal canal, and the
clear plastic anoscope is sutured to the perianal skin to evert the
dentate line. Next, the operating anoscope with depth markings is
used to place a circumferential submucosal purse-string suture 3
to 4 cm proximal to the dentate line, about 2 cm proximal to the
hemorrhoidal pedicle. Caution must be taken to avoid placing a
full-thickness suture, especially in women as injury to the vagina
and subsequent rectovaginal fistula can occur. After placement of the
purse-string suture, the vagina should be checked digitally to ensure
the absence of suture. Once the purse-string suture is complete, it
is tied to the anvil of the stapler. The anvil is then mated with the
stapler, and the stapler is fired. The specimen appears as a ring of
mucosa and submucosa.
Complications of PPH and excisional hemorrhoidectomy are
similar. In some cases, if the staple line is too close to the dentate
line, the patient will have significant postoperative pain, so care
must be taken to place the purse-string suture at the correct level.
Staple line bleeding at the time of the initial operation should be
controlled by oversewing the entire staple line. Rare complications
such as rectovaginal fistula, pelvic sepsis, staple line stricture, and
rectal perforation have been reported, and most complications result
from misplacement of the purse-string suture. PPH outcomes are
similar to hemorrhoidectomy however; long-term recurrence is
higher with stapled hemorrhoidopexy. Overall, PPH patients have
less pain, faster recovery, and better quality of life scores compared
with excisional hemorrhoidectomy patients.
Doppler-Guided Hemorrhoid Artery Ligation and
Mucopexy
Doppler-guided hemorrhoidal artery ligation (DGHAL) is a technique that utilizes one of two patented anoscopes, the THD (transanal hemorrhoid dearterialization) or the HAL (hemorrhoid artery
ligation). Both systems utilize Doppler guidance to isolate the hemorrhoidal arteries for ligation. Typically used on grade II to III hemorrhoids, it allows selective and specific ligation of the hemorrhoidal
arteries, reducing arterial inflow to the hemorrhoids and returning
the tissues to normal physiologic condition. Up to 90% of patients had
improved symptoms, with less postoperative pain than other surgical
options, because all suturing is done proximal to the dentate line.
Similar to other hemorrhoid procedures, the DGHAL is performed in the operating room in the prone jack-knife position. The
proprietary anoscope is placed in the anal canal to 6 to 7 cm from
the anorectal junction. The vessels are localized with the attached
Doppler, usually about 2 cm above the anorectal junction (Fig. 10).
A Z-stitch is placed at this location through the slot on the anoscope,
and ultimately six sutures are placed. For patients with grade III or
IV hemorrhoids, a mucopexy, or “rectoanal repair,” can be added to
help draw up and flatten out the tissues. Overall complication rates
are low and are mostly related to bleeding and recurrence.
Open Transanal Hemorrhoidopexy
Open transanal hemorrhoidopexy can be performed alone or in
conjunction with other operative procedures. It involves suturing the
ANORECTAL 293
6 cm
Distance
5 cm
4 cm
3 cm
2 cm
1 cm
0 cm
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A
B
FIG. 9 (A) EEA hemorrhoid and prolapse stapler with DST Series technology. (B) Stapled hemorrhoidopexytechnique.A purse-string suture is applied
4cm above the dentate line (left). The stapler is advanced into the rectum, and traction is held on the suture (center).The staple line is shown after completion of the procedure (right). (A courtesy Medtronic, copyright 2019.)
Z point
Fixation
1–4
3
12
5
7
FIG. 10 Schematic of transanal hemorrhoidal dear-
terialization and mucopexy. Marker point denotes the
location of the best Doppler signal for hemorrhoidal
ligation. A Z-stitch is placed at this location for ligation
alone. For higher-grade hemorrhoids, mucopexy with
running suture is performed starting proximally and
encompassing the ligation point, pulling the redundant
mucosa up into the rectum (right side of image). (From
Ratto C, de Parades V. Doppler guided ligation of hemorrhoidal arteries with mucopexy: a technique for the future.
J Visc Surg. 2015;152:S15–S21.)
Anorectal
Junction
Dentate line
Marker point
Max Doppler signal
Sound level
4
6
8
Mucopexy ending
10 9
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anal mucosa to the rectal wall using a Z-stitch. At 4 cm from the anal
verge, a suture including mucosa and submucosa is placed through
the rectal wall and then at the upper level of the hemorrhoid tissue
near the vascular pedicle. Before tying the suture, a 1-cm strip of
mucosa between the two sutures is excised after injection of lidocaine with epinephrine. The suture is then tied down, drawing the
prolapsing hemorrhoid higher into the anal canal. Our practice is to
perform this procedure, with or without excision of the intervening
tissue, during other operative treatment for the hemorrhoids, and
it can be a useful adjunct. Complications related to bleeding and
thrombosis are most common. Recurrences may be managed with
a repeat procedure.
