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_894_Библиотеки_им_академика_М_И_Перельмана.pdf
298
D. E. Beck
it is wide. The distal edge is grasped with a netoothed pickup and the dissection is performed
with scissors. Dissection in the proper plane
results in elevation of all the varicosities with the
specimen, while the sphincter muscles remain in
their normal anatomic position. With the
previously scored mucosa as a guide, the
dissection is continued into the anal canal.
At the superior edge of the hemorrhoidal bundle, the remaining vascular pedicle is clamped
and the hemorrhoid is detached. The editor
(SDW) does not clamp the pedicle, but does
ligate it. The hemorrhoid specimen should be
sent for pathologic evaluation. In the absence of
suspicion or some abnormality, it may be
unnecessary to separately label each bundle (i.e.
left lateral, right posterior) [13, 62]. Any bleeding
vessels are cauterized with the electrocautery. An
absorbable suture (e.g. 3-0 Vicryl) is utilized to
suture ligate the pedicle beneath the clamp. This
suture is then used to reapproximate the mucosal
edges. It is important to take small bites at the
edge of the mucosa and a small bite of the
sphincter with each bite. This running suture is
continued to close the wound and eliminate dead
space. As sutures are placed, the mucosa is
advanced in a cranial direction to reestablish the
normal anal anatomy and result in a “plastic”
closure. At the outer edge, the suture is loosely
tied to itself to provide an escape for any
hematoma developing after surgery. The other
hemorrhoidal bundles are handled in a similar
manner. The number of bundles that are excised
will depend on the amount of excess tissue but
usually should not involve more than three
columns. The procedure preserves bridges of
anoderm between the major bundles and
maintains the dentate line in its anatomic position.
Technique variations include the use of
electrocautery instead of scissor excision and
elimination of the pedicle stitch.
At St. Marks Hospital, Milligan et al. [63]
popularized an open technique of hemorrhoidectomy, which was widely adopted. The procedure starts with gentle anal canal dilatation to
two or three ngers. The hemorrhoidal complex
is then everted by traction on a forceps placed
just beyond the mucocutaneous junction.
Additional forceps can then be placed toward the
level of the anorectal ring. The hemorrhoid is
excised from the subajacent sphincter and the
proximal pedicle is ligated with strong suture
material. Three quadrants are usually removed.
Hemostasis is accomplished and an anal dressing is applied. Care must be taken to ensure that
adequate islands of anoderm are retained to prevent anal stenosis with healing of the open hemorrhoid wounds [13].
Another operative technique, described by
Whitehead [64], used a circumferential incision
made at the level of the dentate line. Submucosal
and subdermal hemorrhoidal tissue was dissected
out and excised. After redundant rectal mucosa
was removed, the proximal rectal mucosa was
sutured circumferentially to the anoderm. While
Whitehead described good results with his procedure, many surgeons who attempted the procedure encountered problems. When performed
improperly, the procedure was associated with
high rates of stricture, loss of normal sensation,
and the development of ectropion commonly
referred to as the “Whitehead deformity”
(Fig. 17.12). These postoperative complications
are often challenging to correct. Common
mistakes in performing the Whitehead procedure
include excising excess anoderm and fail to
recreate the dentate line in the correct location.
Despite its poor reputation, some surgeons have
obtained good results after modifying and simplifying the procedure [65].
Fig. 17.12 Completely circumferential anal ectropion
(classic “Whitehead” deformity). Courtesy of the
American Society of Colon and Rectal Surgeons (ASCRS)
Library
17 Hemorrhoidal Disease
299
The type of hemorrhoidectomy a surgeon performs is based primarily on that surgeon’s experience and training; few comparative trials are
available. Seow-Choen and Low [66] compared a
modied Whitehead hemorrhoidectomy to a
modied Ferguson technique (four bundles excised
with retention of anodermal bridges) in 28 patients.
The four-bundle technique was found to be easier
and required less operative time to perform. At
6 months there was no difference in patient
perception of success. Recent experience has been
directed toward performing hemorrhoidal surgery
as outpatient surgery. With the proper support
systems, patient preparation, and appropriate
technique, hemorrhoidectomy can safely be
performed as an outpatient procedure [67].
Acute, incapacitating hemorrhoids consisting
of prolapse, thrombosis, and strangulation of
hemorrhoidal tissue can involve one or all three
primary complexes [13]. Although conservative
therapy with bed rest, ice packs, and analgesics
has been used with success, an emergency
(acute) hemorrhoidectomy is preferred by most
experienced surgeons. This provides rapid resolution of symptoms and prevents recurrence of
hemorrhoidal symptoms. A closed hemorrhoidectomy as described previously is performed.
Injection of an epinephrine solution (1:100,000)
with 150units of hyaluronidase (Wydase, WyethAyerst Laboratories, Philadelphia, PA) into the
hemorrhoidal complex produces considerable
shrinkage of the tissue and reduction of the edema.
This simplies the operation. Care must again be
taken to preserve adequate anoderm. Recovery for
these patients is similar to those with less acute
disease.
Alternate Energy Sources
Laser hemorrhoidectomy (using a laser rather
than a scalpel or scissors to remove the hemorrhoidal tissue) has received a lot of attention.
