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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1520_Библиотеки_им_академика_М_И_Перельмана
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17
2 Hemorrhoids
preparations, contains a variety of ingredients including bismuth oxide, balsam
peru, and zinc oxide and has mild antiseptic, protective, and astringent properties
(i.e., constricts blood vessels). Online advice from http://www.netdoctor.co.uk
states that Anusol suppositories inserted into the rectum are more suitable for treat-
ing internal piles. These products are enormously popular – with nearly 1.5 million
prescriptions for hemorrhoidal preparations each year, with many millions more
bought over the counter. Patients use these preparations, and their anal symptoms
improve. They return to these agents if the symptoms return, not realizing that the
natural history of hemorrhoidal symptoms is for them to fl uctuate and the symptoms
would likely to have improved with simple hygiene.
In France and other parts of the world, venotonic drugs (fl avinoids) are com-
monly taken to help hemorrhoid symptoms. There is at least some evidence to sup-
port the use of this treatment. In a meta-analysis of nine studies (949 patients and
204 events) comparing fl avonoids with placebo, there was a 67% reduction in the
relative risk of bleeding or remaining symptomatic, in those taking fl avonoids [
6 ] .
However, these agents are not currently available in the UK.
2.7.2 Outpatient Treatment
Several outpatient treatments for symptomatic hemorrhoids are available. In the
UK, the most common outpatient treatment is by rubber band ligation, although
injection sclerotherapy is preferred by some surgeons. Other treatments include
infrared coagulation and cryotherapy, although the latter has been all but abandoned
because of troublesome mucus discharge after treatment. The mechanism of action
of these outpatient treatments is to produce cicatrization at the base of the hemorrhoid,
reducing blood supply and “fi xing” the hemorrhoidal cushion within the upper anal
canal.
2.7.2.1 Rubber Band Ligation
The target of rubber band ligation is the base of the anal cushion, avoiding at all
costs the dentate line and any surface with somatic sensation. The original Barron
technique involved pulling the base of the hemorrhoid into the ring applicator.
This required at least three hands and in most hospitals has been superseded by a
range of disposable suction band applicators. Even when done carefully, rubber
band ligation can be an upsetting and traumatic procedure for the patient (particu-
larly young uptight men), who can feel unwell and faint after the procedure. Some
surgeons only ligate hemorrhoids in the surgical day unit or the endoscopy room
with a facility for the patient to recover after the procedure, although with care it
is possible to perform three-site ligation in the outpatient clinic (the author’s
preference).
18
J.G. Williams
Bands are applied above each hemorrhoidal cushion to be treated. Gentle move-
ment of the proctoscope brings each site into view. If a band is placed too low, the
patient will experience immediate pain, and the band should be removed. This can
usually be achieved with a small scalpel blade, with immediate relief of the symp-
toms. A strong desire to evacuate the bowels is a common feature of band ligation
and usually passes quickly.
Rubber band ligation is recognized to be more painful than other outpatient treat-
ments and is not without its problems. Signifi cant complications include:
Pain – which may last for some days after the procedure and requires strong •
analgesia.
Bleeding – minor bleeding after the procedure is common. Secondary hemor-•
rhage is unusual but can be spectacular (the risk is around 1 in every 700 bands
applied), requiring hospital admission and suture ligation under GA. Band liga-
tion should be avoided in patients on warfarin or clopidogrel, as these drugs
increase the risk of hemorrhage.
Pelvic sepsis and death – fortunately is very rare and originally was associated •
with immunosuppressed young men. Sinister clinical features heralding local
sepsis are perineal pain, urinary retention, and fever, occurring from 2 to 7 days
after treatment and leading to progressive edema and cellulitis affecting the
perineum, thighs, and abdomen.
How Effective Is Rubber Band Ligation?
It is surprising how little good scientifi c study has been performed on the mecha-
nism of action and outcome of hemorrhoidal band ligation, considering how
many patients are treated in the UK. Most surgeons agree that the treatment has
a short-term success rate of about 70%, but more than one treatment may be
required.
In a meta-analysis of 18 studies of outcome after hemorrhoid therapy [ •
7 ] , rubber
band ligation was superior to sclerotherapy as treatment for all hemorrhoids
( P = 0.005) as well as for hemorrhoids stratifi ed by grade (grades 1–2; P = 0.007;
grade 3 hemorrhoids, P = 0.042), with no difference in the complication rate
( P = 0.35).
Patients treated with sclerotherapy ( • P = 0.031) or infrared coagulation ( P = 0.0014)
were more likely to require further therapy than those treated with rubber band
ligation, although pain was greater after rubber band ligation ( P = 0.03 for scle-
rotherapy; P < 0.0001 for infrared coagulation).
Most published studies examine short- and medium-term outcome. If success
were defi ned as permanent relief of symptoms or a marked improvement in symp-
tomatology with rare manifestation of bleeding (<1/month), the proportion of
patients free from hemorrhoid symptoms after rubber band ligation decreases as a
function of time (Fig.
2.1 ).
19
2 Hemorrhoids
2.7.2.2 Injection Sclerotherapy
Injection sclerotherapy is performed using a purpose designed Gabriel syringe,
which allows injection of 2–3 ml of a viscous solution of 5% phenol in almond oil
at each of the three hemorrhoidal sites.
