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_890_Библиотеки_им_академика_М_И_Перельмана.pdf
324
S.D. Holubar and D.E. Rivadeneira
Fig. 20.12 Acute thrombosed hemorrhoid following banding
(Courtesy of Richard Billingham, MD)
Pain
Discomfort and pain after rubber band ligation is common
(5–60 %), but severe pain uncommon is estimated to occur in
approximately 5 % and may be related to either anospasm or
from placing the bands too close to the dentate line. In general, bands should be placed at least 1–2 cm proximal to the
dentate line. If this is the case, the band should be immediately removed with a small blade. Occasionally, especially
when patients re-present several hours later, there may be
acute swelling that mandates examination under anesthesia
to both remove the band and rule out signs of sepsis. Pain
may also result from overzealous examination and resultant
acute anal fi ssure. Typically this will get better on its own
quickly, though may benefi t from topical pain medications
such as lidocaine.
In a prospective study of over 512 patients, 2.5 % were
hospitalized—half due to delayed massive bleeding, the others for fever and urinary retention, and three with severe pain
due to acute thrombosis of external hemorrhoids (Fig. 20.12 )
39 ]. In this series, another 4.6 % developed minor complica-
[
tions, almost half of these for thrombosed external hemorrhoids, and even several for priapism.
Bleeding
After banding, bleeding may be immediate or delayed, minor
or massive [ 40 ].
Some surgeons suggest that patients who are on anticoagulants or antiplatelet agents are best managed by excisional hemorrhoidectomy as compared with rubber band
ligation as the excisional technique hemostasis would seem
to be more reliable to avoid delayed bleeding. However, at
least one large study suggests the risk of bleeding to be low
(1–2 %) even if these medications are not held, with the
exception of Plavix, which accounted for 50 % of the bleeding episodes [ 41 ]. In general, banding on anticoagulation
medications and most antiplatelet agents is a relative contraindication [
1 ].
Vasovagal Symptoms and Syncope
Placing patients in steep Trendelenburg’s position for the
several minutes required for exam and band placement, as
well as the stress and severe embarrassment some patients
experience, may result in vasovagal symptoms and even syncope. It is wise to have smelling salts within reach of the
providers so as to recognize pre-syncope and hopefully avoid
a traumatic fall off the table.
Sepsis
Often discussed but rarely observed, perianal sepsis from
rubber band ligation has been reported to result in need for
fecal diversion and potentially death, largely due to overwhelming sepsis from Fournier’s gangrene. Of note, this has
also been observed after excisional hemorrhoidectomy and
PPH [ 42 ]. You must be familiar with presenting signs and
symptoms, which include delayed urinary retention, fever,
worsening/severe pain, excessive drainage, and shock. We
tell our patients if they experience any one of these to report
to the emergency department. Work-up may reveal leukemoid reaction and extraluminal (retroperitoneal) gas and
fl uid collections. Examination may range from relatively
normal or a small amount of edema/infl ammation to cellulitis and gangrene (Fig. 20.13 ). Given the potential for disas-
trous outcomes, broad-spectrum antibiotics and prompt
examination under anesthesia with debridement of necrotic
tissue are recommended (Fig. 20.14 ).
Recurrence
The durability of rubber band ligation is known to be inferior
to excisional hemorrhoidectomy, especially for grade III disease. In many ways, recurrence can be more of an anticipated
outcome than a complication, and patients should be counseled thusly [ 43 ]. Given a recurrence, we should note that
prior banding is generally not a contraindication to additional banding. In fact, most banding patients are satisfi ed
with this treatment option. The impact of disease on the
patient’s quality of life and ability to tolerate the increased
time off work and pain associated with excisional
he morrhoidectomy need to be reassessed prior to choosing
the next treatment option. Nonetheless, re-banding is
generally safe and moderately effi caciousness as reported by
20 Hemorrhoidal Disease: Postoperative Complications
Fig. 20.13 Fournier’s gangrene
with cellulitis and
ischemia (Courtesy of Philip
Y. Pearson, MD)
325
Fig. 20.14 Wide debridement of Fournier’s gangrene (Courtesy of
Philip Y. Pearson, MD)
Iyer et al. [ 44 ]. In their series of 805 patients and 2,114
bands, symptoms were successfully treated in 60–74 % of
recurrences, with an overall cumulative success rate of 80 %.
Stapled Hemorrhoidopexy (PPH)
Indications: When Should We Be Using This Procedure?
Key Concept: There are a wide variety of opinions on the
utility of stapled hemorrhoidopexy.
