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4 Hemorrhoids 93
Table 4.3 (continued)
Complication Procedures in which they
Early recurrent
hemorrhoidal prolapse
Severe post-procedure
pain
Incontinence LigaSure™
Discharge from mucosal
sloughing
Late complications
Fistula Thrombosed external
Anal stenosis Transanal hemorrhoidal
Anal fissure Rubber band ligation None
occur
Transanal hemorrhoidal
dearterialization
Rubber band ligation • Remove band that is in too close
Transanal hemorrhoidal
dearterialization
hemorrhoidectomy
Injection sclerotherapy • No more than 2–5 mL of injectant
LigaSure™
hemorrhoidectomy
Cryotherapy None
hemorrhoid excision
dearterialization
Injection sclerotherapy • Minimize volume injected to
LigaSure™
hemorrhoidectomy
Laser hemorrhoidectomy None
Preventative measures would “none”
be appropriate in empty areas?
• Adequate stitches to prevent early
pull through of mucopexy
proximity to dentate line
• Remove stitch that is in too close
proximity to dentate line
• Often temporary from post
operative laxative use and impaired
sensation while healing
• Injection episodes minimum 6–
12 weeks apart
• Inject into submucosa (not more
superficial or deeper)
• From break down of wound edges
since no sutures are placed
None
prevent radial extravasation
• Careful elevation of mucosa from
sphincter with local anesthesia
injection
• Short bursts of energy to prevent
lateral spread of heat
• Sharp excision of anoderm for the
external component instead of with
LigaSure™ cautery
Rubber Band Ligation for Internal Hemorrhoids
Rubber band ligation is an office-based treatment for internal hemorrhoids; it does
not address any component of external hemorrhoids. Most practitioners will use this
method for grade II and some grade III hemorrhoids. An anoscope is placed and the
base of the hemorrhoid elevated with a forceps or suction device. A rubber band is
placed just proximal to the base of the hemorrhoid causing ischemia of the banded
tissue and resultant scarring and fixation of the hemorrhoid to the underlying tissue.
Practitioners vary in the number of hemorrhoids treated in one session. Some will
94 J. Cintron et al.
band all three hemorrhoids in one session while others treat individual hemorrhoids
over multiple sessions.
Complications of Rubber Band Ligation Complications
Early Complications
Most patients have mild tenesmus for 24–48 h post procedure [89–93]. If there is
immediate pain during placement, the band is too close to the dentate line and
should be removed and repositioned. It is helpful to ask the patient to compare the
sensation while the anoscope is in place and when the hemorrhoid is drawn up into
the banding ring before deployment of the rubber bands. Additionally, a suction
ligator tends to mimic the post banding sensation better than a grasping forceps. If a
sharp pain is felt, the hemorrhoid should be released and the ligator repositioned
more cephalad. If the pain is intense for more than 24 h, patients require operative
hemorrhoidectomy and removal of rubber band [92]. A case report exists of referred
sciatic pain from rubber band ligation that resolved with removal of the band [94].
Other minor complications occurring at very low rates are urinary retention, priapism, slipped bands, thrombosis of hemorrhoids, and itching [90]. These minor
complications occur at higher rates if multiple hemorrhoids are banded in a single
treatment [95–97].
Mild bleeding for the first few days is common and should be differentiated from
secondary bleeding at 10–14 days. When the banded tissue sloughs off, secondary
or delayed bleeding occurs in 1–2% of the patients and can be quite massive. Most
large case series have small numbers of hemorrhage requiring admission and
transfusion but not operations. Nonoperative hemor rhage is more common in
patients on warfarin and aspirin, but the rates are not high enough for these medications to be an absol ute contraindication. Cirrhosis and portal hypertension do not
appear to be a contraindication to rubber band ligation [97–99]. Topical application
of 1/100 Epinephrine on a Q tip causes significant arterial constriction and the
bleeding either becomes minimal or stops altogether. The round central dot can then
be cauterized with silver nitrate.