Proponents have claimed that this technique
involves less pain and has a better cosmetic
result. Both the carbon dioxide (CO2) and the
neodymium:yttrium-aluminum-garnet (Nd:YAG)
have been used to surgically manage hemorrhoids
[13]. Unfortunately, there are very few articles
available in the English literature describing
excisional hemorrhoidectomy with the laser, and
the relatively small number of well-controlled
prospective studies have demonstrated no
advantage of a laser over traditional techniques
[8, 22]. Senagore etal. [68] reported a prospective,
randomized study comparing the Nd:YAG to a
cold scalpel in 86 patients. Each method resulted
in similar degrees of postoperative discomfort,
requirements for postoperative analgesia, and
time away from work.
Wang etal. [69] reported a randomized trial
comparing Nd:YAG laser hemorrhoidectomy to a
closed technique in 88 patients. Overall complications were similar, but prolonged wound healing was noted in the laser-treated group. Based
on the available evidence, the Standards of
Practice Task Force of the American Society of
Colon and Rectal Surgeons produced the following statement [70]:
No controlled trials have yet been completed to
demonstrate superiority or even equivalence of the
laser to more traditional treatment methods.
Isolated reports suggest that the laser can be used
with success, but there is as yet no reason to believe
that results will be superior to current techniques.
The additional cost and safety requirements of
the laser equipment along with the lack of signicantly better results argue against its routine use.
Other energy devices (e.g. Ligasure, Covidien,
Minneapolis, MN and harmonic scalpel, Ethicon,
Cincinnati, OH) have been evaluated to reduce
blood loss and pain in hemorrhoidectomy. A
Cochrane Systemic Review in 2009 evaluated 12
studies with 1142 patients that had randomized
hemorrhoidectomy patients to conventional diathermy to a Ligasure-technique [71]. The authors
concluded that the Ligasure technique resulted in
less postoperative pain without adverse effect on
post-operative complications. A randomized
study of 151 patients randomized to harmonic
scalpel and Ferguson’s with electrocautery found
that the harmonic scalpel was safe and effective
and resulted in less blood loss and postoperative
pain than the Ferguson’s with electrocautery
[72]. However, none of these studies addressed
the cost of the alternate energy devices (several
hundred dollars) or their utilization with modern
multi-modality pain management (described
300
D. E. Beck
below). In the authors experience, the cost of
these devices far outweighs any potential
advantages.
Postoperative care after hemorrhoidectomy
focuses on two areas: prevention of potential
complications and relief of pain. Preparing the
patients mentally as well as physically aids in
both areas. Truthful descriptions of the postoperative recovery allow the patient to develop a
sense of relief as well as condence. Patients are
told that pain will occur, but depending on the
type of anesthesia, it will not occur for several
hours after the procedure and medication will be
given to minimize their discomfort.
Several actions have been shown to reduce the
incidence of postoperative urinary retention.
Intravenous uids are kept to a minimum during
the intraoperative and postoperative period
(<250mL). The patient is asked to attempt to void
soon after surgery. An adequate dose of the
parasympathomimetic drug bethanecol (10 mg
subcutaneously) has been shown to increase the
likelihood of spontaneous voiding [73]. Patients
who live close to the medical facility and are
reliable may be discharged after surgery. They are
instructed to return if bleeding or urinary retention occurs. An adequate amount of a strong, preferably non-constipating, oral narcotic is given for
outpatient pain control. An alternative is patient
controlled anesthesia using a subcutaneous
morphine pump [74]. Bulking agents and thricedaily Sitz baths are also prescribed. If constipation
occurs, the patient may be administered a 500-mL
warm tap water enema or gentle laxative. Most
patients are seen 5–10days after discharge.
Postoperative complications after hemorrhoid surgery are unusual (Table 17.4) [2, 75,
76]. Hemorrhage, usually at one of the pedicles,
represents the most acute problem and occurred
in 4% of 500 patients in a study by Buls and
Goldberg [77] with a 1% incidence of bleeding
severe enough to warrant a return trip to the
operating room for suture ligation of a vessel.
This agrees with a study from the Ferguson
Clinic in which over 2000 hemorrhoidectomies
were reviewed [78].
Major hemorrhage usually requires an adequate examination and suture ligation of the
bleeding vessel. A 1–2mL submucosal injection
Table 17.4 Post-hemorrhoidectomy complications
Incidence, %
Acute (rst 48h)
Bleeding 2–4
Bleeding requiring reoperation 0.8–1.3
Urinary retention 10–32
Early (rst week)
Fecal impaction <1
Wound infection <1
Thrombosed hemorrhoid <1
Late
Skin tags 6.00
Anal stenosis 1.00
Anal ssure 1–2.6
Incontinence <0.4
Anal stula <0.5
“Recurrent” hemorrhoids <1
a
>2500 patients
a
2
of 1/10,000 adrenaline at the bleeding point has
also been successful [79].
Sepsis related to the wound itself is extremely
rare. It is not unusual, however, to see erythemia
and drainage from the wound edges. If there is
suspicion of infection (fever, increased pain,
difculty voiding) and no obvious other source,
the patient should be empirically started on
antibiotics and watched carefully. Outpatient
observation is acceptable if the patient manifests
no signs of toxicity, but severe pain or worsening
symptoms should prompt consideration for
in-hospital management and careful examination,
under anesthesia if necessary.