As mentioned in the surgical decision-making section
earlier in the chapter, due to its increased recurrence rate,
PPH should be used selectively as an alternative to conventional or bipolar excisional hemorrhoidectomy in patients
with circumferential grade III hemorrhoidal disease without
an especially large external component. PPH may also potentially be used in early grade IV hemorrhoidal disease, though
we do not use it in these cases, or in the presence of gangrenous hemorrhoids (Fig. 20.15 ).
Pescatori et al. reviewed the literature on severe complications of PPH including chronic pain, rectal luminal obliteration, rectovaginal fi stula, pelvic sepsis, and need for
proximal fecal diversion [ 45 ]. Their review found that
fourth-degree hemorrhoidal disease was a relative contraindication to PPH as the results are worse and complications
rates higher than in third-degree disease. Another relative
326
S.D. Holubar and D.E. Rivadeneira
complication is poor sphincter function, while anticipated
future anoreceptive intercourse, enteroceles, and anismus are
absolute contraindications. Complications after PPH are
summarized in Table 20.9 [ 35 , 45 , 46 ]. Overall urinary reten-
tion is most common. Among the others:
Chronic Pain
Pain and tenesmus after PPH can be a chronic problem after
PPH. Cheetham et al. reported on 16 patients who were followed for over 6 months, and 1/3 had pain and urgency
which lasted for as long as 15 months [
patients had muscle incorporated into the donut (Fig.
47 ]. Most of these
20.16 ),
emphasizing the importance of mucosal only bites on the
purse-string suture .
Recurrence
One of the weaknesses of this minimally invasive approach
is that the long-term durability is questionable, especially
given the short- and medium-term results are inferior to that
of excisional hemorrhoidectomy [ 23 ]. In the Cochrane meta-
analysis, similar to the more recent meta-analysis described
above, the authors found that for all outcomes related to
recurrence, excisional hemorrhoidectomy was superior to
the PPH by an odds ratio of 2.7–3.6, although the proportion
of asymptomatic patients was no different between the procedures in this analysis. We also do not have experience in
performing repeat stapled hemorrhoidopexy (following an
initial PPH) but worry about leaving two staple lines close
together with a potentially ischemic area of mucosa between.
Sphincter Damage
The width (size) of the PPH device is 33 mm and the circular
anoscope up to 37 mm. Although this is slightly smaller than
Fig. 20.15 Gangrenous hemorrhoids
Table 20.9 Complications of stapled hemorrhoidopexy
Complication Frequency Possible preventive measures Management
Acute pain 26–60 % Avoid incorporating muscle Analgesics, sitz baths, tincture of time
Chronic pain
and/or urgency
(post- PPH
syndrome)
Rectal stenosis <21 % Fiber supplementation to avoid constipation-induced
Delayed
bleeding from
staple line
Recurrence 7.5 % Optimal patient selection, expectation management,
Sphincter
damage/
incontinence
Pelvic sepsis Rare Proper technique and patient selection but likely
Rectal
perforation
Rectal
obstruction
Rectovaginal
fi stula
5–31 % Avoid too low stapler placement, avoid
incorporating muscle. Mucosal-submucosal
purse- string/staple line should be in distal rectal
mucosa not anal canal
staple extrusion with subsequent fi brosis
1–13 % Completion anoscopy with suture ligation of
bleeders or hemostatic agents, i.e ., FloSeal
optimal technique
1 % Gentle serial dilation. Avoid in patients with
borderline continence
unpreventable
Rare All cases involved full-thickness wall rectal excision Resuscitation, broad-spectrum antibiotics, fecal
Rare Ensure proper purse-string suture placement so that
both are cut by the stapler
Rare Ensure anterior purse-string in mucosal-submucosal
and not full thickness. Double-check vagina before
fi ring stapler
the size of the transanal endoscopic microsurgical operating
Anti-infl ammatories, calcium channel blockers
Gentle digital rectal dilation without sedation
Assess for unrecognized coagulopathy, exam under
anesthesia, suture ligation
Lifestyle modifi cation, rubber band ligation, THD,
redo PPH, excisional hemorrhoidectomy?
Kegel exercises, pelvic fl oor retraining, bulking agents,
antimotility agents, others as appropriate
Broad-spectrum antibiotics, CT scan, exam under
anesthesia +/− laparotomy and fecal diversion
diversion
Exam under anesthesia, transanal or endoscopic
purse-strong cutting
Large/highly symptomatic: fecal diversion Small/
mildly symptomatic: transvaginal/endorectal
advancement fl ap(s)
20 Hemorrhoidal Disease: Postoperative Complications
327
Fig. 20.16 Stapled hemorrhoidopexy specimen demonstrating varying
degrees of thickness
proctoscope (40 mm), caution should still be used in those
patients with preexisting sphincter injury or fecal incontinence. For those without these contraindications, slow, gentle, serial dilation from one-fi nger breathe to the size of the
device is optimal. The other mechanism by which sphincter
damage during PPH may occur is by placing the purse-string
suture too deep. When fi red, especially when the stapler is
placed too low (i.e., in the anal canal), the staple line may
incorporate muscle fi bers. If this occurs, you have to fall
back on medical management of bulking and bowel-slowing
agents, and again, waiting to see their eventual function.
