Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
.pdf
378
https://t.me/med1917
Fig. 7 Final incision
S. Sharma and J. T. Saraidaridis
2.2 Postoperative Care
Following denitive stula repair, patients are recovered in the recovery room. They
are asked to void prior to discharge. Pain control is emphasized with non-opioid
options and narcotics as needed. Patients are typically followed for 3–4months to
assess healing.
2.3 Common Complications
ure of stula repair, or stula persistence. Patients should be followed for a minimum of 3months following repair to assess for persistence and recurrence. Fistula
repair wounds often include signicant amounts of drainage and granulation tissue,
which can cloud the issue.
Anorectal Fistula Repair
https://t.me/med1917
379
be observed, but large scale bleeding requires EUA.
retention following surgery. Patients should be made to void prior to discharge from
the recovery room.
their continence following denitive stula repair. It is essential that patients are
counselled appropriately regarding this risk pre-operatively.
References
1. Malik AI, Nelson RL.Surgical management of anal stulae: a systematic review. Color Dis.
2008;10(5):420–30.
2. Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal abscess, stula-in-ano, and rectovaginal stula. Dis Colon Rectum.
2016;59(12):1117–33.
3. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA.Prospective comparison of faecal incontinence
grading systems. Gut. 1999;44(1):77–80.
4. Buchanan GN, Williams AB, Bartram CI, Halligan S, Nicholls RJ, Cohen CR. Potential
clinical implications of direction of a trans-sphincteric anal stula track. Br J Surg.
2003;90(10):1250–5.
5. Cirocco WC, Reilly JC.It is time to retire Goodsall’s Rule: the Midline Rule is a more accurate
predictor of the true and natural course of anal stulas. Tech Coloproctol. 2020;24(4):317–21.
6. Cirocco WC, Reilly JC.Challenging the predictive accuracy of Goodsall’s rule for anal stulas. Dis Colon Rectum. 1992;35(6):537–42.
7. Sahebally SM, O’Byrne L, Troy A, Byrnes KG, Burke J, McNamara D.A meta-analysis
of marsupialisation versus none in the treatment of simple stula-in-ano. Int J Color Dis.
2021;36(3):429–36.
8. Hall JF, Bordeianou L, Hyman N, etal. Outcomes after operations for anal stula: results of a
prospective, multicenter, regional study. Dis Colon Rectum. 2014;57(11):1304–8.
9. Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K.Total anal sphincter saving technique for stula-in-ano; the ligation of intersphincteric stula tract. J Med Assoc Thail.
2007;90(3):581–6.
10. Parthasarathi R, Gomes RM, Rajapandian S, etal. Ligation of the intersphincteric stula tract
for the treatment of stula-in-ano: experience of a tertiary care centre in South India. Color
Dis. 2016;18(5):496–502.
11. Bleier JI, Moloo H, Goldberg SM.Ligation of the intersphincteric stula tract: an effective
new technique for complex stulas. Dis Colon Rectum. 2010;53(1):43–6.
12. Laird DR.Procedures used in treatment of complicated stulas. Am J Surg. 1948;76(6):701–8.
13. Madbouly KM, El Shazly W, Abbas KS, Hussein AM.Ligation of intersphincteric stula tract
versus mucosal advancement ap in patients with high transsphincteric stula-in-ano: a prospective randomized trial. Dis Colon Rectum. 2014;57(10):1202–8.
14. Uribe N, Balciscueta Z, Cuneo B, etal. Long-term functional and clinical outcomes following
transanal advancement ap for complex anal stula repair: are there predictors of recurrence
and incontinence? Color Dis. 2020;22(11):1649–57.
Hemorrhoid Management
https://t.me/med1917
S.ThomasKang andRobertHollis
1 Indications
Hemorrhoids are a normal anatomic structure within the anal canal. They are
believed to aid in continence. Anatomically, three hemorrhoidal columns are classically described: left lateral, right anterior, and right posterior. Increased intraabdominal pressure and straining (i.e. chronic coughing from COPD, constipation) as
well as increased venous pressure preventing blood return (i.e. pregnancy, cirrhosis,
toilet straining) seem to contribute to hemorrhoidal engorgement can contribute to
hemorrhoidal engorgement and subsequent pathology. Common presenting symptoms include pruritis, prolapse, bleeding, difculty with hygiene, thrombosis, and
pain. Of these, the most frequent complaint is painless bleeding. Though often
insignicant, hemorrhoidal bleeding can cause anemia and in specic circumstances
may be life-threatening [1].