Postoperative pain is generally moderate in the
rst 24–48h, and traditionally controllable by oral
or parenteral narcotics. Patients were encouraged
to take oral medications such as oxycodone or
propoxyphene as soon as possible and informed
that while bowel movements will be uncomfortable,
they will not be as painful as they have heard from
other patients. The use of multimodality pain
management has signicantly reduced the pain
associated with hemorrhoidectomy. A multicenter
randomized, double blind placebo-controlled trial
of 186 patients undergoing hemorrhoidectomy
found that patients receiving an extended-release
bupivacaine (Exparel
®
, Pacira Parsippany, NJ) had
signicantly less pain through 72 h, decreased
opioid requirements and improved patient
satisfaction [80]. The addition of intravenous
17 Hemorrhoidal Disease
301
acetaminophen and Ibuprofen further reduces the
need for narcotics and improve the patient
experience [81]. The use of warm soaks and stool
normalizers (ber bulking agents) as described in
previous sections is also helpful.
Fecal impaction may occur in the rst
7–10days after hemorrhoidectomy and should be
suspected if the patient reports watery feculent
discharge, rectal pressure, and constipation during the early postoperative period. This problem
is best avoided by giving the patient a high ber
diet with added psyllium or another bulking agent
two or three times per day for the rst several
weeks after surgery [82]. An added mild laxative
such as mineral oil or milk of magnesia can be
offered to help stimulate the rst evacuation.
Treatment of an impaction should consist of two
or three gentle, warm, 500-mL tap water enemas
given through a soft latex catheter until the
impaction is cleared. Anal pain or inability to
clear the impaction by these methods may require
manual disimpaction under anesthesia.
If external thrombosis or swelling of the external hemorrhoids occurs subsequent to hemorrhoidectomy, the usual cause is a subcutaneous
bleeding vessel. Gentle compression should be
applied to the wound for 10min if it appears to be
enlarging. Comfort measures such as Sitz baths,
analgesics, and local application of a topical soothing cream may then be used. The area will generally resolve spontaneously, and only rarely require
any additional therapy. Tense edema and swelling
may require excision of the external hemorrhoid as
described earlier, again erring on very conservative removal of the anoderm.
Edematous skin tags, often of concern to
patients, should be left alone for 3–4 months
since they usually shrink signicantly over that
time and usually require no treatment beyond
reassurance. If tags that are bothersome to the
patient remain after that time they can usually be
excised in the ofce using local anesthesia.
Anal stenosis, although rare, may be the most
troublesome long-term complication and should
nearly always be preventable by conservative
removal of anoderm at hemorrhoidectomy.
Retention of adequate anoderm to prevent stenosis
is conrmed by the ability to close all of the
hemorrhoidectomy incisions without tension
while a medium Hill-Ferguson retractor remains
in the anal canal. Anal stenosis may be treated by
simple anal sphincterotomy [83], leaving the
longitudinally oriented wound open if scarring is
so severe that a closed-type procedure is not
possible. When stenosis is severe (will not allow
insertion of a lubricated index nger or small HillFerguson retractor at surgery), a plastic surgical
correction of the stenosis may be required. Several
of these techniques were described in detail in
Chap. 14. The author’s preference is one or two
“House” advancement aps along with a partial
sphincterotomy as needed.
Ectropion may occur by inadvertent removal of
anoderm and subsequent caudal displacement of
rectal mucosa into the anal canal (Fig.17.10). This
can be avoided by remembering the rule that
anoderm may always be safely advanced above
the dentate line, but rectal mucosa should rarely be
advanced below it. If ectropion does occur
postoperatively, the patient may report wetness,
itching, and irritation [84]. Most patients, unless
entirely asymptomatic, require surgical correction.
Treatment, if conned to only one half or less of
the anal circumference, may be merely excising
the ectopic rectal mucosa, but the author nearly
always prefers performing an anoplasty. One or
more “House” advancement aps as described in
Chap. 14 work well to close the defect created
after the ectopic rectal mucosa is excised.
In cases of circumferential mucosa ectropion,
the classic “Whitehead deformity”, or in cases
where more than 50% of the circumference is
involved, the S-anoplasty remains the procedure
of choice [85]. As described in Chap. 14, it may
be performed on one or both sides of the anus.
Anal ssure may develop in the postoperative
period, heralded by pain or burning bowel
movements. Often, a degree of stenosis is an
associated nding. If ssures occur in the rst
3–4 weeks after surgery and are of mild to
moderate severity, conservative measures such as
Sitz baths, dietary ber, and topical creams
should be adopted. The patient is reassured and
advised that soft, bulky stools are necessary to
dilate the anal passage naturally and that watery,
loose stools can contribute to narrowing of the
area. If symptoms are severe, or if conservative
measures are not helpful, a careful examination
302
D. E. Beck
under anesthesia with a planned sphincterotomy,
possibly with an advancement ap anoplasty,
may be needed.