Postoperative Considerations
Surgical hemorrhoidectomy is a very safe procedure. Postoperative urinary retention occurs in up to 15% of patients and can be
partially mitigated with fluid restriction. Postoperative bleeding
occurs in 1% to 2% of patients. Early bleeding is considered an
operative complication, but bleeding 7 to 14 days later is a known
complication resulting from absorption of sutures. All patients with
significant bleeding must return to the operating room. During
the examination under anesthesia, most often no active bleeding
is seen, but all suture or staple lines should be oversewn. Rarely
more serious complications will occur as mentioned previously.
Overall, most patients will have postoperative pain and should be
given multimodal analgesics to help reduce narcotic usage. Oral
regimens of nonsteroidal antiinflammatory drugs (NSAIDs) as well
as acetaminophen should be given around the clock. Sitz baths to
help reduce discomfort should be utilized liberally. Constipation
and diarrhea should be avoided, and appropriate stool modifiers
should be offered if necessary. Studies have shown that use of topical
calcium channel blockers in the postoperative period reduced overall pain and allowed patients to resume normal activities sooner.
Overwhelmingly the greatest improvement has been with the use of
liposomal bupivacaine, which has demonstrated overall reduction of
pain scores and greater interval in opioid usage in the postoperative
period.
SPECIAL SITUATIONS AND
COMPOUNDING CONDITIONS
Pregnancy
Pregnant patients are susceptible to increased hemorrhoid symptoms
because of the complex physiologic changes that result in increased
intraabdominal pressure and reduced venous return. Labor-related
straining further complicates the problem. Bleeding and pain are the
most common symptoms, and symptoms present at any time during
pregnancy, but most often in the third trimester.
Treatment is almost always conservative and nonoperative as
most hemorrhoid symptoms will regress in the postpartum period.
Unless the hemorrhoids are thrombosed or strangulated, surgery
should be avoided. Stool softeners, sitz baths, and cooling ointments
should be used liberally.
Portal Hypertension
PH is another condition that will result in increased rectal bleeding,
and many of these patients have rectal varices on examination that
may resemble hemorrhoids. Bleeding in the setting of PH should be
treated conservatively. RBL is contraindicated because of the risk of
delayed bleeding. Sclerotherapy and suture ligation of the hemorrhoids can be offered if conservative therapy fails. Ultimately, reducing portal pressure with a transjugular intrahepatic portosystemic
shunt is the terminal procedure. Caution should be taken to avoid
any bedside or office-based procedures in these patients because
bleeding, even from small injection sites, can be brisk and difficult
to control.
Immunocompromised Patients
Managing hemorrhoid symptoms in immunocompromised patients
can be challenging. Conservative measures are first line as the risk
of poor wound healing and pelvic sepsis is increased after surgical
hemorrhoidectomy in this cohort. For patients on immunosuppressants that can be stopped, preference is to have 1 week off medication
before the procedure. In patients with poorly controlled HIV or
AIDS, sclerotherapy is the procedure of choice. Preprocedure antibiotics should be considered in this population and discussed with
the patient and the patient’s other physicians. Patients with well-controlled HIV have a risk similar to non-HIV patients.
Crohn’s Disease
In patients with Crohn’s disease, symptomatic hemorrhoids are rare.
Symptoms are more likely related to the Crohn’s disease when a
careful history and examination are made. Anal fissure and anorectal
abscess are much more common than symptomatic hemorrhoids.
Treatment should always be conservative, and maximal management
of the Crohn’s disease is imperative. Elective operations for hemorrhoids in patients with proctitis should be avoided. Acute, painful
thrombosis may be excised with a small incision.
SUMMARY
Hemorrhoidal disease is very common among adults in the United
States given the incidence of constipation and low-fiber diet. Symptoms must be carefully elucidated by the physician, and a thorough
physical examination and anoscopy are crucial to confirming the
diagnosis. Colonoscopy should be ordered to confirm outlet bleeding and rule out proximal source. Conservative management with
dietary and lifestyle changes are the mainstay of treatment in every
patient. Fiber supplementation and proper toilet hygiene are imperative. When failure of conservative therapy is noted, patients with
grade I to II hemorrhoids and some with grade III will benefit from
office-based procedures. They can be repeated safely to obtain optimal results. Those with grade III and IV hemorrhoids or who fail
office-based procedures have multiple surgical options depending
on anatomy and patient preference. The operation should be tailored
to the patient. Care should be taken when managing patients with
special circumstances as not every procedure is suitable.