The most serious complications are infections. Perianal abscess and resulting
fistula can occur at the band site. Bacteremia occurs less than 1% of the time with a
single case report of the bacteremia causing endocarditis in a patient with a VSD
(Ventricular septal defect) [ 99–101]. There are case reports of pelvic sepsis
requiring IC U admission and IV antibiotics, necrotizing fasciitis causing death or
damage to sphincter requiring permanent fecal diversion [97, 102–104]. For this
reason, complaints of severe pain or fever, especially when delayed a few days and
associated with urinary retention, should be treated aggressively with repeat exam
in office or under anesthesia, removal of rubber bands debridement of necrotic
tissue, and intravenous broad spectrum antibiotics [103].
4 Hemorrhoids 95
Late Complications
Rubber band ligation can lead to problems with delayed healing from mucosal
ulceration lasting for months, and anal fissure [88]. Anal stenosis does not appear to
be a risk of banding, unlike many other hemorrhoidal procedures. A surprisingly
large number (16%) of patients have impaired continence scores when carefully
assessed during follow-up [105]. Recurrence rates are higher than with excisional
hemorrhoidectomy and increase with greater degrees of initial prolapse. Success
and recurrence rates vary widely in the literature, as does the definition of success.
Grade II hemorrhoids have approximately a 10% recurrence rate and grade III
hemorrhoids about a 25% recurrence rate on long-term follow-up [92, 97]. Educating patients regarding optimal bowel habits and encouraging lifelong maintenance of these habits may help to reduce the likelihood of recurrent symptoms.
Infrared Coagulation
Infrared coagulation (IRC) is an outpatient procedure usually used for grade I and II
hemorrhoids. This procedure uses infrared light directed at the mucosa with direct
pressure just proximal to the base of the hemorrhoid. Two to five pulses at each
hemorrhoid generates heat, promoting coagulation in vessels and hemorrhoidal
tissue 3 mm deep by 3 mm wide [106–108]. As the inflamed tissue heals, the
resulting scar fixes the hemorrhoid in place preventing prolapse.
Complications of Infrared Coagulation
Early Complications
No major complications from infrared coagulation have been reported. Patients
describe mild pain during the procedure and for 24–48 h post procedure. There can
be some discharge from the ulceration and mild post procedure bleeding is common
for the first week [89, 106, 109]. Two cases of post-procedure hemorrhage requiring
admission and observation, resolving without surgical intervention have been
reported [110] and low rates of urinary retention and anal fissures have been
reported [89, 111].
Late Complications
The primary long-term complication from IRC is inefficient management of hem-
orrhoidal symptoms. Only about two out of three patients have effective control of
symptoms after one treatment for grade I or II hemorrhoids [107, 112]. Over 50% of
grade III hemorrhoids will have recurrence of prolapse after 1 year [113].
Injection Sclerotherapy
Injection sclerotherapy is an office procedure designed to cause fixation of excess
hemorrhoidal cushions to the underlying tissue and prevent prolapse. It is used for
grade I and II hemorrhoids, since it is more effective to prevent bleeding hemorrhoids and less effective against prolapse. This is a long-standing procedure that has
96 J. Cintron et al.
been used for grade I and II hemorrhoids since the 1860s [114]. 2 –5 mL of phenol
with oil is injected into the submucosa above the dentate line. Repeat injections can
be delivered 6–12 weeks apart.
Complications of Injection Sclerotherapy
Early Complications
The early complications of injection sclerotherapy are well documented in
numerous case reports. They can be categorized into three different reactions: local,
septic, and urologic. Injection of the scler osant should be into the submucosa.
However, if it is injected either too superficially or deep, mucosal sloughing and
bleeding can occur. The sloughing can also occur with too large a volume of
sclerosant or injection sessions too close together. The sclerosant should not be
injected into the vascular space—unlike in lower extremity venous disease—since
this can cause hemorrhoid thrombosis [115].
Septic complications can vary from localized abscesses to severe bacteremia,
sepsis, necrotizing fasciitis, retroperitoneal abscess, and abdominal compartment
syndrome [116–119].