Fecal incontinence is an unusual but potentially
disastrous complication after hemorrhoidectomy
and may occur more frequently than reported in
the literature (<1%). Patients at higher risk include
the elderly, especially women, and patients who
have had prior anal surgery [2]. These patients
required a detailed and carefully documented
inquiry regarding anal continence. Digital rectal
examination at rest and during maximum voluntary
squeeze to ascertain sphincter tone, and anal
manometry should be used to quantify anal
pressures. Patients should be counseled about
goals of the surgery, and nonoperative measures
reconsidered if bowel control is impaired. At
surgery it is acceptable to perform a one- or twoquadrant hemorrhoidectomy, conserving anoderm,
and to rubber band ligate the other quadrants or
leave them alone. The underlying sphincter should
be carefully protected. While this conservative
approach may lead to a slightly greater chance for
recurrence, patients will understand the concern to
protect continence.
Minor incontinence is rare unless an open
sphincterotomy is performed concomitantly with
hemorrhoidectomy as a “pain relieving” measure. Sphincterotomy should be avoided unless
some degree of stenosis is present or when a concomitant ssure is present.
Recurrence of signicant hemorrhoidal disease following a closed hemorrhoidectomy is
unusual—only 1% in the 2038 patients surveyed
by Ganchrow and colleagues [78]. Most symptoms that patients equate with recurrence are
either skin tags or small external hemorrhoids, or
are related to bleeding of small supercial veins
near the hemorrhoidectomy wounds. Tags can be
excised in the ofce under local anesthesia.
Bleeding from the internal hemorrhoids is nearly
always treatable with rubber band ligation,
infrared coagulation, or sclerotherapy.
Special Considerations
Hemorrhoidal disease in human immunodeciency virus (HIV) patients deserves addi-
tional comment. As discussed in Chap. 26, HIV
infection can manifest initially with minimal alterations in health and physiology to complete immunologic failure. The major fear in these patients has
been failure to heal and infection. Experience has
demonstrated that early stage patients can be
treated and expected to respond similar to uninfected patients. Late stage patients even with newer
medical treatment for their HIV remain at signicant risk of problems and should be managed as
conservatively as possible [86, 87]. Most symptoms can be minimized with dietary manipulations
or topical medications. If this fails, infrared coagulation has been used in selected patients with reasonable results.
There is no contraindication to hemorrhoid
treatment during any stage of pregnancy [13].
However, an operative hemorrhoidectomy is usually avoided during pregnancy unless the patient
is suffering from acute disease. With acute disease treatment, as described elsewhere, is accomplished along with special attention afforded the
fetus. Saleeby etal. [88] reported on 12 of 12,455
pregnant women (0.2%) who had surgical
hemorrhoidectomy. Most were in their third trimester of pregnancy and all did well.
Inammatory bowel disease patients also
develop hemorrhoidal disease. Symptoms of
the two conditions must be differentiated. In
known inammatory bowel disease patients
hemorrhoidal symptoms are usually related to
their abnormal bowel movements. The presence
of anorectal diseases increases concern about
Crohn’s disease. Crohn’s disease patients should
not have hemorrhoidectomies unless absolutely
necessary, but in selected patients good results
can be obtained [89]. In ulcerative colitic patients
a safe hemorrhoidectomy can be performed if the
colitis is under control [13].
Summary
Understanding of the pathophysiology of hemorrhoidal disease guides treatment selection. The
author’s preferred treatment plan is summarized
in Table17.5. A recent meta-analysis of hemorrhoidal treatment modalities supports this
approach [90]. Appropriate treatments provide
symptom resolution in a safe and cost effective
manner.
17 Hemorrhoidal Disease
303
Table 17.5 Author’s treatment plan
Symptomatic internal hemorrhoids (bleeding)
1. Trial of supplemental ber (i.e. Konsyl™,
Citrucel ™, Fibercon ™);
2. If symptoms do not resolve, then perform rubber
band ligation;
3. Repeat ligation in 1–6months if symptoms
improving and minimal discomfort with prior
banding;
4. If discomfort with banding, consider infrared
photocoagulation;
5. If symptoms persist, consider operative
hemorrhoidectomy.
Symptomatic external or combined hemorrhoids
1. Operative hemorrhoidectomy (modied Ferguson
technique) with local or regional anesthesia
References
1. Beck DE.Hemorrhoids. In: Beck DE, Welling DR,
editors. Patient care in colorectal surgery. Boston:
Little, Brown; 1991. p.213–24.
2. Milsom JW. Hemorrhoidal disease. In: Beck DE,
Wexner SD, editors. Fundamentals of anorectal surgery. NewYork: McGraw-Hill; 1992. p.192–214.
3. Dirckx JH.The biblical plague of “hemorrhoids”. Am
J Dermatopathol. 1985;7:341–6.
4. Maimonides M. Treatise on hemorrhoids (Rosner F,
Munter S, trans). Philadelphia: J.B.Lippincott; 1969.
5. Beck DE. Hemorrhoids. In: Beck DE, editor.
Handbook of colorectal surgery. St. Louis: Quality
Medical Publishing; 1997. p.299–311.
6. Thompson WHF. The nature of hemorrhoids. Br J
Surg. 1975;62:542–52.