S u g g e S t e d R e a d i n g S
Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American
Society of Colon and Rectal Surgeons Clinical Practice Guidelines for
the Management of Hemorrhoids. Dis Colon Rectum. 2018;61:284–292.
Luchtefeld M, Hoedema RE. Hemorrhoids. In: Steele S, Hull T, Read T,
Saclarides T, Senagore A, Whitlow C, eds. The ASCRS Textbook of Colon
and Rectal Surgery. Cham: Springer; 2016.
Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy
for patients with symptomatic hemorrhoids. Cochrane Database Syst Rev.
2009(1):CD006761.
Pakravan F, Helmes C, Baeten C. Transanal open hemorrhoidopexy. Dis Colon
Rectum. 2009;3:503–506.
Perera N, Liolitsa D, Iype S, etal. Phlebotonics for haemorrhoids. Cochrane
Database Syst Rev. 2012(8):CD004322.
Watson AJ, Hudson J, Wood J, et al. Comparison of stapled hemor-
rhoidopexy with traditional excisional surgery for hemorrhoidal disease
(eTHoS). A pragmatic, multicenter randomized controlled trial. Lancet.
2016;388(11):2375–2385.
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Management of
Fissure-In-Ano
Vernissia Tam, MD, MS, and Heather L. Yeo, MD, MHS
INTRODUCTION
Anal fissures are one of the most common conditions seen in a
colorectal surgery practice. Patients present with sharp tearing or
cutting pain during and after bowel movements, often accompanied
by hematochezia. The pathogenesis is believed to be precipitated
by hard stool or diarrhea passing through the anal canal, causing
mucosal trauma. The trauma causes pain and tightening of the
sphincter. Increased sphincter tone and decreased blood flow along
with repeated trauma prevent fissures from healing, forming the key
targets for treatment.
On anorectal examination, 75% to 90% are located in the posterior midline, and acute fissures appear as a longitudinal tear in the
anal canal, distal to the dentate line (Fig. 1A). After 6 to 8 weeks,
chronic fissures may present with a skin tag or sentinel pile, with
exposed fibers of the internal sphincter visible at the base, and
heaped-up granulation tissue at the edges (Fig. 1B). Up to 20% may
be located in the anterior midline, and off-midline fissures should
prompt evaluation into other underlying infectious, immunosuppressive, or malignant etiologies (Fig. 1C).
NONOPERATIVE MANAGEMENT
Dietary and Lifestyle Modifications
There is no single recommendation for treatment that is best for all
patients. Nonoperative treatment success will partially depend on
patient compliance with lifestyle modifications and topical agents.
The decision to escalate to surgery involves the degree of improvement with conservative measures, the risk for incontinence, and
patient preference. For severely symptomatic patients who do not
have risk factors for incontinence and can accept a small risk of
long-term incontinence, surgery may be offered up front for the
highest likelihood of healing and lowest risk of recurrence. It is our
preference to only use this in very select cases.
Over 50% of acute fissures will resolve with conservative measures and warrant a trial of nonoperative management. Initial recommendations include increased fiber intake (25 to 35 g per day)
via diet or supplements, increased hydration, and warm sitz baths.
Fiber combined with sitz baths alone has been reported to heal up
to 87% of acute fissures. The combination of these conservative
measures with a topical analgesic (e.g., 2% lidocaine, EMLA cream)
and a sphincter relaxant is a reasonable first-line treatment. Failure
of symptoms to improve in 6 to 8 weeks warrants reevaluation and
escalation of treatment. A biopsy should be performed on all longstanding fissures to rule out malignancy.
A
C
B
FIG. 1 (A) Acute posterior midline
fissure. (B) Chronic fissure with sentinel
tag. (C) Off-midline fissure associated with
Crohn’s disease. (B and C courtesy Dr. Kelly
Garrett.)
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Topical Sphincter Relaxants
Topical nitroglycerin releases nitric oxide and relaxes the internal
anal sphincter (IAS), producing healing rates between 49% and
68%. Doses between 0.2% and 0.8% can be applied 2 to 4 times per
day. However, effects are short-lasting (approximately 90 minutes),
which may require diligence and frequent reapplication. The most
significant side effect is headaches and lightheadedness, which may
be mild to severely disabling and can lead to noncompliance and
cessation of treatment.
