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Benign Anal Disease: Third Degree
https://t.me/medicina_free
Hemorrhoids—Who Really Needs
41
Surgery?
ErnieSoto andJonathanLaryea
Introduction
Hemorrhoidal disease is one of the most common anorectal disorders, with a prevalence of 39% [8]. Although quite common, the pathophysiology is not fully understood. The current theory is the sliding anal canal lining. From this theory,
hemorrhoids are dened as the symptomatic enlargement and downward displacement of anal cushions. Anal cushions are folds of tissue which aid in continence and
sense of urgency. They descend from their normal position due to deterioration of
the supporting tissues. Pathologic evaluation of these tissues demonstrate venous
dilation, thrombosis, degeneration of collagen and broelastic tissues along with a
severe inammatory reaction [28]. There have been studies nding dysregulation of
the vascular tone from the superior rectal artery leading to a larger diameter of terminal branches to the hemorrhoidal tissue [28]. Patients with hemorrhoids tend to
have a higher resting anal pressure on anal manometry. In sum, the supporting tissues undergo degeneration leading to the sliding of the anal canal and its associated
anal cushions [28]. Constipation, passage of hard stool and increased intraabdominal pressure are thought to lead to this degeneration, although there is some dispute [28].
Surgeons possess a wide variety of therapeutic options to treat hemorrhoids.
According to the ASCRS clinical practice guidelines for hemorrhoidal disease,
management of symptomatic grade I/II hemorrhoidal disease starts with adequate
uid and ber intake and proper bowel habits, such as avoidance of straining and
E. Soto · J. Laryea (*)
Division of Colon and Rectal Surgery, Department of Surgery, University of Arkansas for
Medical Sciences, Little Rock, AR, USA
e-mail: efsoto@uams.edu; jalaryea@uams.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_41
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E. Soto and J. Laryea
limiting time on the commode, along with medical therapy with phlebotonics to
help increase venous tone [29].
After failing medical management, ofce-based procedures are then considered
to help decrease the size or vascularity of the hemorrhoidal tissue [29]. These therapies include rubber band ligation, sclerotherapy and infrared coagulation. The benets of these in-ofce procedures are the low major complication rate and ability to
perform the procedure multiple times. Although pain and bleeding are some of the
more common complications, perianal sepsis is a life-threatening major complication that can develop with signs such as worsening pain, fever and urinary dysfunction [29].
These therapies are effective for grade I/II whereas grade IV hemorrhoids
commonly require surgery. However, there are no clear-cut guidelines for the
optimal treatment of grade III hemorrhoids. According to ASCRS clinical practice guidelines, select patients with grade III internal hemorrhoids who have
failed medical therapy may undergo office-based treatments. However, select
patients are not defined. Furthermore, Goligher’s grading system for hemorrhoids does not address the size or whether the hemorrhoids are isolated or
circumferential, or include an external component, which are drivers of decision-making [1].
The choice between operative procedures versus ofce-based procedures must
be made by the surgeon, balancing the success and durability of excisional hemorrhoidectomy with its associated cost, postoperative pain and disability [2, 3].
Though associated with less postoperative pain, newer techniques such as the procedure for prolapse and hemorrhoids (PPH) and Doppler-guided hemorrhoidal
artery ligation (DGHAL), are associated with higher recurrence rates. Ofce based
techniques offer a relatively safe and simple approach for many patients, although
long-term durability remains a concern. RBL is relatively contraindicated in patients
using clopidogrel, warfarin, or heparin due to the signicant incidence of postprocedure bleeding [4]. However, of the available ofce-based procedures, RBL is
typically the most effective option and has been used as the comparison group to
surgical hemorrhoidectomy [5].
Complications may result from any technique and can range from minor to
life- threatening. They include bleeding, urinary retention, wound infection,
incontinence, anal-stricture, ectropion, and local sepsis [3]. To appropriately
answer the question of who should have surgery for grade III hemorrhoids, we
must evaluate the ability of a treatment to control symptoms, the re-treatment
rate, postoperative pain, complication rates, disability, and patient satisfaction
(Table41.1).