7. Thulesius O, Gjores JE.Arterio-venous anastomoses
in the anal region with reference to the pathogenesis
and treatment of hemorrhoides. Acta Chir Scand.
1973;139:476–8.
8. Burkitt DP, Grahm-Stewart CW. Hemorrhoidspostulated pathogenesis and proposed prevention.
Postgrad Med J. 1975;51:631–6.
9. Sonneberg A, Koch TR.Epidemiology of constipation
in the United States. Dis Colon Rectum. 1989;32:1–8.
10. Haas PA, Fox TA, Haas GP.The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984;27:442–50.
11. Johansson JF, Sonneberg A.The prevalence of hemorrhoids and chronic constipation: an epidemiologic
study. Gastroenterology. 1990;98:380–6.
12. Hancock BD. Internal sphincter and the nature of
haemorrhoids. Gut. 1977;18:651–5.
13. Mazier WP.Hemorrhoids. In: Maxier WP, Levin DH,
Luchtefeld MA, Senagore AJ, editors. Surgery of the
colon, rectum and anus. Philadelphia: W.B.Saunders;
1995. p.229–54.
14. Nelson RL, Abcarian H, Davis FG, Persky V.
Prevalence of benign anorectal disease in a ran-
domly selected population. Dis Colon Rectum.
1995;38:341–244.
15. Corman ML. Colon and rectal surgery. 2nd ed.
Philadelphia: J.B.Lippincott; 1989. p.49–105.
16. Kluiber RM, Wolf BG. Evaluation of anemia caused
by hemorrhoidal bleeding. Dis Colon Rectum.
1994;37:1006–7.
17. Larach S, Cataldo TE, Beck DE.Nonoperative treatment of hemorrhoidal disease. In: Hicks TC, Beck
DE, Opelka FG, Timmcke AE, editors. Complications
of colon and rectal surgery. Baltimore: Williams &
Wilkins; 1997. p.173–80.
18. Moesgaard F, Nielsen ML, Hansen JB, Knudsen
JT. High ber diet reduces bleeding and pain in
patients with hemorrhoids. Dis Colon Rectum.
1982;25:454–6.
19. Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills
E, Heels-Ansdell D, Johanson JF, Guyatt G. Metaanalysis of avonoids for the treatment of haemorrhoids. Br J Surg. 2006;93(8):909–20.
20. Dodi G, Bogoni F, Infantino A, etal. Hot or cold in
anal pain? A study of the changes in internal sphincter pressure proles. Dis Colon Rectum. 1986;29:
248–51.
21. Gorne SR.Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum. 1995;38:453–7.
22. Blaisdell PC.Prevention of massive hemorrhage secondary to hemorrhoidectomy. Surg Gynecol Obstet.
1958;106:485–8.
23. Barron J. Ofce ligation treatment of hemorrhoids.
Dis Colon Rectum. 1963;6:109–13.
24. Lee HH, Spencer RJ, Beart RW. Multiple hemorrhoidal banding in single session. Dis Colon Rectum.
1994;37:37–41.
25. Lau WY, Chow HP, Dorn GP, Wong SH.Rubber band
ligation of three primary hemorrhoids in a single session. Dis Colon Rectum. 1982;25:331–9.
26. Khubchandani IT. A randomized comparison of
single and multiple rubber band ligations. Dis Colon
Rectum. 1983;26:705–8.
27. Rothberg R, Rubin RJ, Eisenstat T, Salvati EP.Rubber
band ligation hemorrhoidectomy, long-term results.
Am Surg. 1983;49(3):167.
28. Corman ML, Veidenheimer MC. The new hemorrhoidectomy. Surg Clin North Am. 1973;53:417–22.
29. O’Hara VS. Fatal clostridial infection following
hemorrhoidal banding. Dis Colon Rectum. 1980;23:
570–1.
30. Russell TR, Donohue JH. Hemorrhoidal banding: a
warning. Dis Colon Rectum. 1985;28:291–3.
31. Bartizol J, Slosberg P.An alternative to hemorrhoidectomy. Arch Surg. 1977;112:534–5.
32. Steinburg DM, Liegois H, Alexander-Williams J.Long
term review of the results of rubber band ligation of
haemorrhoids. Br J Surg. 1975;62:144–1146.
33. Wrobleski DE, Corman L, Veideheiner MC, Coller
JA. Long-term evaluation of rubber ring ligation in hemorrhoidal disease. Dis Colon Rectum.
1980;23:478–82.
304
D. E. Beck
34. Neiger S. Hemorrhoids in everyday practice.
Proctology. 1979;2:22–8.
35. O’Connor JJ. Infrared coagulation of hemorrhoids.
Pract Gastroenterol. 1979;10:8–14.
36. Dennison A, Whiston J, Rooney S, etal. A randomized comparison of infrared photocoagulation with
bipolar diathermy for the outpatient treatment of hemorrhoids. Dis Colon Rectum. 1990;33:32–4.
37. Gabriel WB.The principles and practice of rectal surgery. London: Lewis; 1963. p.131.
38. Andrews E.The treatment of hemorrhoids by injection. Med Rec. 1879;15:451.
39. Alexander-Williams J, Crapp AR.Conservative management of haemorrhoids, I: injection, freezing, and
ligation. Clin Gastroenterol. 1975;4:595–601.
