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_1393_Библиотеки_им_академика_М_И_Перельмана.pdf
4 Hemorrhoids 83
and 12.7% of the patients following Ferguson hemorrhoidectomy [56]. Patients
should be placed on high fiber diet, increased oral fluid/water intake and stool
softeners. Patients with history of chronic constipation should be started on this
regimen plus daily dose of polyethylene glycol (PEG) powd er for 1–2 weeks
before surgery. Fecal urgency and sense of incomplete evacuation is related to
the inverting type of staple line which does functionally somewhat narrow the
anorectal outlet. With proper bowel management and reassurance, the urgency
abates gradually and resolves in 3–4 weeks postoperatively.
2. Fecal Impaction after stapled hemorrhoidopexy is usually related to overuse of
narcotic analgesic. After 5–6 days of “constipation,” patients have tenesmus and
pass liquid stool which many mistake for diarrhea. Using Loperamide or other
constipating agents at this stage greatly aggravate the condition. Even though
this is rare, patients with postoperative fecal impaction should be disimpa cted
under anesthesia or deep sedation followed by use of PEG or lactulose laxatives.
3. Fecal Incontinence Temporary fecal incontinence was reported in 3.9% of
patients following stapled hemorrhoidopexy and 5.2% of the patients after
Ferguson hemorrhoidectomy [56]. It is more commonly seen in elderly patients
who do not tolerate anal stretch for any rectal surgery. In general the fecal
incontinence is temporary and resolves in 2–4 weeks. If the patient complains of
prolonged periods of fecal incontinence, EAUS can be useful to pinpoint a
sphincter injury, even though this could have been present for years prior to the
operation in an occult asymptomatic state. If a sphincter defect is found, a course
of biofeedback should be recommended, and if this fails, an overlapping
sphincter repair should be attempted.
4. Rectal Obstruction manifesting a severe constipation or obstipation has been
reported [63]. Workup for rectal obstruction must include an early return to the
operating room for examination and endoscopy under anesthesia. The
obstruction may be amenable to local dilation, irrigation, and placement of a
mushroom catheter for subsequent irrigation. However, if local therapy is
unsuccessful, diverting colostomy should be performed to get the patient over
the acute obstruction and allow subsequent workup and elective procedure for
restoration of continuity with or without proctectomy.
5. Rectal Stricture Low staple line contributes to painful and difficult defecation
and may result in anal stenosis. Pescatori reported post anopexy (stapled
hemorrhoidopexy) rectal stricture and discussed its management [64].
6. Obstructed Defecation Syndrome (ODS) Dowden and colleagues report ed on
four cases of obstruction defecation disorder after stapled hemorhoidopexy [65].
ODS is difficult to manage anyway and postoperative ODS leaves the patient
with a significant functional and psychological problems. Biofeedback, pelvic
relaxation exercises and physical therapy may be of help. There is no recommended surgical procedure for this complication.
84 J. Cintron et al.
Bleeding
1. Postoperative bleeding using the 1st generation of staples (PPH33-01)®it was
not unusual to see bleeding points at the staple line at the conclusion of the
stapling procedure. This was easily controlled with 3/0 absorbable sutures
placed across the staple line at the bleeding point. Postoperative bleeding (in
recovery room, at home, the first 24–48 h) is considered as a technical error due
to the same etiology (not diagnosed and treated). The height of the staples was
shortened in subsequent productions (PPH33-03
staple lines and reduction of incidence of staple line bleeding [66]. In our CRS
unit, if a patient with stapled hemorrhoidopexy must be restarted on anticoagulants postoperatively, the entire staple line is oversewn with a continuous
running 3/0 absorbable suture.
2. Submucosal Intramucosal Hematoma causes fullness, tenesmus, and pain in the
rectum. Most often the pressure from hematoma results in its partial decompression through the staple line and this can be easily visualized in the office or
under sedation. Hematoma in rectovaginal septum results in pain and dyspareunia. The hematoma can be safely drained transrectally by removing a few
staples and enlarging the opening gently with the tip of a hemostat.