Table 41.1 Identication of patient population, intervention, comparison and outcomes
Patient population
Patients with 3rd degree
haemorrhoids
Intervention Comparator
Hemorrhoidectomy Rubber Band
Ligation
Outcomes studied
Symptom control and
morbidity
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Search Strategy/Methods
A literature search of MEDLINE, PubMed, the Cochrane Database of Collected
Reviews, and Google Scholar was performed using English language articles from
January 2000 to present. Search terms included hemorrhoids, internal and external
hemorrhoids, hemorrhoid disease, rubber band ligation, hemorrhoidectomy, hemorrhoidopexy and Doppler-guided hemorrhoidectomy. Selected references from articles identied in the primary literature search were used when relevant. Literature
was evaluated using the GRADE evidence quality classication system [6]. Posthoc data analysis was conducted using Fisher’s exact test.
Results
Although high quality evidence comparing ofce techniques to surgical hemorrhoidectomy for grade III hemorrhoids had been lacking previously, several metaanalyses have been published in the past few years. Most data demonstrates EH to
be superior to RBL in the control of hemorrhoidal symptoms at the expense of
increased pain and complication rate. There are several different forms of EH
including open and closed, with or without the use of energy sealing devices that
may improve pain and recurrence rate.
The following discussion includes the results of available studies (Table41.2).
Control ofHemorrhoidal Symptoms
Excisional hemorrhoidectomy is often referred to as the “gold standard” for the
treatment of hemorrhoids when it comes to control of symptoms [8]. A large retrospective case series of 693 patients who underwent EH (Ferguson closed technique)
for grade III and IV hemorrhoids reported a recurrence rate of 1% and 3% at 1 and
2years [9].
RBL has also been shown to control symptoms for many individuals, but to a
lesser extent. A retrospective study of 701 patients showed an overall success rate
(alleviation of symptoms) of 70% [13]. When only patients with grade III hemorrhoids were included, the success rate decreased to 59%. (only Grade II 73.1%)
Three studies were identied that compared outcomes of EH directly to
RBL.Murie etal. evaluated 100 patients with either grade II or III hemorrhoids and
randomized them to EH or RBL [14]. Of the 56 patients with grade III hemorrhoids,
97% of patients undergoing EH had no symptoms of prolapse at 1year compared to
70% in the RBL group (p=0.04). When adding in the patients with grade II hemorrhoids, 86% of EH patients had no bleeding at 1year compared to 74% in the RBL
group (p=0.28).
A systematic review in 2021 by Dekker etal. evaluated 8 RCTs comparing RBL
and EH in grade II/III hemorrhoids [31]. This study found that EH was superior in
the control of hemorrhoidal symptoms at the expense of increased pain and
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E. Soto and J. Laryea
Table 41.2 Results of studies comparing surgery to ofce management of grade III hemorrhoids
Study
Murie
etal. [14]
Group
EH vs
RBL
No. of patients
(Grade 3/total) Results
56/88 RR 0.12 for prolapse for grade III
(95% CI, 0.02–0.87, p=0.04)
Quality of
evidence
Low
RR 0.55 for bleeding for all patients
(95% CI, 0.2–1.3, p=0.2)
RR 1.50 for pain > 48h for all
patients (95% CI, 1.2–1.9, p<0.01)
WMD+29days off work for all
patients (95% CI, 21–36, p<0.01)
Lewis
etal. [15]
EH vs
RBL
56
a
RR 0.44 for short-term symptom
Low