Urinary complications include hematuria, prostatitis, and rectourethral fi stula
especially if injection sclerotherapy is used for anterior injections [120, 121].
Late Complications
Anal stenosis can occur if too much sclerosant is injected with radial extravasation
[122]. Recurrence rates are as high as 30–60% with phenol injections [123]. This
high recurrence rate leads to more repeat procedures than other office-based pro-
cedures such as rubber band ligation or infrared coagulation [124].
Suture Hemorrhoidopexy
Suture hemorrhoidopexy is a technique that includes a combination of hemorrhoid
ligation with fixation. An absorbable suture is placed at the base of the hemorrhoid
to ligate all arterial inflow into the hemorrhoid plexus and a running stitch is
brought out along the hemorrhoid to ligate all redundant tissue and pexy to the
underlying muscle. No tissue is excised and all stitches are placed proximal to the
dentate line to minimize pain. The mucopexy is thought to align the hemorrhoidal
tissue and recreate a straight venous outflow tract. After the absorbable stitch
dissolves, the scar holds the hemorrhoid in place. This is distinct from transanal
hemorrhoidal dearterialization (THD) since the stitch is placed blindly and not
under Doppler guidance.
4 Hemorrhoids 97
Complications of Suture Hemorrhoidopexy
The most common complications are thrombosed external hemorrhoids (1.9%),
urinary retention (1.4%), and secondary hemorrhage (0.6%) [122]. There are no
reports of anal stenosis or infectious complications because there is minimal
necrosis of tissue [125].
Transanal Hemorrhoidal Dearterialization –Mucopexy
Transanal hemorrhoidal dearterialization (THD) with or without mucopexy is a
non-excisional method of managing hemorrhoids. It differs from suture hemorrhoidopexy in that the arterial inflow is identified using a specialized anoscope with
attached Doppler probe and then ligated. First described by Morinaga in the 1990s,
the Doppler is used to locate the hemorrhoidal arteries which are sutured to interrupt
the flow. Six to eight arteries are ligated on average. When mucopexy, also known
as recto-anal repair (RAR), is added to the procedure, the hemorrhoid is lifted back
to the anatomical position to reduce prolapse. Since no tissue is excised and all
stitches are placed proximal to the dentate line, postoperative pain is significantly
less than that experienced by patients after excisional hemorrhoidectomy and there
is faster return to baseline activities [126, 127]. The majority of studies have
evaluated grade II and III internal hemorrhoids but there is eviden ce that grade IV
hemorrhoids can be treated with THD and mucopexy with a recurrence rate of 10%
at one-year follow-up [128].
Complications of Transanal Hemorrhoidal Dearterialization
–Mucopexy
Early Complications
Postoperative bleeding occurs 1–5% of the cases and hemorrhage requiring return
to the operating room was reported once in several case series [127, 129, 130].
Overall ischemic complications are quite low since there is minimal mucosal
necrosis associated with the mucopexy. Some studies reported one to two patients
with fissures, indicating perhaps a small component of ischemia [126, 131]. After
the procedure, 1% of the patients may develop thrombosed external hemorrhoids
and require excision. Urinary retention occurs in 1–2% of patients [127, 128]. Some
mild pain is normal for the first few days; if pain is too severe, it is due to close
proximity of the sutures to the dentate line. If the suture pulls through, early
recurrent prolapse occurs [128].
Late Complications
As expected, there are no reports of incontinence after this procedure, since there is
minimal anal dilation and no excision of tissues [131, 132]. The long-term resolution of symptoms—prolapse, pain and bleeding—appears to be 85–90% but most
studies have evaluated the procedure in grade II and III hemorrhoids only [126,
98 J. Cintron et al.
127, 131, 133]. Undergoing THD does not preclude patients from subsequent
procedures if necessary.
