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HEMORRHOIDS: SYMPTOMS,
DIAGNOSIS AND TREATMENT
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liability is assumed for incidental or consequential damages in connection with or arising out of information
contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in
rendering legal, medical or any other professional services.
HEMORRHOIDS: SYMPTOMS,
DIAGNOSIS AND TREATMENT
PHILIP D. SALINITRI
AND
BENJAMIN M. RASPALLO
EDITORS
Nova Science Publishers, Inc.
New York
Copyright © 2010 by Nova Science Publishers, Inc.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or
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NOTICE TO THE READER
The Publisher has taken reasonable care in the preparation of this book, but makes no expressed
or implied warranty of any kind and assumes no responsibility for any errors or omissions. No
liability is assumed for incidental or consequential damages in connection with or arising out of
information contained in this book. The Publisher shall not be liable for any special,
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Independent verification should be sought for any data, advice or recommendations contained
in this book. In addition, no responsibility is assumed by the publisher for any injury and/or
damage to persons or property arising from any methods, products, instructions, ideas or
otherwise contained in this publication.
This publication is designed to provide accurate and authoritative information with regard to the
subject matter covered herein. It is sold with the clear understanding that the Publisher is not
engaged in rendering legal or any other professional services. If legal or any other expert
assistance is required, the services of a competent person should be sought. FROM A
DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE
AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS.
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA
Hemorrhoids : symptoms, diagnosis, and treatment / editors, Philip D. Salinitri and Benjamin
M. Raspallo.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61728-182-2 (Ebook)
1. Hemorrhoids. I. Salinitri, Philip D. II. Raspallo, Benjamin M.
[DNLM: 1. Hemorrhoids. WI 605 H489 2009]
RC865.H46 2009
616.3'52--dc22
2009040470
Published by Nova Science Publishers, Inc.
New York
CONTENTS
Preface vii
Chapter 1 Hemorrhoids: Symptoms, Diagnosis and Treatments 1
Francesco Di Fabio and Philip H. Gordon
Chapter 2 Treatment of Hemorrhoids 25
Marcello Picchio, Giuseppe Marino
,
Ettore Greco and Erasmo Spaziani
Chapter 3 Stapled Haemorrhoidopexy: From Pathology
to Clinical Outcome and Reinterventions 55
Pierpaolo Sileri, Stefano D’Ugo,
Domenico Benavoli, Vito M. Stolfi
and Achille Gaspari
Chapter 4 Hemorrhoidopexy Using PPH (Procedure for
Prolapse and Hemorrhoids) 79
Manousos-Georgios Pramateftakis,
Dimitrios Kanellos
and Ioannis Kanellos
Chapter 5 Excision Hemorrhoidectomy – New Methods
to Improve Outcomes of an Old Technique 107
Kok-Yang Tan and Francis Seow-Choen
Chapter 6 Videoanoscope Assisted Stapled
Hemorrhoidopexy: A Novel Procedure 121
Ali Dogan Bozdag
Contents
vi
Chapter 7 New Option in the Treatment of Hemorrhoidal
Disease: Doppler Guided Transanal
Hemorrhoidal Dearterialisation 149
Ramón Cantero
Chapter 8 Anal Ultra Slow Wave : A Mysterious
Manometric Finding with Hemorrhoids 161
Hiroyuki Kayaba
Index 173
PREFACE
Hemorrhoidal disease is the consequence of pathological changes of
fibrovascular anal cushions producing symptoms. Symptomatic hemorrhoids may
include bleeding, prolapse, pruritus, soiling, thrombosis and pain. Different
invasive treatment modalities are explored, which vary from office treatment
(rubber bands, sclerotherapy, infrared coagulation, cryotherapy) and surgical
procedure (hemorrhoidectomy, stapled hemorrhoidopexy). Only 5-10% of
patients require surgery. The authors of this book review and discuss recent
innovations of post-hemorrhoidectomy pain control and wound healing. Stapled
haemorrhoidopexy (SH) as an attractive alternative to conventional
haemorrhoidectomy (CH) is looked at as well. In addition, new techniques
(Doppler guided transanal haemorrhoidal dearterialisation) with new devices in
order to attain improved patient satisfaction (THD and haemorrhoid laser
procedure) is analyzed. Finally, anal ultra slow wave (USW), a manometric
finding observed in some patients with hemorrhoids, is presented and its clinical
relevance is discussed.