recurrence (95% CI, 0.2–0.7,
p<0.01)
RR 0.18 for long-term symptom
recurrence (95% CI, 0.1–0.4,
p<0.01)
RR 3.8 for pain requiring systemic
analgesia (95% CI, 2.1–6.8, p<0.01)
Gagloo
etal. [17]
EH vs
RBL
38/100 RR 0.25 for prolapsed for grade III
(95% CI, 0.1–0.8, p=0.2)
Low
RR 5.0 for requiring post-operative
analgesia for all patients (95% CI,
2.8–8.7, p<0.01)
Peng
etal. [19]
PPH vs
RBL
55/65 RR 0.21 for bleeding symptoms
2weeks post op (95% CI. 0.1–0.4,
Moderate
p<0.01)
Dekker
etal. [31]
EH vs
RBL
671/1208 RR 0.2 for recurrence (95% CI,
0.10–0.38, p<0.0001), H=0%
Moderate
RR 6.4 for postoperative pain (95%
CI, 5.2–8.1, p<0.0001), H=76%
(p<0.001)
RR 3.8 for postoperative bleeding
(95% CI, 2.44–6.05, p<0.0001),
H=48% (p<0.001)
RR 25.9 for anal stenosis (95% CI,
3.5–190, p=0.0014)
RR 7.3 for urinary retention (95%
4.3–12, p<0.0001)
Shukla
etal. [30]
EH vs
PPH
52/100 Operative time 50 vs 35 mins,
p<0.05
Low
Day 7 VAS 3.3 vs 2.2, p<0.05
Return to work 16.2 vs 8.08, p=0.001
RR 0.33 for recurrence (95% CI,
0.07–1.6, p=0.1652)
Brown
etal. [31]
RR relative risk, WMD weighted mean difference, aOR adjusted odds ratio
a
A total of 112 patients were in the study, but patients who had anal dilation or cryotherapy were
RBL vs
HAL
128/337 aOR 2.23 for recurrence (95%, CI
1.42–3.51, p=0.0005)
Moderate
excluded from ad-hoc analysis
41 Benign Anal Disease: Third Degree Hemorrhoids—Who Really Needs Surgery?
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complication rate. In this study, RBL was found to have a higher recurrence rate
with a RR 4.77 (95% CI 2.60–8.76); p< 0.001) compared to EH.Inversely, RBL
scored less on post procedural pain surveys with a RR 0.17 (95% CI 0.11–0.28);
p < 0.001), post procedural bleeding with a RR 0.31 (95% CI 0.15–0.66), anal
incontinence RR 0.16 [95% CI 0.02–1.28] p=0.080), and urinary retention RR 0.15
[95% CI 0.09–0.25]; p<0.001). Importantly, these studies did not comment on the
number of RBLs used in the treatment arm, as this is a major advantage of these
ofce-based procedures. A Cochrane Database Systematic Review of three randomized studies comparing EH to RBL was published in 2005 [7]. EH was found to be
superior to RBL for grade III hemorrhoids in terms a of symptom control in two
trials with 116 patients with a RR 1.23 (95% CI 1.04-1.45; p = 0.01). There was,
however, no difference between the two procedures in grade II hemorrhoids in one
trial with 32 patients, RR 1.07 (95% CI 0.94-1.21; p=0.32). Patients undergoing EH
had signicantly more pain, higher complication rate and more time off work.
Despite these outcomes, patient satisfaction and acceptance was similar between
the two procedures.
Comparing EH to other surgical techniques such as PPH, a meta-analysis in 2004
demonstrated that patients undergoing EH were signicantly less likely to complain
of ongoing hemorrhoidal symptoms than those who underwent PPH (6 trials, 388
patients, OR 0.52, 95% CI, 0.3–0.91; p=0.02) [10]. However, this study also found
an earlier return to normal activities in the PPH group (standardized mean difference, −4.03days; 95% CI −6.95 to −1.10; p=0.007). A larger meta-analysis from
2007 [40] reviewing 25 RCTs encompassing 1918 procedures also demonstrated
similar results. Postoperative complications seem to not favor PPH or EH with a
similar overall complication rate (20.5% vs 25.2%; P= 0.06) [40]. These results
seem to have held true over the years as a more recent randomized control trial (100
patients with grade II/III) in 2018 again showed similar ndings [30].