Too Low Stapler Placement: Post-PPH Syndrome
Proper technique suggests that the resulting staple line
should be approximately 2 cm proximal to the apex of the
hemorrhoidal bundles. Placing the purse-string and stapler
too low will result in inadvertent excision of the hemorrhoidal tissues. Given their bulkiness, this is likely to result
in an asymmetric resection of the mucosal ring that will
increase recurrence rate (Fig. 20.16 ). However, low stapler
placement may also cause internal sphincter spasm and
infl ammation, similar to low anterior syndrome following a
proctectomy. This is typically treated with anti-infl ammatory
agents per orum or per rectum but in rare cases may require
removal of the staples.
Bleeding
Bleeding from the staple line is relatively common after the
PPH device is fi red. This can be minimized by holding the
stapler for a minimum of 20 s before fi ring. Post-fi ring careful, circumferential anoscopy to assess for bleeding from the
staple line is a mandatory part of the procedure. We prefer a
placement of hemostatic 3–0 vicryl sutures perpendicular to
the staple line as needed to achieve optimal hemostasis.
Mongardini et al. reported on 197 PPH procedures in which
FloSeal™ was used as a hemostatic adjunct, instead of
hemostatic sutures on the suture line, and no major postoperative bleeding was observed, compared to 1.3 % in other
series [
48 ].
Preventing Complications
Key Concept: Like most things, it is often easier to avoid
complications than to manage them. Here are some helpful
tips we have found regarding hemorrhoid management.
Technical Tips: Excisional Hemorrhoidectomy
Avoid inadvertent excessive excision (cushions vs. anoderm):
In order to obtain the optimal exam under anesthesia, we recommend general anesthesia with neuromuscular blockade
(paralysis). Similarly a four-quadrant intersphincteric block
can aid in optimal exposure (we use a 50-50 mixture of
Marcaine and lidocaine). Preemptive perianal skin block
with this mixture may decrease postoperative discomfort.
However, you must keep in mind that local may distort the
normal anatomy, so consider using a marking pen to mark
the anoderm to be excised prior to instillation of local
anesthetic.
It should always be remembered and taught that the goal
of excisional hemorrhoidectomy is to excise the optimal
amount of hemorrhoidal cushions to prevent recurrence of
the symptoms, while overzealous anodermal excision will
invariably result in anal stenosis. When excising several columns, you should always leave a minimum of 1–2 cm of
anoderm between columns.
Reduce the risk of intraoperative bleeding: In order to
reduce the risk of bleeding during an excisional hemorrhoid-
ectomy, some surgeons choose to place a ligating/pexying
stitch at the apex of the hemorrhoidal bundle and nascent
specimen prior to excision to decrease bleeding during
excision.
Avoid sphincter injury: You can use large curved Mayo
scissors to push the sphincters down against the anorectal
wall during excision of the specimen to decrease likelihood
of injury to the underlying sphincter.
Optimal analgesia: Several adjuncts exist that can help to
reduce postoperative pain.
One includes performing a lateral internal sphincterotomy
at the same time as the hemorrhoidectomy [
49 – 55 ]. Data
328
S.D. Holubar and D.E. Rivadeneira
from randomized trials are few and have mixed results. In
our opinion, especially given long-term outcomes after
sphincterotomy for fi ssure with up to 10 % continence alternations, it cannot be recommended at present. Chemical
sphincterotomy with Botox or calcium channel blockers may
reduce pain in the fi rst postoperative week and may be a seasonable albeit costly alternative [
Several randomized trials have examined the role of electrosurgical devices such as the LigaSure™ or Harmonic
Scalpel™ to incrementally improve excisional hemorrhoidectomy. A meta-analysis from 2007 showed that although the
LigaSure may decrease operative time and blood loss, it does
so at increased cost without decrease in postoperative pain
[ 20 ]. Another medical device reported to reduce post-
hemorrhoidectomy are implantable local infi ltration systems
such as the On-Que™ and other pumps such as a subcutaneous morphine pump [
local availability, and cost all limit widespread adoption.