40. Denckner H, Hjorth N, Norryd C, etal. Comparison
of results with different methods of treatment of internal haemorrhoids. Acta Chir Scand. 1973;139:742–5.
41. Wilson MC, Schoefeld P.Cryosurgical haemorrhoidectomy. Br J Surg. 1976;63:497–8.
42. Savin S. Hemorrhoidectomy-how I do it: results of
444 cryorectal surgical operations. Dis Colon Rectum.
1977;20:189–96.
43. Goligher JC.Cryosurgery of hemorrhoids. Dis Colon
Rectum. 1976;19:213–8.
44. Smith LE, Goudreau JJ, Fonty J. Management of
hemorrhoids: operative hemorrhoidectomy versus
cryosurgery. Dis Colon Rectum. 1979;22:10–6.
45. Yang R, Migikovsky B, Peicher J, Laine L.
Randomized, prospective trial of direct current versus
bipolar electrocoagulation for bleeding internal hemorrhoids. Gastrointest Endosc. 1993;39:766–9.
46. Lord PH.A new regime for the treatment of hemorrhoids. Proc R Soc Med. 1968;61:935–6.
47. Lord PH.Diverse methods of managing hemorrhoids:
dilatation. Dis Colon Rectum. 1973;16:180–3.
48. McCaffrey J. Lord treatment of hemorrhoids: four
year follow-up of fty patients. Lancet. 1975;1:133–4.
49. Allgower M. Conservative management of haemorrhoids, III: partial internal sphincterotomy. Clin
Gastroenterol. 1975;4:608–18.
50. Arabi Y, Gathouse D, alexander-Willimas J, et al.
Rubber band ligation of lateral subcutaneous sphincterotomy for treatment of haemorrhoids. Br J Surg.
1977;64:737–40.
51. Shouten WR, van Vroonhoven TJ. Lateral internal
sphincterotomy in the management of hemorrhoids—
a clinical and manometric study. Dis Colon Rectum.
1986;29:869–72.
52. Leong AFP, Husain MJ, Seow-Choen F, Goh
HS. Performing internal sphincterotomy with
other anorectal procedures. Dis Colon Rectum.
1994;37:1130–2.
53. Wang GQ, Liu Y, Liu Q, Yang RQ, Hong W, Fan K,
Lu M.A meta-analysis on short and long term efcacy and safety of procedure for prolapse and hemorrhoids. Chin J Surg. 2013;51(11):1034–8.
54. Senagore AJ, Singer M, Abcarian H, et al. A prospective, randomized, controlled multicenter trial
comparing stapled hemorrhoidopexy and Ferguson
hemorrhoidectomy: perioperative and one-year
results. Dis Colon Rectum. 2004;47(11):1824–36.
55. Yang HK.Nonsurgical treatment of hemorrhoids. In:
Yang HK, editor. Hemorrhoids. NewYork: Springer;
2014. p.47–63.
56. Morianga K, Hasuda K, Ikeda T.A novel therapy for
internal hemorrhoids: ligation of the hemorrhoidal
artery with a newly devised instrument (Moricorn)
in conjunction with a Doppler owmeter. Am J
Gastroenterol. 1995;90:610–3.
57. Singer M. Hemorrhoids. In: Beck DE, Wexner SD,
Roberts PL, Sacclarides TJ, Senagore A, Stamos M,
editors. ASCRS textbook of colorectal surgery. 2nd
ed. NewYork: Springer; 2007.
58. Giordano P, Overton J, Madeddu F, Zaman S, Gravante
G. Transanal hemorrhoidal de-arterialization: a systemic review. Dis Colon Rectum. 2009;52:16665–71.
59. Ferguson JA, Mazier WP, Ganchow MI, Friend
WG. The closed technique of hemorrhoidectomy.
Surgery. 1971;70:480–4.
60. Mazier WP, Halleran DR. Excisional hemorrhoidectomy. In: Kodner IJ, Fry RD, Roe JP, editors. Colon,
rectal, and anal surgery. St. Louis: C.V. Mosby; 1985.
p.3–14.
61. Ferguson JA, Heaton JR.Closed hemorrhoidectomy.
Dis Colon Rectum. 1959;2:1176–9.
62. Cataldo PA, MacKeigam JM.The necessity of routine
pathologic evaluation of hemorrhoidectomy specimens. Surg Gynecol Obstet. 1992;174:302–4.
63. Milligan ETC, Morgan CN, Nanton LE, Ofcier
R.Surgical anatomy of the anal canal and the operative treatment of hemorrhoids. Lancet. 1937;2:
1119–24.
64. Whitehead W.The surgical treatment of hemorrhoids.
Br Med J. 1882;1:148–50.
65. Bonello JC. Who’s afraid of the dentate line?
The Whitehead hemorrhoidectomy. Am J Surg.
1988;156:182–6.
66. Seow-Choen F, Low HC. Prospective randomized
study of radial versus four piles haemorrhoidectomy
for symptomatic large circumferential prolapsed
piles. Br J Surg. 1995;82:188–9.