DGHAL has also been shown to have a high recurrence rate with 31% of patients
having symptoms within the subsequent 5years [11]. Conversely, a clinical trial
comparing EH to DGHAL with mucopexy demonstrated no difference in symptoms
including pain and bleeding at 2years post-procedure [12].
The HubBLe trial was a multi-center randomized controlled trial comparing
DGHAL to RBL for grade II/III hemorrhoids. This study found a 30% recurrence
rate for DGHAL compared to a 49% in RBL with adjusted OR of 2.23 (95%, CI
1.42–3.51, p=0.0005). When including multiple treatments with RBL, recurrence
dropped to 37% [32].
Lewis etal. compared EH with anal dilatation, RBL and cryotherapy [15]. Of the
26 patients undergoing EH, 100% had fewer symptoms and 65% had no symptoms
at 1year, as opposed to 67% and 13% for RBL.In the long-term (6months–5years)
100% of EH patients had fewer symptoms and 86% had no symptoms. Only 40% of
RBL patients had fewer symptoms and 23% were symptom free. No patients in the
EH group required further treatment compared to 80% in the RBL group.
A systematic review of the two aforementioned trials demonstrated greater efcacy for EH over RBL for the treatment of grade III hemorrhoids (2 trials, 116
patients, RR 1.23, 95% CI 1.0–1.5, p=0.01). However, this difference was not seen
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with grade II hemorrhoids (1 trial, 32 patients, RR 1.07, 95% CI 0.9–1.2, p=0.32)
[16]. When combining grade II and III hemorrhoids, there was no signicant difference between RBL and EH with respect to control of bleeding or prolapse (123
patients; RR 1.12 (95% CI 0.97 to 1.29); P=0.120) (109 patients; RR 1.05 (95% CI
0.98 to 1.12); P=0.160).
A 2011 study randomized 100 patients with grade II/III hemorrhoids to EH or
RBL [17]. Of the grade III patients (38 patients), 12.5% of the EH group experienced recurrent prolapse symptoms after 6months compared to 50% in the RBL
group. Although no statistical analysis was included in the study, post-hoc analysis
reveals this is a statistically signicant nding (p=0.03). Consistent with the systematic review is the nding that RBL leads to better results with grade II hemorrhoids compared to grade III (77% vs. 50% without prolapse at 6 months,
respectively).
In a comparison of PPH with RBL, there was a signicant decrease in the percentage of patients experiencing the symptoms of bleeding from hemorrhoids at
2-weeks post-procedure in the PPH group (27% vs. 68%, p< 0.005). This difference was not seen for prolapse, pruritus, or wound discharge [18]. By 2months,
there was no difference in symptoms experienced in either group. A multicenter
randomized control trial (The Napoleon Trial) has been recently opened in Europe
to evaluate the effectiveness and cost-effectiveness of RBL versus sutured mucopexy versus EH in patients with recurrent hemorrhoidal disease (ClinicalTrials.gov
identier: NCT04101773) [41]. This trial may shed more light on the most effective/cost-effective treatment for patients with recurrent hemorrhoidal disease.
E. Soto and J. Laryea
Post-treatment Pain andComplications
A systematic review of trials comparing EH to RBL for grade II/III hemorrhoids
(including Murie and Lewis, etal.) demonstrated signicantly more patients that
underwent EH experienced postoperative pain (3 trials, 212 patients, RR 1.94, 95%
CI 1.62–2.33, p< 0.001) [16]. There was no statistically signicant difference in
other postoperative complications such as urinary retention, hemorrhage, or anal stenosis. A meta-analysis of the same three trials revealed similar results [5]. The more
recent systematic review by Dekker etal. conrmed some of these ndings. Patients
experienced less post procedural pain after RBL (7 studies, 1110 patients, RR 0.17
(95% CI 0.11–0.28); p<0.001). Patients experienced less bleeding following RBL
(RR 0.31 (95% CI 0.15–0.66); p= 0.002), less urinary retention (6 studies, 1054
patients, random effects; RR 0.15 [95% CI 0.09–0.25]; p<0.001), less anal incontinence (RR 0.16 [95% CI 0.02–1.28] p=0.080). Gagloo etal. found 100% of patients
undergoing EH required postoperative analgesia compared to 20% of patients after
RBL [17]. Severe pain from RBL may result from placement of the band below the
dentate line, which precludes the banding of external hemorrhoids [3].