A recent, exciting development that holds promise in the
reduction of post-hemorrhoidectomy pain is liposomal bupivacaine. The liposomes slowly dissolve, releasing the local
anesthetic over 72 h. To date, several randomized trials of the
effect of this medicine in this patient population have been
published [
patients, Gorfi ne et al. reported that this injection of 300 mg
of liposomal bupivacaine, as compared to placebo, resulted
in a statistically signifi cant reduction in opioid use and
improved patient satisfaction. In another randomized trial
including 100 patients, Haas et al. demonstrated a similar
effect on opioid use and also showed a dose-response curve
up to 266 mg of the liposomal formula compared with 75 g
of non-liposomal bupivacaine. This formulation, which
appears effective as shown by these studies, holds promise.
Due to its relative infancy, current widespread adoption is
limited by the relative lack of literature, as well as its cost.
Prevention of early bleeding: At the conclusion of exci-
sional hemorrhoidectomy, some surgeons use an anal pack
or anal tampon to push the mucosa against the anorectal
wall. This may be as simple as lubricated plain gauze with tie
(tampon string) or as fanciful (and costly) as nonadherent
dressing such as rolled-up “cigarette” of Telfa TM wrapped in
Surgicel® (Ethicon Biosurgery, Cincinnati, OH). Although
these measures provide some reassurance to the surgeon,
they are likely excessive if increased attention is paid to
hemostasis as viewed anoscopically at the end of the case.
Increase the detection of early bleeding: An alternative to
anal packing is an anal dam, which keeps the anus open
enough to allow blood to egress from the canal so as to allow
timely recognition while the patient is still in the recovery
room and hopefully before a patient develops hemorrhagic
shock. The cut end of the surgeon’s rubber glove, or a piece
of Telfa, is placed with one end in the canal and the other
outside of the body. This is felt to be critical important by
58 – 60 ]. In a randomized trial of almost 186
57 ]. In general, lack of high-quality data,
56 ].
some surgeons, following the dictum that with a competent
(closed) anus, the colorectum can store the entire intravascular volume of blood.
Patient Selection
As mentioned throughout this chapter, patient selection is
crucial for optimal outcomes. Optimal treatment recommendations start with a thorough examination, ideally in the
offi ce with a motorized exam table, a selection of different
anoscopes, and high-quality lighting. Patient goals should
also be carefully assessed prior to the examination and again
prior to leaving. For example, a patient may successfully
undergo lifestyle modifi cations and serial rubber band ligation for bleeding internal hemorrhoids. On follow-up, the
bleeding is treated, but the patient still notices (yet does not
complain of) prolapse. Despite the prolapse, from the
patient’s perspective, their goals may have been met without
additional intervention. On the other hand, if a cirrhotic has
chronic bleeding internal hemorrhoids, rubber banding may
result in torrential, unstoppable bleeding, so the patient and
other care provider expectation of no bleeding may not be
reasonable, and simple suture ligation, transjugular intrahepatic portosystemic shunt (TIPS), or palliation of the anemia
with transfusion of blood products may be the safest, most
appropriate treatment (Fig. 20.17 ).
Fluid Restriction (Urinary Retention)
According to the American Society of Colorectal Surgeons
recommendations, intraoperative fl uid restriction will
decrease the likelihood of urinary retention [ 1 , 61 ]. Thus, it is
important for you to communicate this to the anesthesia team
who may not be aware of these recommendations. Protocols
for early recognition prior to discharge need to be established
at each surgeon’s operative facility; we recommend mandatory void >100 cc plus a bladder scan to avoid unnecessary
emergency room visits in those in whom it will develop.
Summary Pearls
Managing patients with hemorrhoidal disease will be a frequent occurrence for anyone treating patients with colorectal
problems. Though diffi cult to summarize everything you
will encounter, we leave you with a few fi nal thoughts.
• Complications after treatment for hemorrhoidal disease,
including recurrence, are relatively common and in many
cases can be avoided by proper patient selection, preoperative optimization, and intervention tailored to the individual’s goals and expectations.
20 Hemorrhoidal Disease: Postoperative Complications
329
Fig. 20.17 Algorithmic approach to selection of hemorrhoidal operation
• Technical complications after operative intervention
can result in permanent negative impact on patient quality of life. Therefore, it is imperative that you as the
surgeon be competent, aware of the technical nuances
of the procedures you offer, and familiar with the frequency and management of procedural-specifi c
complication.
References
1. Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD,
Rafferty JL. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011;54(9):1059–64.
PubMed PMID: 21825884. Epub 2011/08/10. eng.
2. Cataldo P, Ellis CN, Gregorcyk S, Hyman N, Buie WD, Church J,
et al. Practice parameters for the management of hemorrhoids
(revised). Dis Colon Rectum. 2005;48(2):189–94. PubMed PMID:
15711856. Epub 2005/02/16. eng.
3. Gencosmanoglu R, Sad O, Koc D, Inceoglu R. Hemorrhoidectomy:
open or closed technique? A prospective, randomized clinical trial.