3. Rectal Laceration and Perforation results from incorrect use of the stapler,
excessive force in insertion of the anvil or opening and reclosing and firing the
stapler. The perforation may be small and manifest as pelvic hematoma and
peritonitis or could be overt and large with excessive bleeding and
preumo-hemoperitoneum [67, 68]. These emergencies need immediate resuscitation, return to the operating room, transrectal or transpelvic control of
bleeding, repair of laceration/perforation, and diverting sigmoid colostomy.
Even though most colon and rectal surgeons prefer ileostomy for diversion,
following colorectal trauma principles, a sigmoid colostomy is preferable due to
the proximity to the injury and not leaving a long column of stool potentially
decompressing into the pelvis. Hemoperitoneum is treated with thorough
washout and closed external drainage, which can also be performed laparoscopically as in the cases of perforated sigmoid diverticulitis.
®
) and this resulted in tighter
“Air Leaks”
Pneumoperitoneum, pneumoretroperitorum, and pneuomomediastinum have been
reported in association with rectal perforation following stapled hemorrhoidopexy
[69]. When rectal perforation is large, laparotomy and repair of leaks and colostomy
are manda tory. However on occasion, air is seen in retroperitoneum and mediastinums without significant clinical signs and symptoms. After diagnosis is confirmed by CT, the patient may be placed on IV antibiotics, kept NPO and under
4 Hemorrhoids 85
close observation. If fever, leukoytosis, abdominal or pelvic tenderness occurs
timely intervention is indicated. The staple line should always be visualized under
anesthesia and if possible a small defect may be amenable to transanal closure.
Rectovaginal Fistula
This is arguably the most dreaded complications of stapled hemorrhoidopexy. It can
be prevented by closing the stapler mostly outside the anus before advancing it
intraanally to complete the closure. After the stapler is closed, with a finger in the
vagina palpating the posterior vaginal wall, the stapler should be rotated gently to
the right and left axially. Once it is ascertained that the posterior vaginal wall is free,
then the stapler is fired and removed. It is imperative that the surgeon inspects the
doughnut of the resected tissue carefully. The rectal mucosa and the submucosa
have a distinct pink and red appearance while the vaginal wall, in stark contrast, is
whitish in color. If a piece of white tissue is seen in the hemorrhoidal specimen, the
posterior vaginal wall must be carefully examined and visualized using good light
source and retractors, including Lone Star
If despite all precautions, a small segment of vaginal wall is entrapped in the
staple line, the staples causing the vaginal wall defect must be removed, separating
the rectal and vaginal walls. After careful debridement, the vaginal wall is closed
with interrupted 3/0 absorbable sutures. Then the defect in the circular staple line is
closed with absorbable sutures as well.
In the unfortunate circumstances of undiagnosed vaginal wall entrapment where
the patient returns to the surgeon or the emergency room with fecal discharge from
the vagina 5–7 days later, the management is the same as low RVF following EEA
for rectal cancer. The patient should be diverted allowing the infection to subside.
Then in the operating room, the staples at the RVF site are carefully remo ved, both
the vaginal and rectal wall defects debribed and closed separately with interrupted
absorbable sutures. The diverting stoma is closed 6–12 weeks later after endoscopy
and contrast enemas confirm successful closure of the RVF.
®
.
Staple Line Dehiscence
Is the result of faulty technique where the stapler handle has not been squeezed
satisfactorily to fire and close the staples, but the knife has already cut the tissue.
The result is a gap between the proximal rectal and distal anal mucosa with loose
staples in the lumen and significant to massive hemorrhage. This is best handled
immediately by grasping the rectal mucosa with noncrushing clamps, approximating to the distal mucosa with circumferential suturing with running 3/0
absorbable suture and if needed by a second layer of reinforcing running suture.
Although there are anecdotal reports of small bowel prolapse due to staple line
dehiscence, this should never occur because unlike the EEA stapler, the PPH stapler
is designed to resect only the mucosa and submucosa and not the full thickness of
86 J. Cintron et al.
the rectal wall. Erroneous placement of the staple line (too high) in women with a
deep pouch of Douglas may predispose to this rare and unusual complication.