While EH has been repeatedly shown to be associated with more postoperative
pain than RBL, a recent Cochrane Review has demonstrated a signicant decrease
in pain when hemorrhoidectomy is performed with an energy sealing device [20].
Pain scores on the rst postoperative day showed a WMD of −2.07 (10 studies, 835
41 Benign Anal Disease: Third Degree Hemorrhoids—Who Really Needs Surgery?
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patients, CI −2.77−1.38). There was no relevant difference in other postoperative
complications. A study comparing “DGHAL with mucopexy to EH demonstrated
no signicant difference in post-operative pain scores up to 2weeks [12]. A metaanalysis in 2022 by Zhang etal. comparing energy sealing device hemorrhoidectomy vs PPH found that the energy sealing group also had no difference in
postoperative pain (mean difference = 0.55, 95% CI: −0.15 to 1.25, P = .12) and
also had a decreased recurrence rate in the energy sealing device group (RR = 0.21,
95% condence interval (CI): 0.06 to 0.72, P = .01) [34].
In a comparison of PPH with RBL, PPH was associated with a higher maximal
pain score at discharge (5 vs 2, p< 0.001) and at 2 weeks (5 vs 0, p < 0.001).
However, by 2months, no patient in either group complained of pain. There was no
difference in other complications such as urinary retention, bleeding, anal stenosis,
or change in continence. However, his study was not sufciently powered for these
endpoints [18].
There are new studies evaluating bipolar or harmonic hemorrhoidectomy in
search of reduction of pain. Balcisueta etal. published a systematic review and network meta-analysis of randomized trials in 2021. Twenty-nine studies were included
(3309 patients). None of the procedures were associated with severe pain. Open
hemorrhoidectomy was associated with the most pain on postoperative days 1 and
7. Hemorrhoidopexy was the least painful. Additionally, closed hemorrhoidectomy
and use of bipolar energy or Harmonic scalpel was associated with decreased pain
[35]. Moreover, a RCT by Wang etal. found decreased operating times, blood loss,
postoperative pain, parenteral analgesic use and length of stay in patients undergoing hemorrhoidectomy with Ligasure compared to conventional Ferguson hemorrhoidectomy [38]. Aibuedefe et al. in 2021 published a systematic review and
meta-analysis of 26 RCTs including 3137 patients with grade III/IV hemorrhoids.
They showed less pain with laser (OR 0.34, CI 0.01–6.51), and infrared photocoagulation (OR 0.38, CI 0.02–5.61) compared to EH.Notably, they found less recurrence with Starion (OR 0.01, CI 0.00–0.46) and harmonic scalpel (OR 0.00, CI
0.00–0.49), compared to infrared photocoagulation and DGHAL. There were fewer
postoperative clinical complications with infrared photocoagulation (OR 0.04, CI
0.00–2.54) and LigaSure (OR 0.16, CI 0.03–0.79), compared to suture ligation and
open hemorrhoidectomy. Patients undergoing DGHAL (OR 0.26, CI 0.05–1.51)
and stapled (OR 0.36, CI 0.15–0.84) techniques, returned to work earlier when
compared to open hemorrhoidectomy and laser [36].
A systematic review of 9 RCTs including over 523 patients found that patients
receiving metronidazole either topical or oral had decreased pain scores without
increased complication rates. [33]
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Lifestyle (Return toWork andPatient Satisfaction)
Murie etal. reported that 100% of working patients undergoing EH lost time from
work with a mean of 32days compared to 44% of the RBL group with an average
time away from work of 3days (SD 7days-p < 0.01) [14]. However, the newer
techniques of hemorrhoid surgery have considerably improved return to work times.