Dis Colon Rectum. 2002;45(1):70–5. PubMed PMID: 11786767.
Epub 2002/01/12. eng.
4. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intesti-
nal transit time. Scand J Gastroenterol. 1997;32(9):920–4. PubMed
PMID: 9299672. Epub 1997/09/23. eng.
5. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin
F, Spiller RC. Functional bowel disorders. Gastroenterology.
2006;130(5):1480–91. PubMed PMID: 16678561. Epub 2006/
05/09. eng.
6. Cappell MS. Reducing the incidence and mortality of colon cancer:
mass screening and colonoscopic polypectomy. Gastroenterol Clin
North Am. 2008;37(1):129–60, vii-viii. PubMed PMID: 18313544.
Epub 2008/03/04. eng.
7. Zauber AG, Winawer SJ, O’Brien MJ, Lansdorp-Vogelaar I, van
Ballegooijen M, Hankey BF, et al. Colonoscopic polypectomy and
long-term prevention of colorectal-cancer deaths. N Engl J Med.
2012;366(8):687–96. PubMed PMID: 22356322. Pubmed Central
PMCID: 3322371. Epub 2012/02/24. eng.
8. Jover R, Herraiz M, Alarcon O, Brullet E, Bujanda L, Bustamante
M, et al. Clinical practice guidelines: quality of colonoscopy in
colorectal cancer screening. Endoscopy. 2012;44(4):444–51.
PubMed PMID: 22438159. Epub 2012/03/23. eng.
9. Price MJ, Walder JS, Baker BA, Heiselman DE, Jakubowski JA,
Logan DK, et al. Recovery of platelet function after discontinuation
of prasugrel or clopidogrel maintenance dosing in aspirin-treated
patients with stable coronary disease: the recovery trial. J Am Coll
Cardiol. 2012;59(25):2338–43. PubMed PMID: 22698488. Epub
2012/06/16. eng.
10. Alonso-Coello P, Mills E, Heels-Ansdell D, Lopez-Yarto M, Zhou
Q, Johanson JF, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J
Gastroenterol. 2006;101(1):181–8. PubMed PMID: 16405552.
11. Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG.
Symptomatic hemorrhoids: current incidence and complications of
330
S.D. Holubar and D.E. Rivadeneira
operative therapy. Dis Colon Rectum. 1992;35(5):477–81. PubMed
PMID: 1568400.
12. Gentile M, De Rosa M, Pilone V, Mosella F, Forestieri P. Surgical
treatment for IV-degree hemorrhoids: LigaSure hemorrhoidectomy
vs. conventional diathermy. A prospective, randomized trial.
Minerva Chir. 2011;66(3):207–13.
13. Chen CW, Lai CW, Chang YJ, Chen CM, Hsiao KH. Results of 666
consecutive patients treated with LigaSure hemorrhoidectomy for
symptomatic prolapsed hemorrhoids with a minimum follow-up of
2 years. Surgery. 2013;153(2):211–8. PubMed PMID: 22910492.
14. Khanna R, Khanna S, Bhadani S, Singh S, Khanna AK. Comparison
of Ligasure hemorrhoidectomy with conventional Ferguson’s hemorrhoidectomy. Indian J Surg. 2010;72(4):294–7. PubMed PMID:
21938191. Pubmed Central PMCID: 3002768.
15. Fareed M, El-Awady S, Abd-El monaem H, Aly A. Randomized
trial comparing LigaSure to closed Ferguson hemorrhoidectomy.
Tech Coloproctol. 2009;13(3):243–6. PubMed PMID: 19629378.
16. Bessa SS. Ligasure vs. conventional diathermy in excisional hemorrhoidectomy: a prospective, randomized study. Dis Colon
Rectum. 2008;51(6):940–4. PubMed PMID: 18273670.
17. Gravante G, Venditti D. Postoperative anal stenoses with Ligasure
hemorrhoidectomy. World J Surg. 2007;31(1):245; author reply 6.
PubMed PMID: 16957820.
18. Ramcharan KS, Hunt TM. Anal stenosis after LigaSure hemorrhoidectomy. Dis Colon Rectum. 2005;48(8):1670–1; author reply
1. PubMed PMID: 15868225.
19. Chung YC, Wu HJ. Clinical experience of sutureless closed hemorrhoidectomy with LigaSure. Dis Colon Rectum. 2003;46(1):87–92.
PubMed PMID: 12544527.
20. Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Metaanalysis of short-term outcomes of randomized controlled trials of
LigaSure vs conventional hemorrhoidectomy. Arch Surg.
2007;142(12):1209–18; discussion 18. PubMed PMID: 18086990.
Epub 2007/12/19. eng.
21. Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids. Cochrane
Database Syst Rev. 2009;(1):CD006761. PubMed PMID:
19160300.
22. Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon
Rectum. 2007;50(6):878–92. PubMed PMID: 17380367.
23. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid
surgery. Dis Colon Rectum. 2007;50(9):1297–305. PubMed PMID:
17665254.
24. Giordano P, Gravante G, Sorge R, Ovens L, Nastro P. Long-term
outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch
Surg. 2009;144(3):266–72. PubMed PMID: 19289667.
25. Arslani N, Patrlj L, Rajkovic Z, Papes D, Altarac S. A randomized
clinical trial comparing Ligasure versus stapled hemorrhoidectomy.
Surg Laparosc Endosc Percutan Tech. 2012;22(1):58–61. PubMed
PMID: 22318061.
26. Sakr MF, Moussa MM, Elserafy M. Ligasure hemorrhoidectomy
versus stapled hemorrhoidopexy: a prospective randomized clinical
trial. Minerva Chir. 2010;65(3):251–8. PubMed PMID: 20668414.
27. Giordano P, Overton J, Madeddu F, Zaman S, Gravante G. Transanal
hemorrhoidal dearterialization: a systematic review. Dis Colon
Rectum. 2009;52(9):1665–71. PubMed PMID: 19690499.
28. Ratto C, Donisi L, Parello A, Litta F, Doglietto GB. Evaluation of
transanal hemorrhoidal dearterialization as a minimally invasive
therapeutic approach to hemorrhoids. Dis Colon Rectum.
2010;53(5):803–11. PubMed PMID: 20389215.
29. Wang CH. Urgent hemorrhoidectomy for hemorrhoidal crisis. Dis
Colon Rectum. 1982;25(2):122–4. PubMed PMID: 7067546.
30. Rasmussen OO, Larsen KG, Naver L, Christiansen J. Emergency
haemorrhoidectomy compared with incision and banding for the
treatment of acute strangulated haemorrhoids. A prospective randomised study. Eur J Surg. 1991;157(10):613–4.
31. O’Donovan S, Ferrara A, Larach S, Williamson P. Intraoperative
use of Toradol facilitates outpatient hemorrhoidectomy. Dis Colon
Rectum. 1994;37(8):793–9. PubMed PMID: 8055724.
32. Dodi G, Bogoni F, Infantino A, Pianon P, Mortellaro LM, Lise M.
Hot or cold in anal pain? A study of the changes in internal anal
sphincter pressure profi les. Dis Colon Rectum. 1986;29(4):248–51.
PubMed PMID: 3948615. Epub 1986/04/01. eng.
33. Shafi k A. Role of warm-water bath in anorectal conditions. The
“thermosphincteric refl ex”. J Clin Gastroenterol. 1993;16(4):304–8.
34. Corman M. Colon and rectal surgery. 5th ed. Philadelphia:
Lippincott-Raven; 2005.
35. Gordon PH, Nivatvongs S. Principles and practice of surgery for the
colon, rectum, and anus. 3rd ed. New York/London: Informa
Healthcare; 2007.
36. Kurbonov KM, Mukhabbatov DK, Daminova NM. [Errors and
complications in the treatment of hemorrhoids]. Khirurgiia.
2001;(3):43–5. PubMed PMID: 11400452. Oshibki i oslozhneniia
v lechenii gemorroia.
37. Sayfan J. Complications of Milligan-Morgan hemorrhoidectomy.
Dig Surg. 2001;18(2):131–3. PubMed PMID: 11351158.
38. Pattana-arun J, Wesarachawit W, Tantiphlachiva K, Atithansakul P,
Sahakitrungruang C, Rojanasakul A. A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed
hemorrhoidectomy. J Med Assoc Thai. 2009;92(12):1610–5.
39. Bat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Complications
of rubber band ligation of symptomatic internal hemorrhoids. Dis
Colon Rectum. 1993;36(3):287–90. PubMed PMID: 8449135.
40. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg. 1997;40(1):14–7. PubMed
PMID: 9030078. Epub 1997/02/01. eng.
41. Nelson RS, Ewing BM, Ternent C, Shashidharan M, Blatchford GJ,
Thorson AG. Risk of late bleeding following hemorrhoidal banding in
patients on antithrombotic prophylaxis. Am J Surg. 2008;196(6):994–
9; discussion 9. PubMed PMID: 19095121. Epub 2008/12/20. eng.
42. McCloud JM, Jameson JS, Scott AN. Life-threatening sepsis following treatment for haemorrhoids: a systematic review. Colorectal Dis.
2006;8(9):748–55. PubMed PMID: 17032319. Epub 2006/10/13. eng.
43. Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele
RJ, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev.
2005;(3):CD005034. PubMed PMID: 16034963.
44. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band
ligation for symptomatic primary and recurrent internal hemorrhoids.
Dis Colon Rectum. 2004;47(8):1364–70. PubMed PMID: 15484351.
45. Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal
resection (STARR) procedures. Tech Coloproctol. 2008;12(1):7–
19. PubMed PMID: 18512007. Pubmed Central PMCID: 2778725.
46. Correa-Rovelo JM, Tellez O, Obregon L, Miranda-Gomez A,
Moran S. Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial. Dis Colon Rectum.
2002;45(10):1367–74; discussion 74–5. PubMed PMID: 12394436.
47. Cheetham MJ, Mortensen NJ, Nystrom PO, Kamm MA, Phillips
RK. Persistent pain and faecal urgency after stapled haemorrhoidectomy. Lancet. 2000;356(9231):730–3. PubMed PMID: 11085693.
48. Mongardini M, Custureri F, Schillaci F, Cola A, Maturo A, Fanello
G, et al. [Prevention of post-operative pain and haemorrhage in
PPH (Procedure for Prolapse and Hemorrhoids) and STARR
(Stapled Trans-Anal Rectal Resection). Preliminary results in 261
cases]. G Chir. 2005;26(4):157–61. PubMed PMID: 16035252. La
prevenzione del dolore e dell’emorragia post-operatoria nella PPH
20 Hemorrhoidal Disease: Postoperative Complications
331
(Procedure for Prolapse and Hemorrhoids) e nella STARR (Stapled
Trans-Anal Rectal Resection). Risultati su una serie di 261 pazienti.
49. Mathai V, Ong BC, Ho YH. Randomized controlled trial of lateral
internal sphincterotomy with haemorrhoidectomy. Br J Surg.
1996;83(3):380–2. PubMed PMID: 8665199.
50. Galizia G, Lieto E, Castellano P, Pelosio L, Imperatore V, Pigantelli
C. Lateral internal sphincterotomy together with haemorrhoidectomy for treatment of haemorrhoids: a randomised prospective
study. Eur J Surg. 2000;166(3):223–8.
51. Khubchandani IT. Internal sphincterotomy with hemorrhoidectomy
does not relieve pain: a prospective, randomized study. Dis Colon
Rectum. 2002;45(11):1452–7. PubMed PMID: 12432291.
52. Kanellos I, Zacharakis E, Christoforidis E, Angelopoulos S,
Kanellos D, Pramateftakis MG, et al. Usefulness of lateral internal
sphincterotomy in reducing postoperative pain after open hemorrhoidectomy. World J Surg. 2005;29(4):464–8. PubMed PMID:
15770383.
53. Hosseini SV, Sharifi K, Ahmadfard A, Mosallaei M, Pourahmad S,
of hemorrhoids: a randomized clinical trial. Arch Iran Med.
2007;10(4):504–8. PubMed PMID: 17903056.
54. Chauhan A, Tiwari S, Mishra VK, Bhatia PK. Comparison of internal sphincterotomy with topical diltiazem for post- hemorrhoidectomy
pain relief: a prospective randomized trial. J Postgrad Med.
2009;55(1):22–6. PubMed PMID: 19242074.
55. Diana G, Guercio G, Cudia B, Ricotta C. Internal sphincterotomy
reduces postoperative pain after Milligan Morgan haemorrhoidectomy. BMC Surg. 2009;9:16. PubMed PMID: 19852840. Pubmed
Central PMCID: 2774293.
56. Siddiqui MR, Abraham-Igwe C, Shangumanandan A, Grassi V,
Swift I, Abulafi AM. A literature review on the role of chemical sphincterotomy after Milligan-Morgan hemorrhoidectomy.
Int J Colorectal Dis. 2011;26(6):685–92. PubMed PMID:
21212965.
57. Goldstein ET, Williamson PR, Larach SW. Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management. Dis Colon Rectum. 1993;36(5):439–46. PubMed PMID:
8482162.
58. Gorfine SR, Onel E, Patou G, Krivokapic ZV. Bupivacaine
extended-release liposome injection for prolonged postsurgical
analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Dis
Colon Rectum. 2011;54(12):1552–9. PubMed PMID:
22067185.
59. Haas E, Onel E, Miller H, Ragupathi M, White PF. A double-blind,
randomized, active-controlled study for post-hemorrhoidectomy
pain management with liposome bupivacaine, a novel local analgesic formulation. Am Surg. 2012;78(5):574–81. PubMed PMID:
22546131. Epub 2012/05/02. eng.
60. Bergese SD, Ramamoorthy S, Patou G, Bramlett K, Gorfi ne SR,
Candiotti KA. Effi cacy profi le of liposome bupivacaine, a novel
formulation of bupivacaine for postsurgical analgesia. J Pain Res.