Immediate laparotomy, reduction of the prolapsed small bowel, closure of the rectal
defect or Hartmann’s procedure with proximal end colostomy is mandatory.
The long litany of complications after stapled hemorrhoidopexy is significant for
two reasons. First, there are many complications which did not exist during decades
of Milligan–Morgan or Ferguson hemorhoidectomies. Second, it affirms clearly that
the operation must be performed only by surgeons experienced with this technique
and capable of dealing with potential complications. Review of the vast literature
dealing with complications of stapled hemorrhodiopexy is a testament that majority
of the complications have occurred in the hands of a less experienced surgeon
during their “learning curve.”
To avoid complications, the surgeon must pay attention to details, adhere to
strict operative indications and technique, be familiar with all potential complications during and after surgery and whenever possible learn from others’ mistakes.
The famous quote of Danish surgeon Søren Laurberg from Arhus, “A fool with a
tool is still a fool” is quite appropriate in stapled hemorrhoidopexy.
Complication of Sutured Hemorrhoidopexy
Sutured hemorrhoidopexy is an operative technique based on the principal of
caudad sliding of hemorrhoidal cushions during defecation demonstrated by anatomic and radiographi c studies [70, 71]. Microscopically, hemorrhoids are submucosal arteriovenous cushions in the anal canal which are suspended to the
muscularis propria with the muscular and elastic fibers seen at the typical anatomic
location of hemorrhoids [72, 73]. Gradual deterioration and degeneration of the
suspensory muscles and elastic fibers allows for downward displacement of hemorrhoidal cushions resulting in protrusion. Bleeding is caused by rupture of the
hemorrhoidal cushions or overlying mucosal ulceration due to hard stools [ 74 ].
Ultimately, 10% of the patients with symptomatic hemorrhoids will need surgical
treatment [75].
The traditional hemorrhoidectomy, whether closed (Ferguson) or open (Milligan–Morgan) are based on excision of hemorrhoids and this includes all subsequent
variations using banding, electrocautery, laser, freezing. In 1996, Morinaga and
colleagues described a novel technique of liga tion of hemorrhoidal arteries with the
aid of Doppler flow meter and without actual excision of the arteries [76]. The
stapled hemorrhoidopexy or PPH proposed by Longo essentially accomplished the
same procedure, i.e., elevation and fixation of hemorrhoidal complex at the level of
the anorectal ring without resection of hemorrhoidal cushions [77].
Stapled hemorrhoidopexy has one major advantage over excisional h emorrhoidectomy, i.e., significantly less postoperative pain, allowing for surgery to be
performed on outpatient basis, reducing postoperative sick days, morbidity, and
time off work. The results of stapled hemorrhoidopexy were compared with
4 Hemorrhoids 87
Milligan–Morgan hemorrhoidectomy in the UK and in a randomized, controlled
trial with long-term follow-up supporting the above-mentioned benefits [78].
A similar study in the US comparing early and late results of multicenter, postoperatively randomized, controlled trial of stapled hemorrhoidopexy with Ferguson
hemorrhoidectomy validated similar results, i.e., less postoperative pain, early
return to work, and equivalent short and long-term results [56].
Hemorrhoids as a disease afflicts patients in every country, among them many
third world or lesser affluent countries, where hemorrhoidopexy staplers or transanal hemorrhoidal dearterialization devices are simply unaffordable. Therefore,
attempts have been made to replicate the hemorrhoidal preserving, elevation, and
fixation procedu res using sutures and without the need for special costly devices.
The early results of the reported case series have been encouraging and the complications have been quite low [79, 80].