LigaSureTMHemorrhoidectomy
The LigaSure™ (Medtronic, Minneapolis, MN) technique of hemorrhoidectomy is
a modern modification of the classic Ferguson hemorrhoidectomy [134]. The
hemorrhoid is grasped with forceps and excised with LigaSure™ cautery. The
wound itself is left open to heal or sutured closed. This technique is used to treat
grade III and IV hemorrhoids and can be used to remove an external component at
the same time. Proponents of LigaSure™ hemorrhoidectomy note the advantages of
decreased operative time, less blood loss, and decreased postoperative pain.
Complications of LigaSureTMHemorrhoidectomy
Early Complications
Multiple meta-analyses and randomized control trials have compared complications
of LigaSure ™ hemorrhoidectomy with conventional Ferguson hemorrhoidectomy
and have failed to demonstrate statistically different rates of postoperative bleeding,
urinary retention, or incontinence of gas or stool. Incontinence is likely secondary
to impaired sensation during healing process or postoperative laxative use since it
resolves within a few weeks after surgery [134–137]. There are only a few case
reports of bleeding requiring return to the operating room for control. The LigaSure™ hemorrhoidectomy uses bipolar energy to coagulate the base of the hemorrhoid and scissors to transect the tissue. If the hemorrhoid is not transected
precisely along the line of coagulation, the edge may bleed [134]. LigaSure™
hemorrhoidectomy has less immediate postoperative pain and faster return to work
for the patient than conventional hemorrhoidectomy. However, since the mucosal
edges are not sutured, the wounds can break down and cause some pain from open
wounds [138, 139]. These open wounds can cause increased temporary pruritus and
mucus discharge [136]. There are no reports of perineal sepsis or abscess from
wound break down and only one report of superficial infection requiring IV
antibiotics [134].
Late Complications
The most concerning long-term complication of LigaSure™ hemorrhoidectomy is
anal stenosis. Most studies report only a few occurrences per study and a few
different theories on etiology. If elevation of the submucosa with local anesthetic is
not adequate, the underlying sphincter could be damaged by thermal spread and
cause stenosis [140] LigaSure™ is often used for combined external and internal
hemorrhoids and if the anoderm is not excised sharply with scalpel or scissors, the
scarring can cause stenosis [141]. Other authors have advocated short bursts with
the energy device to reduce lateral spread of heat [142].
4 Hemorrhoids 99
Laser Hemorrhoidectomy
Laser hemorrhoidectomy is a generic term that encompasses two separate techniques and two types of lasers. The most popular technique is similar to Milligan–
Morgan or Ferguson conventional hemorrhoidectomy but the dissection is done
with laser instead of cautery/scalpel/scissors. The thought was that the laser would
provide less tissue destruction than conventional cautery. Wh ile most often done
with a CO
surface laser ablation of the hemorrhoid with CO
laser, Nd:YAG lasers have also been studied. The second technique is
2
or Nd:YAG laser causing
2
vaporization and/or coagulation of the hemorrhoidal tissue. The laser can be placed
using a direct contact or noncontact technique [143, 144]. This method was
developed in the 1980s and has since fallen out of favor. There are few randomized
control trials comparing laser hemorrhoidectomy to conventional hemorrhoidectomy and only one comparing cost in the era of outpatient hemorrhoidectomies.
Complications of Laser Hemorrhoidectomy
Early Complications
The early complications of a conventional style hemorrhoidectomy performed with
laser are similar to any excisional hemorrhoidectomy. Urinary retention, bleeding,
infection and skin tags occur at low rates, similar to that of conventional excisional
hemorrhoidectomy [145–147]. Some studies reported lower levels of pain and
faster return to work for patients than conventional hemorrhoidectomy but others
found no statistical significance [148, 149]. While there were higher rates of wound
dehiscence at 10 day follow-up there was no impact on long-term healing or
stenosis [148]. There was a case report with evidence of laser damage to underlying
sphincter and hemorrhoidal arteries leading to fatal hemorrhage [150]. Proponents
of the surface ablation method were enthusiastic that, as a topical method, it would
be associated with less pain and minimal scarring compared to conventional
hemorrhoidectomy. However, even with the surface coagulation of the mucosa,
enough underlying damage can be done to the sphincters promoting stenosis [151].