2012;5:107–16. PubMed PMID: 22570563. Pubmed Central
PMCID: 3346068. Epub 2012/05/10. eng.
61. Place R, Hyman N, Simmang C, Cataldo P, Church J, Cohen J, et al.
Practice parameters for ambulatory anorectal surgery. Dis Colon
Rectum. 2003;46(5):573–6. PubMed PMID: 12792430. Epub
2003/06/07. eng.
Fistula-in-Ano
David E. Beck
2 1
Key Points
• Although it seems very basic, correctly identifying
the internal and external openings without missing
secondary or high blind tracts or creating false passages is the key to minimizing failures and
recurrences.
• Imaging studies are typically not required outside
of complex and recurrent fi stulae.
• While several methods are used in the surgical management of fi stula-in-ano, they all work on the basic
premise of destroying or sealing the internal
opening.
• When in doubt, preserve the sphincter muscle
complex.
Background
Fistula-in-ano is one of the most common anorectal disorders you will encounter. Many of them will be straightforward and heal without any recurrence or functional defi cits.
Others will be almost as trying on you as they are debilitating
on your patient. It is important that you have a stepwise
approach to anal fi stulas and always consider the anatomy of
the tract(s), sphincter complex involved, prior history of your
patient (e.g., anorectal surgery continence status), and any
underlying pathology (e.g., IBD). My goal in this chapter is
to provide you with information regarding the diagnosis and
D. E. Beck , MD, FACS, FASCRS
Department of Colon and Rectal Surgery ,
Ochsner Clinic foundation , 1514 Jefferson Highway ,
New Orleans , LA 70121 , USA
e-mail: dbeckmd@aol.com
treatment, and along the way give you some of my thoughts
and biases about how I think about this problem.
Pathophysiology
Key Concept: A cryptoglandular origin is the source of
~80 % of all anal fi stulas.
A fi stula-in-ano is an abnormal tract or cavity communicating with the rectum or anal canal by an identifi able internal
and external opening. Most fi stulas are thought to arise due to
cryptoglandular infection and can be classifi ed as described by
Parks and colleagues (Fig. 21.1 and Table 21.1 ) [ 1 ]. Other
causes include infections (e.g., HIV), infl ammation (e.g.,
IBD), neoplasms, and trauma [ 2 ]. While these are fairly
straightforward concepts, it is important to remember that
approximately 30–50 % of anorectal abscesses will lead to an
anal fi stula. When draining an anorectal abscess, you should
inform your patient of this fact, to both manage expectations
and allow them to follow-up appropriately if this should occur.
Evaluation and Workup
History
Key Concept: Most routine fi stulas you can elicit on history
alone. Use the history to tease out those that are more concerning for sources other than cryptoglandular.
A patient with a fi stula-in-ano will often recount a history
of an abscess that has been drained either surgically or spontaneously. Patients may complain of drainage, pain with defecation, bleeding due to the presence of granulation tissue at
either opening, swelling, and/or decrease in pain with drainage. Additional bowel or systemic symptoms (i.e., abdominal pain, bloody diarrhea, weight loss, immunosuppression)
may be present when the fi stula is not cryptoglandular.
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_21, © Springer Science+Business Media New York 2014
333
334
D.E. Beck
Fig. 21.1 Classifi cation of fi stula-in-ano. ( a ), Intersphincteric. ( b ), Transsphincteric. ( c ), Suprasphincteric. ( d ) Extrasphincteric (With permission
from Vasilevsky [
Table 21.1 Classifi cation of fi stula-in-ano
Intersphincteric
Simple low tract
High blind tract
High tract with rectal opening
Rectal opening without perineal opening
Extrarectal extension
Secondary to pelvic disease
Transsphincteric
Uncomplicated
High blind tract
Suprasphincteric
Uncomplicated
High blind tract
Extrasphincteric
Secondary to anal fi stula
Secondary to trauma
Secondary to anorectal disease
Secondary to pelvic infl ammation
2 ] )
Physical Examination
Key Concept: Although you may not always readily fi nd the
internal opening on physical examination, you can often get
a feel for the extent of the disease process and exclude other
sources of pathology.
The external or secondary opening may be seen as an
elevation of granulation tissue discharging pus. This may
be elicited on digital rectal examination. In most cases, the
internal or primary opening is not apparent. The number of
external openings and their location may be helpful in
identifying the primary opening. According to Goodsall’s
rule (Fig.
transversely across the perineum will originate from an
internal opening in the posterior midline. An anterior
external opening will originate in the nearest crypt.
Generally, the greater the distance from the anal margin,
the greater the probability of a complicated upward
21.2 ), an opening seen posterior to a line drawn