One of the earliest reports of sutured hemorrhoidopexy was published by
Pakravan in 2009 [80]. In this report, they presented a z stitch placed above the
dentate line in multiple quadrants elevating and fixing the hemorrhoidal cushions
without actual hemorrhoidectomy. A small mucosal window was removed in order
to enhance fixation. Eighty-four percent of their patients (32/38) were free of
Fig. 4.10 Z-shaped suture approximately 4 cm above the dentate line. Submucosal injection of
adrenaline solution (1:100,000)
88 J. Cintron et al.
Fig. 4.11 Excision of 1 cm (square mucosa)
complaints in one week. Only six pati ents needed oral analgesics such as diclofenac
for postoperative pain. In 6 months follow-up, 34/38 (89%) were asymptomatic, 2
(3%) had a minor segmental prolapse without need for intervention, and 2 (5%) had
pruritus ani. The technique of sutur ed hemorrhoidopexy is depicted in Figs. 4.10,
4.11 and 4.12.
The authors concluded that “Transanal Open Hemorrhoidopexy” is simple,
effective, and cost effective in comparison to other tissue sparing procedures [80].
Gemici and colleagues reported a larger series (116) of patients with a one-year
follow-up [81]. A “vascular Z-shaped ligation technique” for treatment of he morrhoids was utilized. Men comprised 65% of the patients and women 35%. The
mean operative time was 12 ± 4.8 min. The Visual Analogous Score (VAS) at
3,7,21 days averaged 2.2, 1.8, and 1.2, respectively, during the same intervals.
Acute bleeding 4.3%, infection 1.6%, urinary retention 6.9%, and recurrence 3.5%
were reported [81]. No stenosis was seen in any patient [81].
4 Hemorrhoids 89
Fig. 4.12 Lifting of the hemorrhoidal tissue by tightening of the Z-shaped suture
Complications of Sutured Hemorrhoidopexy
There are analogous to hemorrhoidal ligation covered in another chapter in this
book.
1. Thrombosed hemorrhoids occur in 1.9–4.3% of the patients [79–81].
2. Urinary Retention occur in 1.4% [79] and 6.9% [81] of the patients.
3. Hemorrhage Acute bleeding was seen in 4.3% of patients [81].
Secondary bleeding in 0.6% [79] and 3% [80] was minimal in nature and
needing no intervention.
4. Infection and Anal Stenosis has not been reported due to minimal tissue necrosis
in suture hemorrhiodopexy [79, 81].
The simplicity and cost effectiveness of this procedure mandates its inclusion in
the armamentarium of all surgeons operating on treatment hemorrhoids.
90 J. Cintron et al.
Non-excisional Hemorrhoidectomy
Kristine Makiewicz and Marc I. Brand
There is a broad range of surgical options for the management of hemorrhoids.
Excisional hemorrhoidectomy remains the most definitive management, but there
are always new technologies in development to treat hemorrhoids with the less
amount of pain, the lower rates of recurrence, and minimal complications. All
hemorrhoid procedures have a similar range of complications and are quite painful
since the anoderm is well innervated. Damage to the underlying sphincter complex
can cause incontinence, and removing too much tissue causes stenosis. The most
feared complication is sepsis and death, fortunately a very rare occurrence.
Introduction
Hemorrhoid symptoms are an extremely common medical condition with a prevalence of 4.4% in the USA [82]. The internal and external hemorrhoidal cushions are
a normal part of the continence mechanism but can become pathologically enlarged.
Internal hemorrhoids cause bleeding and prolapse, while external hemorrhoids cause
intense pain when thrombosed. There are many management choices that are various
combinations of removing excess tissue, fixing the prolapsed mucosa in place and
managing vascular congestion. Table 4.2 catego rizes the management of hemorrhoids into management of thrombosed external hemorrhoids, internal hemorrhoids,
and combined internal and external hemorrhoids.
Anatomy and Grading System
Hemorrhoids are typically three vascular plexuses in the anal canal in the right
posterior, right anterior, and left lateral positions. The internal component is
proximal to the dentate line and the external hemorrhoid is distal. External
Table 4.2 Non-excisional management of hemorrhoids
Condition Procedure Grade
Thrombosed external hemorrhoids Observation
Excision
Internal hemorrhoids Rubber band ligation
Infrared coagulation
Injection sclerotherapy
Suture hemorrhoidopexy
Transanal dearterialization
Combined internal and external hemorrhoids LigaSure™ hemorrhoidectomy
Laser hemorrhoidectomy
Cryotherapy
External
II & III
I&II
I&II
II & III
II & III
III & IV
I–IV
I–III
4 Hemorrhoids 91
hemorrhoids thrombose causes pain. Internal hemorrhoids prolapse and bleed.