As with any disease process, careful history and physical are paramount.
Surgeons should maintain a wide differential during any initial evaluation including
anal ssure, inammatory bowel disease (i.e. Crohn’s disease), malignancy, and
stula-in-ano. Multiple anorectal pathologies can present simultaneously, and treatment of hemorrhoidal disease will be altered by these other pathologies [2].
Hemorrhoids are categorized into internal and external hemorrhoids delineated
by the dentate line. Patients may have both internal and external components to their
hemorrhoidal disease. On physical exam, internal hemorrhoids can be identied by
the presence of columnar mucosa whereas external hemorrhoids will have anoderm.
Internal hemorrhoids are further classied by the level of prolapse from grade 1
S. T. Kang (*) · R. Hollis
Department of Surgery, Division of Gastrointestinal Surgery,
University of Alabama– Birmingham, Birmingham, AL, USA
e-mail: rhollis@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_32
381© The Author(s), under exclusive license to Springer Nature
382
https://t.me/med1917
Table 1 Classication of internal hemorrhoids and classic symptoms
1st degree 2nd degree 3rd degree 4th degree
Description Engorged
hemorrhoid
within the
anal canal
Frequent
associated
symptoms
Painless
bleeding
Engorged
hemorrhoid that
protrudes with
straining/bowel
movement but
reduces
spontaneously
Perianal itching,
irritation
Engorged
hemorrhoid that
protrudes with
straining/bowel
movement and
requires manual
reduction
Mucus leakage,
perianal irritation/
itching, feeling of
incomplete
defecation, fecal
seepage, challenge
with perianal
hygiene
S. T. Kang and R. Hollis
Prolapsed
irreducible
hemorrhoids
Painless vs painful
bleeding, mucus/
stool leakage,
perianal irritation/
burning/itching,
difculty with
perianal hygiene
through 4 (Table1). Grade 1 is characterized by internal hemorrhoids bulging into
the anal canal often associated with painless bleeding. Grade 4 hemorrhoids are
dened as prolapsed tissue that’s unable to be reduced and are at risk for strangulation. Notably, these grades are based on patient reported symptoms as opposed to
physical exam, though exam ndings can help suggest which grade hemorrhoids the
patients are experiencing (i.e. exam ndings of non-reducing prolapsed internal
hemorrhoid conrming grade 4 disease) [1, 2].
Hemorrhoidal treatment should focus on relieving the specic symptoms that the
patient is experiencing. It must be emphasized during consultation that any intervention should be directed at improving patient symptoms; asymptomatic prolapsing hemorrhoids do not require excision. Complications of hemorrhoidectomy,
while rare, can include anal stenosis, fecal incontinence, and stula-in-ano. As such,
starting medical management as an initial therapy is prudent including lifestyle
changes such as ber supplementation, avoidance of prolonged time on the toilet
and straining, staying hydrated, and stool softeners [2].
2 Treatment
2.1 Medical
Treatment of hemorrhoidal disease is targeted at symptom relief. One of the most
commonly prescribed medications is ber supplementation. Fiber is an unabsorbed
carbohydrate that works to draw in water to the stool, preventing hard bowel movements, and also can provide bulk to loose stools. Dietary guidelines suggest consumption of 25 to 50g of ber per day, which can be challenging based purely on a
typical Western diet. Over-the-counter options such as methylcellulose and psyllium are helpful adjuncts to achieve adequate ber supplementation goals. Patients
Hemorrhoid Management
https://t.me/med1917
should be informed that ber supplementation has the best impact on stools when
taken with adequate hydration. Use of Sitz baths, NSAIDs, and topical therapies
such as steroidal and lidocaine creams can provide additional non-invasive symptomatic relief [2]. Topical therapies should typically be limited to no longer than
7days as extended application can exacerbate perianal irritation, and thinning of the
anoderm can occur with prolonged topical steroids [3, 4].