Late Complications
There were no long-term studies that evaluated recurrence rates after laser hemorrhoidectomy. There were reports of anal stenosis after laser hemorrhoidectom y
indicating underlying sphincter damage [144].
Cryotherapy
Cryotherapy for hemorrhoids was an office-based method used in the 1970s to
freeze external and internal hemorrhoids. A probe with liquid nitrogen or liquid
nitrous oxide was held against the hemorrhoid causing intracellular ice crystallization and cell membrane destruction [146, 152]. Immediately after the procedure,
the wound develops intense edema and drainage. As the wound heals, the excess
tissue sloughs and is replaced by healthy tissue. With freezing, a white line clearly
100 J. Cintron et al.
marks healthy versus destroyed tissue allowing for precise application. This technique has been abandoned because the open wounds led to prolonged healing, foul
smelling drainage and pain [144].
Complications of Cryotherapy
Early Complications
Despite advocates stating that cryotherapy caused no pain during the procedure
because the nerve endings were frozen along with the hemorrhoids, most patients
reported discomfort lasting for approximately 2 weeks after the procedure [152,
153]. The primary reason this method was abandoned was that patients found the
degree of discharge and drainage unacceptable [146, 152, 154]. A small number of
patients developed bleeding in the second postoperative week when the greatest
degree of slough occurred [153, 154]. Skin tags developed in 25% of patients,
although only a few of these were significant enough to require operative removal
[152, 154].
Late Complications
Cryotherapy was a procedure in use for only decade with very few long-term
follow-up studies. Therefore, the recurrence rates and other late complications are
unknown. Oh et al. reported an 11% recurrence rate of the hemorrhoids although it
is unclear what the true length of follow-up was for his patients [153].
Traditional Chinese Medicine
Traditional Chinese medicine considers hemorrhoids an imbalance of Yin and Yang
with Damp-Heat (traditional concepts) as the underlying pathology. A large variety
of herbs are used in combination to counteract these imbalances. Traditionally, the
herbs are taken orally. However the Western method of injection sclerotherapy has
been modified, with the injection of Xiaozhiling into the hemorrhoid to cause
sclerosis. Xiaozhiling is an extract of Galla chinensis and Alumen herbs [155]. The
most common oral compounds are Radix and Sephora species [156]. It is difficult to
determine efficacy because recurrence rates were quoted as less than 1% and most
studies did not report complications [155]. Injection of Xiaozhiling likely has
similar complications to Western injection sclerotherapy of sloughing, infection,
and anal stenosis. Many Acupuncture clinics offer treatment for hemorrhoids,
however, there were no clinical studies studying its efficacy.
Hemorrhoids and Cancer
Colon, rectal, and anal cancer can present with rectal bleeding, but the most
common cause of rectal bleeding is hemorrhoids. Care must be taken by primary
care physicians, ER physicians and general surgeons who initially see complaints of
rectal bleeding to do a complete history and physical including rectal exam and
consider the need for endoscopy to rule out malignant etiologies prior to assuming a
4 Hemorrhoids 101
benign diagnosis of hemorrhoids. Anal cancer and melanoma are especially rare
diagnoses that must be considered, since there is evidence that a diagnosis of
“hemorrhoids” can delay necessary treatment [157]. Anal melanoma, while very
rare, is the third most common site of primary melanoma [158].
Hemorrhoidectomy is one of the most commonly performed surgical procedures
and pathologic management of the specimens has been debated. Routine pathologic
evaluation is expensive but recent studies show rates of 1.4–3 .2% of normal
appearing hemorrhoid specimens with malignancy on microscopic examination
[159, 160]. Adenocarcinoma, squamous cell carcinoma, melanoma, and carcinoid
have all been identified [160, 161 , 162, 163 ]. With the increasing prevalence of anal
squamous cell cancer, routine histopathological examination should be considered
[160, 162].
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