67. Patel N, O’Connor T. Suture haemorrhoidectomy: a
day-only alternative. Aust N Z J Surg. 1996;66:830–1.
68. Senagore A, Mazier WP, Luchtefeld MA, MacKeigan
JM, Wengert T. The treatment of advanced hemorrhoidal disease: a prospective randomized comparison
of cold scalpel vs. contact Nd:YAG laser. Dis Colon
Rectum. 1993;36:1042–9.
69. Wang JY, Chang-Chein CR, Chen JS, Lai CR, Tang
R.The role of lasers in hemorrhoidectomy. Dis Colon
Rectum. 1991;34:78–82.
70. Standards Task Force American Society of Colon and
Rectal Surgeons. Practice parameters for the treatment
of hemorrhoids. Dis Colon Rectum. 1990;33:7A–8A.
71. Niehuis S, de Hingh I.Conventional versus LigaSure
hemorrhoidectomy for patients with symptomatic hemorrhoids. Cochrane Database Syst Rev.
2009;1:CD006761.
17 Hemorrhoidal Disease
305
72. Bulus H, Tas A, Coskun A, Kucukazman M.
Evaluation of two hemorrhoidectomy techniques:
harmonic scalpel and Ferguson’s with electrocautery.
Asian J Surg. 2014;37:20–3.
73. Gottesman L, Milsom JW, Mazier WP.Postoperative
urinary retention treated with Urecholine: a prospective, randomized, blinded study. Dis Colon Rectum.
1989;32:867–80.
74. Goldstein ET, Williamson PK, Larach SW.
Subcutaneous morphine pump for postop hemorrhoidectomy pain management. Dis Colon Rectum.
1993;36:439–46.
75. Smith LE.Current therapy on colon and rectal surgery.
In: Fazio VW, editor. Current therapy in colon and rectal surgery. Philadelphia: B.C.Decker; 1990. p.9–14.
76. Dean KI, Wong WD.Hemorrhoidal surgery. In: Hicks
TC, Beck DE, Opelka FG, Timmcke AE, editors.
Complications of colon and rectal surgery. Baltimore:
Williams & Wilkins; 1997. p.163–72.
77. Buls JG, Goldberg SM.Modern management of hemorrhoids. Surg Clin North Am. 1978;58:469–78.
78. Ganchrow MI, Mazier WP, Friend WG, et al.
Hemorrhoidectomy revisited—a computer analysis of
2038 cases. Dis Colon Rectum. 1971;14:128–33.
79. Nyam DCNK, Seow-Choen F, Ho YH.Submucosal
adrenaline injection for posthemorrhoidectomy hemorrhage. Dis Colon Rectum. 1995;38:776–7.
80. Gorne 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;54:1552–9.
81. Beck DE, Margolin DA, Babin S, Russo CT.Benets
of a multimodal regimen for postsurgical pain
management in colorectal surgery. Ochsner J.
2015;15(4):408–12.
82. Corman ML. Management of postoperative constipation in anorectal surgery. Dis Colon Rectum.
1979;22:149–51.
83. Milsom JW, Mazier WP.Classication and management of postsurgical anal stenosis. Surg Gynecol
Obstet. 1986;163:60–4.
84. Granet E. Hemorrhoidectomy failures: causes, prevention, and management. Dis Colon Rectum.
1968;11:45–8.
85. Ferguson JA.Repair of “Whitehead deformity” of the
anus. Surg Gynecol Obstet. 1959;108:115–6.
86. Wexner SD. AIDS: what the colorectal surgeon
needs to know. Perspect Colon Rectal Surg. 1989;2:
19–54.
87. Morandi E, Merlini D, Salvaggio A, Foschi D,
Trabucchi E. Prospective study of healing time
after hemorrhoidectomy: inuence of HIV infection, acquired immunodeciency syndrome, and
anal wound infection. Dis Colon Rectum. 1999
Sep;42(9):1140–4.
88. Saleeby RG, Rosen L, Stasik JJ, et al.
Hemorrhoidectomy during pregnancy: risk or relief?
Dis Colon Rectum. 1991;34:260–1.
89. Wolkomir AF, Luchtefeld MA.Surgery for symptomatic hemorrhoids and anal ssures in Crohn’s disease.
Dis Colon Rectum. 1993;36:545–7.
90. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. Dis Colon Rectum.
1995;38:685–94.
Proctalgia Fugax, Levator Spasm,
and Pelvic Pain: Evaluation and
Dierential Diagnosis
AmirL.Bastawrous andJenniferK.Lee
18
Introduction
Pelvic pain is a common complaint with a wide
range of causes involving multiple organ systems, making the diagnosis particularly complicated. The expansive differential can be divided
into acute and chronic etiologies. The most common causes of acute pain include thrombosed
external hemorrhoids, perianal abscesses, stulas
and anal ssures. Chronic pelvic pain also has a
broad differential that includes several pelvic
oor syndromes. The differential can be divided
into organic or functional etiologies, the later of
which relates to diagnoses that do not have a
structural or anatomical cause.