383
2.2 Procedures
Surgical interventions for hemorrhoidal disease can broadly be divided into ofcebased and operating room-based procedures. In the operative theatre, moderate
sedation or general anesthesia can be advantageous. In-ofce procedures are limited
to use of local anesthetics and should typically only target internal hemorrhoid
pathology above the dentate line. Due to the lack of somatic sensory innervations
within the anal canal above the dentate line, procedures performed above it should
not cause pain but can cause some mild discomfort or sensation of fullness in the
rectum. Positioning for in-ofce procedures, such as for hemorrhoidal band ligation
may be performed in left lateral decubitus or prone jackknife positions. The authors’
preference is jackknife position for optimal exposure. In the operating theatre,
patient positioning may either be in lithotomy versus prone jackknife [2].
There are no specic dietary restrictions before ofce-based interventions. When
bowel preparation is deemed necessary, it most often includes provision of two
eets or water-based enemas to clear the distal rectum of stool either in ofce or the
morning prior to operative procedures [2].
For operating room-based procedures under anesthesia, patients will need to be
nil-per-os (NPO) and perioperative management of any other medical co- morbidities
must be considered. As hemorrhoidal procedures are generally low-risk for most of
the population, no specic preoperative workup is typically warranted. However,
specic patient conditions such as anticoagulation status and any pre-existing liver
disease should be noted and addressed accordingly. Surgical site infection is very
rare after hemorrhoidectomy and prophylactic antibiotics are usually not indicated
[5]. Pressure points should be off-loaded when positioning the patient. The anal and
perianal surgical area can be prepared with betadine scrub if no allergies are listed.
Perianal anesthetic blocks are routinely applied.
2.3 Ofce-Based
2.3.1 Rubber-Band Ligation
Best-suited for 1st, 2nd, and small 3rd degree hemorrhoids, rubber-band ligation is
a quick and effective procedure that can easily be done in the ofce setting. Using a
slotted anoscope or an anal speculum, the internal hemorrhoidal tissue is bunched
384
https://t.me/med1917
S. T. Kang and R. Hollis
into the slot of the anoscope. The apex can then be either grasped or suctioned to
allow application of the rubber band to the column, cause ischemia, necrosis, and
scarring. Patients may report rectal fullness and over the ensuing days pass sloughed
mucosa. If extreme pain occurs immediately upon placement of the band, it is likely
the provider placed the band below the level of the dentate line and the band should
be removed. It is typically not recommended to band more than 1 to 2 internal hemorrhoidal columns at a time, and more than one banding session at separate clinic
visits may be necessary. A very rare complication of pelvic sepsis should be mentioned to patients during consent and to seek further evaluation if fevers were to
develop. Banding should not be performed on patients actively taking anticoagulants or patients with cirrhosis [1, 2, 6].
2.3.2 Sclerosis
The principle behind sclerotic injection therapy is to administer an agent that causes
scarring of the hemorrhoid. Appropriate for 1st through 3rd degree internal hemorrhoids, 1 to 5mL of sclerosing agent (i.e. 5% phenol in oil or hypertonic saline) is
injected submucosally into each hemorrhoidal column [7]. In males, special care
should be taken for anterior hemorrhoidal injections as the prostate or periprostatic
venous complex could be injured. This therapy is often considered in cirrhotic
patients with refractory symptoms or in patient who are high risk for stopping any
anticoagulant therapy [2].
2.3.3 Infrared/Laser Coagulation
A therapy best suited for 1st and 2nd degree hemorrhoids, the tip of a beroptic
probe is applied through an anoscope to the apex of the hemorrhoid pedicle and
infrared radiation coagulates the vascular plexus. Laser coagulation involves doppler ultrasound to help target superior hemorrhoid arteries approximately 3 cm
above the dentate line [2, 6]. This therapy is not routinely performed across the
United States, but can be considered in well-equipped centers with prior experience.
2.3.4 Incision andEvacuation ofThrombosed External Hemorrhoid
Patients with thrombosed external hemorrhoids most often present with a history of
abrupt onset of anal pain with an associated perianal lump or swelling. Physical
exam ndings can reveal a swollen, edematous, discolored external hemorrhoid as
shown in Fig.1. Treatment of a thrombosed external hemorrhoid is often dependent
on the patients symptoms at the time of presentation which will generally peak at
intensity on day three after onset. In patients with symptoms that are improving,
conservative management with sitz baths, ber supplementation, and lidocaine
creams are provided. In patients with ongoing or worsening pain with physical
exam ndings showing presence of an acute thrombosis, incision and evacuation of
Hemorrhoid Management
https://t.me/med1917
Fig. 1 Thrombosed
hemorrhoids
385
the thrombosed external hemorrhoid in the clinic ofce can provide symptomatic
relief. For this procedure, local anesthetic is rst applied in the area of the thrombosed hemorrhoid. A knife is then used to incision over the tense clot within the
hemorrhoid, allowing it to be evacuated with easy manual manipulation. Bleeding
is typically not an issue due to the thrombosed nature of the hemorrhoid and can be
controlled with manual pressure, silver nitrate, or suture if necessary. For patients
with large, thrombosed hemorrhoids or who cannot tolerate an in-ofce procedure,
hemorrhoidectomy in the operating room may be considered.