Chapter 1 – Hemorrhoidal disease is the consequence of pathological changes
of fibrovascular anal cushions producing symptoms. Symptomatic hemorrhoids
may present with bleeding, prolapse, pruritus, soiling, thrombosis and pain. All
the potential differential diagnoses of hemorrhoidal disease must be considered in
the diagnostic process, as many different colorectal diseases may cause
overlapping signs and symptoms.
Treatment includes conservative management (dietary management and
lifestyle modifications), which may be effective in the treatment of grade I and
some grade II hemorrhoids. Patients still reporting symptoms after conservative
management may be candidates for minimally invasive office procedures. These
are recommended for most patients with refractory grade I, grade II or grade III
Philip D. Salinitri and Benjamin M. Raspallo
viii
hemorrhoids. Surgical hemorrhoidectomy is the treatment of choice for grade IV
hemorrhoids, strangulated hemorrhoids and some symptomatic grade III
hemorrhoids. Surgical excision is also indicated when minimally invasive office
procedures fail to relieve hemorrhoidal symptoms and when patients are not able
to tolerate office procedures. Only 5-10% of patients require surgery. Surgical
hemorrhoidectomy is considered the most effective treatment for hemorrhoids
with fewer recurrences. However, it is associated with more pain and
postoperative disability compared to minimally invasive office procedures.
Chapter 2 - Hemorrhoids are one of the most frequent pathologies, with an
estimated prevalence of 4.4%. Treatment strategies are various and can be divided
into conservative therapies (either paharmacological or instrumental) and surgery.
Medical therapy includes vasoactive agents (flavonoids) and various topical
agents aiming to reduce symptoms.
Instrumental therapies (elastic band ligation, sclerotherapy, cryotherapy,
cauterization, etc.) can be effective in about 70–90% of patients in the short term
with a significant rate of recurrence in the long term.
Surgical therapy guaranties satisfactory results, which are significantly better
that those obtained with conservative therapies, especially for grade III and IV
hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorroids,
with closure (Fergusson‘s technique) or without closure (Milligan-Morgan
procedure) of the ensuing defect. This traditional approach is effective, but causes
significant postoperative pain because of wide external wounds in the innervated
perianal skin. Stapled hemorrhopidopexy, proposed by Longo, has gained vast
acceptance because of less postoperative pain and faster return to normal
activities. This technique aims to reduce the hemorrhoidal prolapse by
repositioning the hemorrhoidal masses into the anal canal and by reducing the
venous engorgement with transaction of feeding arteries and redundant mucosa.
The procedure results in a stapled mucosa anastomosis in the rectum, at least 3 cm
above the dentate line where sensitive receptors are few, without any dissection or
trauma in the area of anal mucosa and anoderm.
The superiority of stapled hemorrhoidopexy in terms of less postoperative
pain and quicker recovery was confirmed by a recent systematic review of 25
randomized trials comparing stapled hemorrhoidopexy and conventional
hemorrhoidectomy. However, the long-term control of hemorrhoid symptoms as
well as the recurrence of prolapsing hemorrhoids should be addressed in order to
draw a final conclusion about the efficacy and effectiveness of stapled
hemorrhoidopexy. In the recent literature, a significant incidence of recurrence
after stapled hemorrhoidopexy was reported. In particular, when compared with
conventional hemorrhoidectomy, stapled hemorrhoidopexy resulted in a higher