Patients may present shortly after the acute
pain starts or delay seeing a provider due to
anxiety and embarrassment. Many may also
ignore the pain altogether. Pelvic pain is
especially distressing as it affects a sensitive area
of the body that is difcult for patients to
examine themselves. Nevertheless, with a
systematic approach to the history and physical,
the physician can identify most diagnoses and
treat them successfully.
General Approach tothePatient
withPelvic Pain
History
Many patients come with a predetermined
diagnosis, such as hemorrhoids or anal ssure,
which can be a distractor. It is essential to listen
to key descriptions provided by the patient,
focusing on pain characteristics such as character, duration, location, causative factors and associated signs and symptoms.
Evaluate the past medical, surgical and gynecological history. A family history may point
towards a malignant etiology. A history of inammatory bowel disease may raise suspicion of anal
stulas or ssure and a history of diabetes or HIV
may point to an infectious cause. Sexual history
may raise suspicions for sexually transmitted disease, anal dysplasia or cancer. A history of physical, emotional or sexual abuse may underlie
certain chronic pelvic pain symptoms.
Physical Examination
While a complete examination is important,
high-yield portions include the examination of
A. L. Bastawrous (*) · J. K. Lee
Swedish Colon and Rectal Clinic, Swedish Cancer
Institute, Seattle, WA, USA
e-mail: amir.bastawrous@swedish.org;
Jennifer.lee@swedish.org
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_18
the abdomen, inguinal region, perianal skin and
soft tissue, buttocks and gluteal cleft, anal
canal and rectum. The abdominal exam starts
with inspection. Scars may reveal a history of
307
308
A. L. Bastawrous and J. K. Lee
operations or trauma. Palpation helps appreciate
distention and tympani in the setting of
constipation. The point of maximum tenderness
in the leftlower quadrant can reveal diverticulitis.
Metastases may present with hepatomegaly. The
inguinal exam may identify lymphadenopathy,
which may raise suspicions of an infectious and
neoplastic process. Anal and low rectal cancers
can present with palpable lymphadenopathy in
metastatic disease [1].
The external and internal anal exams are crucial. This part of the evaluation requires extreme
sensitivity on the part of the examiner, as it is
both a physically and psychologically sensitive
examination event for the examinee. Warn the
patient before initiating any portion of the perianal and internal anorectal exam. By putting the
patient at ease and earning trust, one can obtain
helpful information in a more efcient manner
and with minimal discomfort.
Starting with the external exam, visualization
of the gluteal, intergluteal and perianal skin can
reveal discoloration of the skin, thickened folds
or scaling, masses, secondary openings of stulae, swelling from abscesses, pilonidal pits, skin
tags or thrombosis of external hemorrhoids.
Gentle distraction of the buttocks may reveal anal
ssures. Palpation of the perianal skin can identify abscesses or a mass concerning for a neoplastic process. Assess the size, rmness, xation and
tenderness of any lesions.
The digital rectal exam is best tolerated with
adequate lubrication and in the case of pelvic
pain, topical anesthetic should be considered to
maximize patient tolerance. In the case of a visualized ssure on external exam, it is helpful to
gently insert the examining nger to place initial
pressure on the contralateral side. Palpate for
masses and dene the location in regards to anterior, posterior, right or left lateral quadrants.
Dene the distance of the lesion from the anal
verge and anorectal ring. The rmness and xation of the lesion are also discernable on digital
exam and should be recorded.
Assess anal sphincter tone, which is usually
hypertonic in most cases of anal ssures, but can
also be found to be normal in some patients,
which alters the treatment options for ssures.
Starting at the coccyx, rotate the nger to each
lateral quadrant, feeling for muscle spasm of the
levator complex. This should also reproduce pain
in the setting of levator syndrome.
Palpate for uctuance with concomitant pain
in the setting of perirectal abscesses. Posteriorly,
fullness on palpation can identify presacral
masses. Palpation of the coccyx can diagnose
coccygodynia. For completion, rotate the nger
anteriorly in men to identify point tenderness of
the prostate in cases of prostatitis and for rectocele in women with a history of constipation.
If the patient is unable to tolerate the process,
an exam under anesthesia should be performed.
Repeated and aggressive pain-inducing examinations will not yield helpful information, especially in setting of investigating pelvic pain.
Anoscopy/Rigid Proctoscopy
Anoscopy and sigmoidoscopy allow for visualization of intraanal and rectal lesions. These ndings can range from enlarged hemorrhoids to
distinct neoplastic lesions to mucosal changes
from sexually transmitted infections or inammatory bowel disease.
Imaging/Testing
There are certain circumstances when diagnostic
or conrmatory studies are required after a history and physical exam. This especially occurs
when the history is concerning for an anorectal
abscess but there are limited physical exam ndings. A pelvis computed tomography (CT) may
be helpful in this case and may have already been
ordered by inexperienced practitioners. Diagnosis
of pelvic oor disorders can be visualized with a
defecogram or dynamic pelvic magnetic resonance imaging (MRI). Patients with a history
concerning for outlet obstruction can be diagnosed with high-resolution anorectal manometry
and a balloon expulsion study. A history of a
retained foreign body should prompt an abdominal and pelvic radiograph in order to identify
some objects, as well as evaluate for free air.
Finally, the standard workup for an anal or rectal
cancer includes staging with ultrasound or MRI