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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1513_Библиотеки_им_академика_М_И_Перельмана.pdf
In: Hemorrhoids: Symptoms, Diagnosis… ISBN: 978-1-60876-478-5
Authors: P. Salinitri et al., pp. 25-54 © 2010 Nova Science Publishers, Inc.
Chapter 2
TREATMENT OF HEMORRHOIDS
Marcello Picchio
1
*, Giuseppe Marino
,
* Ettore Greco*
and Erasmo Spaziani
†
* Department of Surgery, Hospital ―P. Colombo‖, Via Orti Ginnetti 7,
00049 Velletri, Rome, Italy
†
Department of Surgery, University of Rome ―La Sapienza‖–Polo Pontino,
Hospital ―A. Fiorini,‖ Via Firenze, 04019 Terracina, Latina, Italy
ABSTRACT
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
1
Correspondence to: Marcello Picchio, MD, Viale Giulio Cesare 58, 04100 – Latina (Italy).
Tel.: +39773695488; E.mail: marcellopicchio@libero.it
Marcello Picchio, Giuseppe Marino, Ettore Greco et al.
26
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 hemor-
rhoidopexy 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 hemorrhoid-
opexy was reported. In particular, when compared with conventional
hemorrhoidectomy, stapled hemorrhoidopexy resulted in a higher incidence
of recurrence and a worse clinical outcome. The higher recurrence rate may
be sometimes the result of inappropriate patient selection. Therefore, with the
presence of large-volume prolapsing internal hemorrhoids, we could imagine
that stapled hemorrhoidopexy using two staplers would not be appropriate.
Further prospective studies with more attention to appropriate patient
selection are necessary to assess the efficacy of the various surgical
procedures for hemorrhoids.
INTRODUCTION
Anal cushions are normal structural components of the anal canal, serving as
a conformable plug to ensure its complete closure. Hemorrhoids should be
considered pathologic when symptomatic prolapse occurs. Hospital-based
proctoscopy studies reported the presence of hemorrhoids in up to 86% of
patients, even though many of them were asymptomatic [1]. The need for
treatment is influenced by the severity of symptoms. Management should aim to
control symptoms and can be broadly classified as conservative, alternative and
surgical.
Treatment of Hemorrhoids
27
CONSERVATIVE THERAPY
Minimizing constipation and the prolonged straining that may be associated
are among the main purposes of lifestyle modifications recommended in primary
care to manage hemorrhoid disease. The effectiveness of increasing fluid intake as
a treatment for constipation remains unknown. Dietary fiber intake may alleviate
occasional and moderate constipation [2,3]. A recent meta-analysis confirmed that
fiber supplements moderately improve overall symptoms and bleeding and should
be recommended in grade I–II hemorrhoids [4]. Because diarrhea exacerbates
hemorrhoidal symptoms, controlling it with fiber, antimotility agents and specific
treatment of any underlying cause will likely be of benefit. The traditional
recommendation to avoid alcohol, spices and pepper is justified because they were
recognized as risk factors for hemorrhoidal crisis [5]. Other lifestyle modifications
such as improving anal hygiene and taking sitz baths are used in primary care and
may help in the treatment and prevention of hemorrhoids, although the evidence
for this is lacking.
Medical treatment includes both oral and local drugs. Venotonics represent a
group of drugs that may improve venous tone and lymphatic drainage and reduce
capillary hyperpermeability by protecting the microcirculation from inflammatory
processes. Flavonoids, including diosmin, hidrosmin, hesperidin and rutosides, are
the most popular. Micronised purified flavonoid fraction is an oral phlebotropic
drug made up of 90% micronised diosmin and 10% flavonoids expressed as
hesperidin, particularly favored and marketed in Europe and the Far East.
Although flavonoids seem to have a beneficial effect in the treatment of
symptomatic hemorrhoids, larger and better-designed trials are needed to
strengthen the quality of evidence [6].