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A Cochrane review comparing LigaSure hemorrhoidectomy to standard EH demonstrated a return to work 4.88days earlier (4 studies, 451 patients, CI 2.18–7.59).
When comparing DGHAL to EH, DGHAL patients returned to work after 10days
compared to 22days in the EH group (p=0.09) [12].
A systematic review demonstrated similar overall patient satisfaction in both EH
and RBL patients (RR 1.02, 2 studies, 148 patients, 95% CI, 0.94–1.10) [16].
Gagloo, etal. reported 70% of patients considered EH an “excellent” modality compared to 64% for RBL [17]. There was no difference noted between PPH and RBL
in terms of patient satisfaction at discharge, 2weeks, 2 or 6months [18].
E. Soto and J. Laryea
Cost
None of the identied studies comparing EH to RBL evaluated cost. However, in the
current healthcare climate, cost of therapy must be a consideration. Factors that may
impact cost include operative time, equipment, and need for further treatment. In
addition, the time of convalescence nancially impacts patients, and the economy as
a whole.
There is considerable variation of operative time based on surgical technique.
Multiple studies have demonstrated EH to have longer operative times than other
techniques such as PPH [21]. However, when accounting for equipment costs, EH
was demonstrated to be less expensive than PPH ($252 vs. $504) [22]. The addition
of disposable LigaSure diathermy forceps adds an additional $225 per operation to
EH [23].
RBL does not require operating room time and the cost of equipment is minimal.
However, a long-term study of over 700 patients demonstrated that 30% of patients
require re-treatment with a median 2 bandings per patient and a range of 1–17 bands
placed [13]. Also, as previous studies have demonstrated increased pain with multiple bandings in a single session, patients often need to be brought back for several
sessions [13, 24, 25]. However, as stated above, RBL does allow a considerably
earlier return to work, reducing lost wages.
Recommendations
There are insufcient randomized controlled trials to make a strong recommendation based on high-quality evidence. However, there are trends in the literature sufcient for recommendations.
1. Most patients with uncomplicated grade III internal hemorrhoids may be effec-
tively treated with ofce procedures as rst line treatment after appropriate medical therapy. Strong recommendation based on moderate quality evidence.
Due to the relatively low complication rate, decreased pain, faster return to
work and reasonable efcacy, ofce techniques such as rubber band ligation may
be an appropriate rst option for many patients. While not as efcacious as surgical hemorrhoidectomy, many patients may succeed without a trip to the operat-
41 Benign Anal Disease: Third Degree Hemorrhoids—Who Really Needs Surgery?
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ing room. This technique does not burn any bridges and therapy may always be
escalated to surgical management.
2. Patients with large multi-column grade III hemorrhoids with mixed internal/
external component should undergo surgical hemorrhoidectomy. Strong recommendation based on moderate quality evidence.
Large hemorrhoids may not be treated as effectively with ofce-based procedures. This may be due to the small size of the ligation barrel limiting the size of
the hemorrhoid banded [26]. In these cases, surgical hemorrhoidectomy is the
better choice to remove all affected tissue. In addition, as multi-column disease
may require multiple banding episodes, these patients may be good candidates
for surgery. Finally, as rubber band ligation should not be applied below the
dentate line, patients who seek treatment for mixed component hemorrhoids
should preferably undergo surgery.
3. Patients who are unable to tolerate or have failed ofce-based techniques should
undergo surgical hemorrhoidectomy. Strong recommendation based on moderate quality evidence.
While ofce based procedures such as rubber band ligation may have the
advantages of decreased invasiveness, many patients require repeat therapy. In
addition, while the risk of late bleeding after RBL is similar in patients who take
no antithrombotic therapy and those who hold antithrombotic therapy, not all
patients are able to do so [27]. Patient preference may play a large role in how
many times this is done. In patients who continue to be symptomatic from their
hemorrhoids or no longer wish to have repeat procedures, surgical therapy is
appropriate.