Grade I hemorrhoids are enlarged but do not prolapse, grade II prolapse and reduce
spontaneously, grade III prolapse and reduce manually, and grade IV prolapse and
do not reduce.
Excision of Thrombosed External Hemorrhoids
Patients with acute thrombosed external hemorrhoids present with acute anal pain
and a bulge thought to be brought on by an intravascular clot triggered by the
pressure of constipation [83]. Thrombosed external hemorrhoids are usually managed conservatively with days to weeks of Sitz baths, topical and oral pain medications. As the clot begins to resorb and the swelling improves, the pain resolves.
The other option is to excise the thrombosis and clear the clot to speed the healing
process. Surgical management can be a formal hemorrhoidectomy or incision and
evacuation of clot. Incision and evacuation has been abandoned by colorectal
surgeons because of the higher rates of recurrence and bleeding with this procedure
[84–86]. Complete excision of the clot under local anesthesia is a common procedure that is not well studied [84, 87, 88].
Complication of Excision of Thrombosed External Hemorrhoid
Early Complications
The primary early complication of thrombosed external hemorrhoid drainage results
from inadequate evacuation of the clot from the thrombosed veins. Incomplete clot
removal can lead to re-accumulation of clot and bleeding [84, 85]. Under local
anesthesia, an ellipse of skin is excised and the underlying clot completely evacuated. Rates of post surgical abscess and fistula development are not well studied.
Jongen et al. reported a 2.1% rate in a study of 340 patients but did not evaluate
predisposing factors [87].
Late Complications
Late recurrence of thrombosed external hemorrhoid s appears to be more common
with medical management than with surgical excision [84]. It is unclear if recurrences are repeat episodes in the same hemorrhoids or similar episodes in a new
area. Anal tags and hypertrophic papilla can develop from the healing and
resorption of clot following either medical or surgical management of thrombos ed
external hemorrhoids [87]. Excision does not cause anal stenosis or incontinence
because these are quite localized one or two column procedures with no involvement of the internal anal canal or sphincter complex. Injudicious extension of the
excision into the anal canal may result in an anal fissure as delayed complication
(Table 4.3).
92 J. Cintron et al.
Table 4.3 Summary of complications
Complication Procedures in which they
Early complications
External hemorrhoid
recurrence
Anal tags + hypertrophic
papilla
Urinary retention Rubber band ligation • Perform only single column
Priapism Rubber band ligation • Perform only single column
Thrombosed external
hemorrhoids
Secondary/delayed
bleeding
Perianal
abscess/sepsis/necrotizing
fasciitis
Hematuria, prostatitis,
rectourethral fistula
occur
External hemorrhoid
incision and evacuation
External hemorrhoid
excision
Suture hemorrhoidopexy
Laser hemorrhoidectomy
Cryotherapy
Infrared coagulation None
Suture hemorrhoidopexy
and transanal hemorrhoidal
dearterialization
LigaSure™
hemorrhoidectomy
Laser hemorrhoidectomy
Rubber band ligation • Perform only single column
Injection sclerotherapy • Avoid injecting intravascularly
Rubber band ligation None
Infrared coagulation
Suture hemorrhoidopexy
Transanal hemorrhoidal
dearterialization
LigaSure™
hemorrhoidectomy
Laser hemorrhoidectomy • Avoid aiming laser deep toward
Cryotherapy None
Rubber band ligation • Removal of bands in the OR at the
Injection sclerotherapy None
Injection sclerotherapy • Do not inject anteriorly
Preventative measures would “none”
be appropriate in empty areas?
• Early: Excision rather than incision
• Late: surgical excision reduces
recurrence more than medical
management
None
banding at any one session
banding at any one session
banding at any one session
• Cut hemorrhoid precisely along line
of cautery to remove otherwise cut
edge can bleed
hemorrhoidal arteries
first sign of increasing pain, fever,
urinary retention
(continued)