Calcium dobesilate (calcium 2,5-
dihydroxybenzenesulfonate) is a drug with the ability to decrease capillary
permeability, platelet aggregation and blood viscosity and to increase lymphatic
transport. Together with a high-fiber diet it achieved both improvement of
symptoms and reduction of anitis in patients suffering from acute attacks of grade
I–II hemorrhoids [7]. There is a variety of topical drugs aiming to alleviate
symptoms with different mechanisms. Over-the-counter topical preparations that
contain a combination of local anesthetics, corticosteroids, astringents and
antiseptics are largely used, although there is no evidence supporting their
efficacy. In particular, long-term use of steroid creams should be discouraged
because it can permanently damage or cause ulceration of the perianal skin [8].
Topical glyceryl trinitrate is a nitric oxide donor and produces vasodilatation of
blood vessels with relaxation of the internal anal sphincter muscle (chemical
sphincterotomy). Spasm of the internal anal sphincter may be a factor contributing
Marcello Picchio, Giuseppe Marino, Ettore Greco et al.
28
to symptoms either in patients with hemorrhoids or after surgery. In particular,
patients with grade I–II hemorrhoids and high maximum resting anal canal
pressure benefit from topical glyceryl trinitrate [9]. After hemorrhoidectomy, both
pain decrease and accelerated healing are obtained with the local application of
glyceryl trinitrate [10].
Conservative therapies may relieve symptoms in early stages but cannot
definitively cure hemorrhoids.
ALTERNATIVE THERAPY
Alternative treatment includes a number of ambulatory interventions that
usually do not need anesthetics.
SCLEROTHERAPY
Sclerotherapy consists of injection of sclerosing substances, normally 5% oily
phenol, in the submucosa of the proximal part of the hemorrhoidal bulk 1 cm
above the dentate line with the aid of a syringe and a proctoscope (Figure 1). It is
cheap and easy to perform, but it has a high failure rate. Complications with
sclerosants are rare but include local infections, prostatitis, portal pyemia, and
erectile dysfunction [11].
Conservative treatment with fiber supplementation may
be as effective as injection sclerotherapy [12].
A novel sclerosing agent containing the active ingredient aluminum
potassium sulfate was proposed for the treatment of grade III and IV hemorrhoids
with early satisfactory results [13].
CRYOTHERAPY
This procedure consists in freezing the external and internal hemorrhoids with
liquid nitrogen to –196°C or liquid nitrous oxide to –89°C. The main disadvantage
of this technique is the prolonged healing time, with resultant pain and drainage.
At present, cryotherapy is substantially disappeared.
Treatment of Hemorrhoids
29
Infrared coagulation, bipolar diathermy, direct-current electrotherapy, laser
therapy
These procedures all rely on the coagulation, occlusion, and obliteration or
sclerosis of the hemorrhoidal vascular pedicle above the level of the anal
transition zone.
Figure 1. The patient is laid down in the left lateral position. A proctoscope with a wide-
bore is inserted into the anal canal to illuminate the hemorrhoid to be injected. Injection
should be done at the base of the hemorrhoid, above the dentate line, where no or little
pain should be felt. Once the correct injection site is located, the needle is inserted about
1 to 2 cm deep in the submucosal space, parallel to the anal canal. About 3 to 5 ml of
sclerosant is injected slowly, allowing time for dispersion in the tissue. Injection should be
stopped, if it causes pain. In most patients, a maximum of three separate injections to the
base of the hemorrhoids are given.
Infrared photocoagulation consists of coagulating hemorrhoids by means of
infrared radiation from a tungsten-halogen lamp via a polymer probe tip.
According to two randomized studies, hemorrhoidal bleeding was successfully
controlled in 67–96% of patients with first- or second-degree hemorrhoids
[14,15]. Complications, including pain and bleeding, are uncommon.