2.4 Surgical
2.4.1 Open andClosed Hemorrhoidectomy
Excisional approaches to hemorrhoids are generally recommended as the last resort
as discomfort from the operation can last several weeks. Open hemorrhoidectomy,
also known as the Milligan-Morgan hemorrhoidectomy, is best suited for highly
symptomatic and/or Grade III and IV hemorrhoids [2].
386
https://t.me/med1917
S. T. Kang and R. Hollis
The initial step to either open or closed hemorrhoidectomy involves visualizing
the hemorrhoidal columns using an anoscope. With the hemorrhoid grasped to provide tension, an elliptical incision is made proximal to the anal verge and dissection
proceeds proximally towards the dentate line separating the hemorrhoid tissue from
the underlying internal sphincter. This dissection can either be done sharply or using
electrocautery. The dissection proceeds towards the hemorrhoidal pedicle just above
the dentate line at which point the pedicle is suture-ligated. In the open hemorrhoidectomy, the hemorrhoid bed is left open to heal by secondary intention after achieving hemostasis [2, 8].
Closed hemorrhoidectomy (the Parks or Ferguson hemorrhoidectomy) is performed much in a similar manner to open hemorrhoidectomy. The difference is
after suture ligation of the pedicle, the same suture is used to re-approximate the
mucosal edges in a running (simple or locking) fashion. About 3–4 mm of the
distal-most incision may be left open to promote drainage. It is crucial to re-align
the edges properly so as to not cause ectropion or bothersome external skin
tag [2, 8].
When performing hemorrhoidectomy of more than one column, it is imperative
to ensure that a bridge of skin be maintained between each excised column in order
to prevent anal stenosis. The risk for anal stenosis is highest when hemorrhoidectomy is performed for multiple columns of thrombosed external hemorrhoids, and
surgeons should be mindful when deciding to perform hemorrhoidectomy under
these circumstances [2, 9].
2.4.2 Transanal Hemorrhoidal Dearterialization (THD)
THD utilizes a specialized anoscope equipped with a doppler to locate the terminal
6–8 branches of hemorrhoidal arteries and apply suture ligation. Mucosal redundancy is addressed via mucopexy by running the suture used for suture ligation of
the hemorrhoid artery down to the dentate line and tying back to the knot at the prior
suture ligation, drawing redundant tissue back into the anal canal. Recurrence rate
as high as 50–60% have been reported although this is based on short-term follow
up. Because no tissue is excised and sutures are placed above the dentate line, the
THD procedure has been advertised to have less pain compared to hemorrhoidectomy. Trials comparing postoperative pain, quality of life, and bowel function have
not shown signicant differences between THD and hemorrhoidectomy, albeit these
are short-term results [8].
2.4.3 Ligasure andHarmonic Scalpel Hemorrhoidectomy
Excisional hemorrhoidectomy can also be performed using energy devices and has
been compared to traditional hemorrhoidectomy. Depending on the study, shortterm results indicate decreased operative time, blood loss and pain. Ligasure
Hemorrhoid Management
https://t.me/med1917
387
hemorrhoidectomy can signicantly reduce operative times, yet the increased cost
for the energy device justies this shortened operative time is often determined by
each individual operative center and surgeon [10, 11].