4. For patients undergoing surgical hemorrhoidectomy, the type of procedure performed should be driven by surgeon expertise. Moderate recommendation based
on moderate quality evidence.
There are some benets to new techniques including energy sealing devices
or stapling devices that may be benecial in regard to operating time and postoperative pain, but can have similar complications, such as blood loss, anal
incontinence, stenosis, or urinary retention with an increase to operating
cost [39].
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Expert Opinion
Most patients with symptomatic grade III hemorrhoids present with tissue prolapse,
bleeding, mucous drainage, and pruritus ani. Some patients present with difculty
with anal hygiene and a minority with pain from engorgement with the prolapse.
Non-operative measures alone are inadequate for grade III hemorrhoidal prolapse.
When the symptoms are mainly related to bleeding or the prolapse, ofce-based
RBL is offered. I routinely use the Saeed Shortshot Multi-Band Ligator kit, which
also contains a trislot anoscope. The anoscope is fashioned such that when it is
inserted to limit, it covers the dentate line and ensures that the bands will not be
placed below the dentate line. The use of the trislot anoscope also ensures a single
positioning of the anoscope without a need to reposition it. This system, with the
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E. Soto and J. Laryea
use of suction, allows the use of one hand to deploy the bands. I typically band 1–3
columns in one session, depending on the size of the columns. Banding more than
one column in one session is safe and not associated with increased risk of complications. I warn patients to expect a gush of blood in 4–5days post procedure, however, it may be mixed with stool and may not be easily recognized. I also warn
patients that some slight bleeding with wiping is expected once the hemorrhoids
slough off. Additional complications discussed include urinary retention and sepsis.
I typically see the patients back in 8weeks to allow the resulting ulcers from the
banding to heal. Patients with extremely large hemorrhoids may require repeat
banding. I routinely caution patients on expectations of rectal ‘spasms’ or ‘pressure’
which may last up to 48hours. I counsel patients to do warm Sitz baths to help with
this. I do not typically prescribe any analgesics other than Acetaminophen for discomfort. I warn patients that severe pain is a sign of a serious complication that
requires a phone call and immediate evaluation.
When patients are anticoagulated on medications beyond aspirin, we hold the
anticoagulation prior to RBL due to the risk of hematoma and bleeding. For patients
who cannot hold their anticoagulation for elevated risk of thromboembolic complications, excisional hemorrhoidectomy is recommended.
For patients presenting with symptomatic, circumferential grade III hemorrhoids, I offer them PPH. This offers a durable resolution of symptoms in one setting as opposed to serial RBL. When patients present with mixed symptomatic
internal/external hemorrhoids or when they do not tolerate in-ofce anoscopy and/
or RBL, I offer EH.I typically excise 1–3 columns depending on the situation. I use
the Harmonic Focus bipolar device for excisional hemorrhoidectomy. This is associated with less blood loss (in most cases no blood loss) and less postoperative pain.
I typically do the Ferguson (closed) technique, however, in some cases, I do not
close all the incisions to avoid anal stenosis. I routinely use Liposomal Bupivacaine
to help with postoperative pain. Doppler-guided hemorrhoid artery ligation remains
an alternative, however, I do not typically use this technique. It is associated with an
increased rate of recurrence. The addition of mucopexy improves outcomes and
long term success. However, I nd mucopexy to be antithetical to the principles of
surgery. No wonder the enthusiasm for this procedure has waned signicantly after
an initial strong acceptance.
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3. Sneider EB, Maykel JA.Diagnosis and management of symptomatic hemorrhoids. Surg Clin
North Am. 2010;90:17–32.
4. Rivadeneira DE, Steele SR, Ternent C, etal. Practice parameters for the management of hemorrhoids (revised 2010). Dis colon rectum. 2011;54:1059–64. CrossrefPubMed.
5. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. Dis Colon
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