Bipolar diathermy aims to produce tissue destruction by the heat generated by
a bipolar probe. It has been used to treat first-, second-, and third-degree internal
Marcello Picchio, Giuseppe Marino, Ettore Greco et al.
30
hemorrhoids with success rates range from 88% to 100% and failure to eliminate
prolapse in up to 20% of patients [16].
Direct-current electrotherapy requires the prolonged (up to 14 minutes)
application of 110V direct current (up to 15 mA) to the base of the hemorrhoidal
complex. A prospective, crossover trial between direct current electrotherapy and
medical therapy found no difference [17].
Both Nd:YAG and CO
2
laser have been used to coagulate grade I–II
hemorrhoids by using a contact probe. However, its use was not recommended
because it may destroy muscles in addition to hemorrhoids with rather disastrous
results [18].
RUBBER-BAND LIGATION
Rubber-band ligation is the most commonly used alternative therapy,
originally proposed by Blaisdell and later modified by Barron [19,20]. The
procedure consists in applying an elastic band at the base of the hemorrhoids, well
proximal to the dentate line (Figure 2). At present the commonest practiced
technique is the suction method, which makes the procedure a one-person effort.
The procedure is performed through a proctoscope, which is inserted and placed
about 2 cm above the dentate line. The hemorrhoidal cushion is allowed to
prolapse into the lumen of the proctoscope. After introduction of the McGown
ligator, suction is applied until the tissue is taut into the drum and the trigger is
released expelling a rubber O-ring around the base of the hemorrhoid. The rubber
band must be applied at least 1–2 cm above the dentate line. If it is placed too far
distally, near the anal transition zone, severe pain usually occurs due to the
presence of somatic sensory afferents. The procedure aims to strangulate
hemorrhoid, which becomes necrotic and sloughs off, while the underlying tissue
undergoes fixation by fibrotic wound healing. The procedure may also be
performed using a flexible endoscope with the same technique applied for the
treatment of esophageal and gastric varices [21]. The success rates of the method
vary, depending on the degree of hemorrhoids treated, length of follow-up, and
criteria for success. Wrobleski et al. [22] reported that 80% of their patients
improved and 69% were symptom-free at a mean follow-up of 5 years. Steinberg
et al. [23]
reported 89% patient satisfaction at a similar follow-up interval, but
only 44% of their patients were symptom free.
Many authors reported that
recurrence rate may be as high as 68% at 4 or 5 years of follow-up and symptoms
usually respond to repeated ligation, but only 10% of such patients requires
excisional hemorrhoidectomy [24,25].
Treatment of Hemorrhoids
31
Figure 2. The elastic band is positioned at the base of the hemorrhoid, well proximal to the
dentate line.
A review of 39 studies incorporating 8,060 patients undergoing rubber-band
ligation showed post-banding complications in the form of severe pain in 5.8%,
hemorrhage in 1.7%, infection in 0.05% anal fissure and fistula in 0.4% [26].
CONCLUSION
Two meta-analyses found that rubber-band ligation was more effective than
sclerotherapy, less likely to require additional therapy than either sclerotherapy or
infrared photocoagulation, and more likely to cause pain [27,28]. When compared
with surgery, rubber-band ligation should be adopted as the procedure of choice
for grade II hemorrhoids, as it has results similar to those of operation but without
the side effects [29].
Marcello Picchio, Giuseppe Marino, Ettore Greco et al.
32
Combined sclerotherapy and rubber-band ligation was proposed for early
hemorrhoids and incomplete mucosal prolapse. The procedure can be performed
in an office setting. Each hemorrhoid must be first injected with 5% phenol in
almond oil, with subsequent rubber-band ligation. This technique guarantees good
results with low rates of recurrence and complications [30].
Each method of alternative therapy was compared with one or more of the
others in randomized controlled trials, but adequate studies considering all the
techniques are lacking. At present, the exact role of each technique in the treat-
ment of hemorrhoids is still controversial.