2.4.4 Stapled Hemorrhoidopexy/Procedure forProlapsed
Hemorrhoids (PPH)
Aimed at removing redundant prolapsing mucosa and stapling off the feeding hemorrhoid vessels, PPH stems from Whitehead’s hemorrhoidectomy. Whitehead’s
hemorrhoidectomy historically included circumferential excision of the hemorrhoidal tissue and suture approximation of the anal mucosa to the dentate line. This
procedure is no longer performed as it has been associated with high rates of anal
stenosis, among other complications like ectropion [1]. PPH uses a circular stapling
device that allows the surgeon to place a purse string via an anoscope about 4–5cm
proximal to the dentate line [2]. The anvil and the stapler are inserted peranus and
the purse string draws the internal hemorrhoids and mucosa into the device. The
stapler excises redundant mucosa and re-approximates the tissue. Initially, PPH was
associated with complications like rectal occlusion, pelvic sepsis, chronic pelvic
pain, and rectal perforation. Meta-analyses comparing PPH and excisional hemorrhoidectomy have not demonstrated a clear advantage to PPH over traditional hemorrhoidectomy with regards to postoperative pain [12]. In addition, PPH was shown
to have increased symptoms of prolapse, need for additional operation for recurrence at 1year. As a result, many surgeons have removed PPH from their practice.
2.4.5 Special Postoperative Issues
Excisional hemorrhoidectomy can be quite uncomfortable for the patients especially in the rst few weeks from the operation. Multimodal pain regimen using
acetaminophen, NSAIDs, and narcotics can help circumvent postoperative pain in
addition to the routine use of perianal local anesthetic during operative procedures.
Maintaining soft stools and avoiding constipation are paramount to prevent exacerbation of pain, non-healing wounds or recurrent hemorrhoidal symptoms in the long
term [2, 8]. The authors routinely recommend once to twice daily MiraLAX for
30days after the procedure. Other adjuncts include Sitz baths, muscle relaxant, and
topical analgesics. Urinary retention can be prevented by minimizing intravenous
uid during the operation, and patients can consider simple measures such as warm
baths/showers to help relax the pelvic oor if experiencing symptoms while at
home. Patients should be counseled on signs and symptoms including fever, severe
pelvic pain, purulent discharge, and acute urinary retention that can signify pelvic
sepsis. Postoperative bleeding may occur, and patients can be counseled on easy
methods to address slow bleeding at home such as applying pressure to the perianal
area by sitting on a rolled towel in a hard-seated chair.
388
https://t.me/med1917
S. T. Kang and R. Hollis
3 Summary
Hemorrhoid disease is one of the most common anorectal pathologies. Surgical
evaluation should include careful history and physical exam to pinpoint patient
symptoms and pathology. Treatment of hemorrhoids should center around individualized discussions for symptom relief.
References
1. Cameron JL, Cameron AM, et al., editors. Current surgical therapy. 13th ed. Philadelphia:
Elsevier; 2020.
2. Steele SR, etal., editors. The ASCRS textbook of colon and rectal surgery. 4th ed. Cham:
Springer; 2022.
3. Cusano F, Luciano S.Contact dermatitis from pramoxine. Contact Dermatitis. 1993;28(1):39.
4. Kawanda A, et al. Fixed drug eruption induced by lidocaine. Contact Dermatitis.
1996;35(6):375.
5. Nelson DW, Champagne BJ, et al. Prophylactic antibiotics for hemorrhoidectomy: are they
really needed? Dis Colon Rectum. 2014;57(3):365–9.
6. Townsend CM, et al., editors. Sabiston textbook of surgery: the biological basis of modern
surgical practice. 20th ed. Philadelphia: Elsevier; 2017.
7. ASGE Technology Committee. Devices for the endoscopic treatment of hemorrhoids.
Gastrointest Endosc. 2014;79(1):8–14.
8. Mulholland MW, etal., editors. Operative techniques in surgery. Philadelphia: Wolters Kluwer
Health; 2015.
9. Milsom JW, Mazier WP.Classication and management of post-surgical anal stenosis. Surg
Gynecol Obstet. 1986;163(1):60–4.
10. Nienhuijs S, de Hingh I.Conventional versus LigaSure hemorrhoidectomy for patients with
symptomatic hemorrhoids. Cochrane Database Syst Rev. 2009;1:CD006761.
11. Fleshman J.Advanced technology in the management of hemorrhoids: stapling, laser, harmonic scalpel, and ligasure. J Gastrointest Surg. 2002;6(3):299–301.
12. Lumb KJ, Colquohoun PH, Malthaner R, Jayaraman S.Stapled versus conventional surgery
for hemorrhoids. Cochrane Database Syst Rev. 2006;4:CD005393.
Соседние файлы в папке Библиотека им академика М.И. Перельмана