Topical gels containing nifedipine or diltiazem similarly relax the
internal sphincter and encourage blood flow. Oral doses are available
but may lead to orthostatic hypotension. Studies comparing topical
nitrates to calcium channel blockers have showed conflicting results,
and both are considered equivalent, with selection largely based on
provider preference and pharmacy availability. We prefer a dose of 2%
to 5% topical diltiazem cream applied 2 to 3 times daily. If tolerated,
oral doses of 60 mg twice-daily have been successfully described.
Chemical Denervation
Botulinum A toxin (Botox, Allergan Inc.) chemically paralyzes
the internal sphincter, which lowers the resting anal pressure and
increases blood flow. Injections can be performed as an outpatient
or clinic-based procedure. We prefer treatment with 60 to 100 units
diluted in 2 to 5 mL sterile saline solution. Four divided doses are
injected into the intersphincteric groove directed toward the IAS
in four quadrants. Depending on sphincter tone, another 1 mL is
injected on either side of the fissure (Fig. 2).
Effects of Botox are not compromised with patient noncompliance, and results are longer-lasting than topical relaxants. However,
the long-term durability of cure is not as clear, and recurrence has
been reported to be as high as 40% at 4 years. Nevertheless, there are
decreased rates of permanent incontinence compared with surgical
sphincterotomy. In a Cochrane review of nonsurgical therapy for anal
fissure including 23 studies and 1236 patients, topical nitroglycerin
was found to be better than placebo in healing fissures (49% vs. 36%, P
< 0.0009), though nearly 50% of those initially cured had a recurrence.
Botox and calcium channel blockers were equally efficacious to nitroglycerin and benefited from fewer adverse events. Overall, no medical
therapy approached the superior efficacy of surgical sphincterotomy.
OPERATIVE MANAGEMENT
Manual dilation of the sphincter muscle using fingers, various retractors, and pneumatic balloons has been abandoned secondary to poor
outcomes including incontinence, recurrence, trauma, and patient
discomfort. Fissurectomy has been proposed to address the chronic
anatomic changes that may prevent a fissure from healing. Minimal
debridement or “trimming” eliminates the fibrosis, sentinel pile, and
rolled edges back to healthy tissue that may encourage a fissure to heal.
It has limited success when used alone but may be performed in conjunction with chemical denervation, sphincterotomy, or advancement
flaps.
Lateral Internal Sphincterotomy
LIS is the gold standard surgical treatment for chronic fissures, offering the highest rates of healing (up to 95%) and low recurrence with
durable results. It can be performed as an open or closed approach,
with equivalent rates of healing and recurrence. In a Cochrane
review of 2056 patients in 27 studies analyzing 13 different procedures, there was no difference between open versus closed LIS in
fissure persistence and incontinence risk.
In the open approach, a small radial incision is made over the
intersphincteric groove. The internal sphincter muscle is dissected
out and exposed before dividing under direct visualization (Fig. 3).
The overlying incision can then be closed with an absorbable suture.
Our group favors the closed approach. In the closed approach, a
blade is inserted in the intersphincteric groove parallel to the muscle
fibers. The blade is then turned 90 degrees, and the IAS muscle fibers
are divided against a finger inserted into the anal canal, without
going through the mucosa. Manual spreading of the divide fibers
in a gentle sweeping motion in the anal canal can confirm adequate
division and separation (Fig. 4). The cut typically includes all fibers
below the dentate line.
The overall rate of transient disturbed continence from a systematic review was 14% among over 4500 patients, with <1% reporting
accidental defecation or stool seepage. Although there are some studies reporting higher rates of permanent incontinence following the
open technique, results are inconsistent, and both open and closed
sphincterotomies are well-accepted approaches.
To reduce the risk of incontinence, a tailored sphincterotomy
has been proposed by dividing the IAS to the height/internal apex
of the fissure, rather than the dentate line, which may result in
excessive division. This approach should be considered in populations at higher risk for postoperative incontinence, including
women who may have shorter anal canals and less muscle, multiple
vaginal deliveries, or prior obstetric injuries; individuals with other
sphincter or perineal injuries; and individuals with inflammatory
bowel disease.
FIG. 2 Chemical denervation. (A) Palpation of
the intersphincteric groove with a lubricated
finger guides (B) injection in four quadrants.
(From Braasch JW, Sedgwick CE, Veidenheimer
MC, Ellis H, eds. Atlas of Abdominal Surgery.
Philadelphia: Saunders; 1991:199)
A
B
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