SURGICAL THERAPY
Surgery is the most effective treatment for hemorrhoids and is particularly
recommended in prolapsing piles during defecation that may be reduced manually
(grade III) and irreducible hemorrhoids (grade IV) with respect to nonoperative
techniques [28]. Other indications for surgery are failure of nonoperative manage-
ment, patient preference and concomitant conditions (such as fissure or fistula)
that require surgery. Contraindications are generally relative. Surgical option
should be carefully proposed if the anesthesiologic risk is high, serious hemostatic
and/or coagulative disorders are present, and the presence of anal sphincter and/or
continence impairment may lead to postoperative occurrence and/or worsening of
incontinence. Caution is also required if Crohn‘s disease is present [31].
PROCEDURES
Numerous methods have been proposed for the surgical therapy of
hemorrhoids. Anal dilatation and lateral internal sphincterotomy aimed at
relieving the elevated anal sphincter pressure [32,33].
Anal sphincter hypertone
was presumed as one of the etiologic factors contributing to the disease [34].
These procedures were abandoned because results were not satisfactory and
incontinence was a serious and frequent complication [33,35-37].
Hemorrhoidectomy, performed with various techniques, focuses on resection
of both internal and external hemorrhoids and ligature of the main supplying
vessels. The rationale of these procedures is based on the theory that hemorrhoids
are caused by vascular hyperplasia of the arteriovenous network within the
anorectal submucosa.
Treatment of Hemorrhoids
33
In 1937, Milligan and Morgan [38] described their technique to perform
surgical excision of hemorrhoids. The hemorrhoid is dissected out from the
underlying anal sphincter, the vascular pedicle is ligated, and the mucosal defects
are left open and allowed to granulate by secondary intention (Figure 3). Different
instruments are available to perform excision of the hemorrhoidal tissue,
including electrocautery, scissors, scalpel, laser, bipolar scissors, linear staplers,
LigaSure (Valleylab, Tyco Health Care Group), or Harmonic Scalpel (Ethicon
Endo-Surgery, Inc.).
Ferguson‘s (closed) hemorrhoidectomy was developed in 1952 in the United
States [39]. After excision of each hemorrhoid component, the ensuing defect is
closed primarily.
Sir Alan Parks [40] in 1956 described a technique that dissects the submucosa
containing the hemorrhoidal tissue with transfixation of the uppermost part of the
pedicle. Reconstruction of the anal mucosa is done by fixing the mucosal flaps down
to cover the wound, incorporating a largish bundle of internal sphincter. An area is
deliberately left bare between the pedicle ligature and the mucosal fixation stitch.
Whitehead‘s hemorrhoidectomy, described by Whitehead [41] in 1882, was
devised to eradicate enlarged internal hemorrhoidal tissue in a circumferential
fashion and to relocate the prolapse dentate line, which often is a component of
prolapsing hemorrhoids.
At present, this procedure is rarely performed because of
high complication rates, including stricture, loss of anal sensation, and
development of mucosal ectropion [42].
Doppler-guided hemorrhoidal artery ligation was first described in 1995 by
Morinaga et al. [43].
It is performed using a specially-designed proctoscope with
an inbuilt Doppler probe that can locate feeding arteries; these vessels are then
ligated using absorbable sutures. Disrupting the inflow to the vascular cushion is
thought to reduce the size of the hemorrhoid.
Longo [44] recently proposed the use of a circular stapler instrument to
perform hemorrhoidopexy. Thompson [45] suggested that the nature of
hemorrhoids is the weakening and fragmentation of the tissue supporting the
hemorrhoidal cushions, due to ageing and repeated passage of hard stool, leading
to their descent and prolapse. The technique aims at reducing the hemorrhoidal
prolapse and transecting the superior hemorrhoidal arteries.
Marcello Picchio, Giuseppe Marino, Ettore Greco et al.
34
A)
B)
Figure 3. (Continued)