The aim is to place the sclerosant in the submucosa at the base of the cushion at
the junction of the normal pink rectal mucosa and the purplish mucosa of the cush-
ion. The injection should be painless – any pain means the tip of the needle needs to
be repositioned or the procedure abandoned. Particular care must be taken if inject-
ing the midline anteriorly because of the proximity of the prostate and urethra in the
male and the vagina in the female.
How Effective Is Sclerotherapy?
One large study measured the medium- to long-term outcome following single-ses-
sion large-dose injection sclerotherapy for symptomatic hemorrhoids (all had rectal
bleeding) in 189 patients after single-session, large-dose (3 × 5 ml) phenol injection
therapy. At 4-year follow-up, 53 patients (28.0%) were cured, 26 (13.7%) were
improved, 35 (18.5%) remained unchanged, 59 (31.2%) deteriorated, and 16 (8.5%)
required surgical intervention . Among the patients who were not cured, symptoms
were minimal in 50%. Sclerotherapy was associated with a reduced incidence of
bleeding ( P < 0.05), but an increase in diffi culty in perineal cleaning was observed
( P < 0.05). The authors concluded that “single-session sclerotherapy provides only
short-term benefi ts in the majority of patients with symptomatic haemorrhoids” [ 8 ] .
0.4
0.5
0.6
0.7
0.8
0.9
0
0.1
0.2
0.3
200 400 600 800 1,000 1,200 1,400
Fig. 2.1 The proportion of patients free ( y -axis) from hemorrhoid symptoms after rubber band
ligation ( x -axis is number of days) Data from Iyer et al. 2004 [
8 ]
20
J.G. Williams
In a study of bulk laxative with injection of phenol (5%) in arachis oil
(20 patients) (group 1), or a bulk laxative alone (23 patients) (group 2) – no addi-
tional reduction in bleeding was seen in association with sclerotherapy, which at
6 months follow-up was still present in about 50% of patients in each group [
9 ] .
In 1984, Goligher stated that “considering how extensively injection therapy has
been used for haemorrhoids …… how few worthwhile studies of the results of treat-
ment have been performed.” This holds true 25 years later in an age of evidence-
based medicine!
2.7.2.3 Infrared Coagulation
Infrared coagulation is thought to work in a similar fashion to sclerotherapy and
rubber band ligation. The source of the infrared energy is a 1.5-V halogen lamp with
a gold-plated refl ector that focuses the light through a quartz shaft to the mucosa.
A 1.5-s pulse gives a tissue temperature of 100°C and a 3-mm-diameter and 3-mm-
deep zone of coagulation. After 10–14 days, the dead tissue separates, leaving an
ulcer, and reepithelization is complete within 4 weeks. For a long time, the infrared
generator has not been available in the UK, although recently a new model has
become available (
http://www.stericom.com/infrared-coagulation2/ ) .
There is some data to indicate the effectiveness of infrared coagulation, although
it is very uncommon to have a study of a hemorrhoid therapy versus no therapy and/
or fi ber alone. In one analysis of the pooled results of several trials comparing infra-
red coagulation with rubber band ligation, there was no difference in effectiveness
between rubber band ligation and infrared coagulation, although a much greater
proportion of patients who had infrared coagulation required further treatment for
their hemorrhoidal symptoms [ 7 ] . However, it could be argued that this simply indi-
cates that as infrared coagulation is recognized to be less painful, more patients are
prepared to undergo repeat treatment.
Case Scenario 1
A 41-year-old male company director has suffered with recurrent bouts of anal
discomfort and irritation, swelling, and bright red rectal bleeding on defeca-
tion for many years. In the past, he had his hemorrhoids injected with phenol,
with only temporary resolution of his symptoms. He is otherwise fi t and well
and has no signifi cant past medical history or family history of note. He is not
on any regular medication. On examination, he has a number of anal skin tags
but nothing else to feel. Sigmoidoscopy to 20 cm is normal, but he does have
large second-degree hemorrhoid visible on proctoscopy. A friend has told him
of a newspaper article describing “painless” treatment of hemorrhoids.
How would you assess the situation further?
What discussion would you have with the patient about the various treatments
available?
21
2 Hemorrhoids
2.7.3 Surgical Treatment
2.7.3.1 Hemorrhoidectomy
Surgical excision of hemorrhoids is perhaps one of the oldest surgical operations
performed. A variety of techniques of excising symptomatic hemorrhoids have been
described, but some, such as the Whitehead circumferential excision of the anal
cushions, have been abandoned. Currently, two methods of traditional hemorrhoid-
ectomy are popular: the open excision described by Milligan and Morgan from St
Mark’s Hospital (favored by UK surgeons) and the closed hemorrhoidectomy
described by Ferguson (favored by North American surgeons). A newer variation of
closed hemorrhoidectomy using the Ligasure
®
coagulator is becoming more popu-
lar. The principle of conventional hemorrhoidectomy is to remove the swollen hem-
orrhoid tissue from outside and inside the anal canal, preserving suffi cient mucosa
and anoderm to maintain function of the anal canal, particularly in sealing the anal
canal between bowel movements.
Open (Milligan-Morgan) Hemorrhoidectomy
Traditionally, the patient is placed in the lithotomy position, and the procedure is
performed under a general anesthetic. Examination of the anal canal with a proc-
toscope or Sims anal retractor will confi rm the position of the hemorrhoids to be
removed. The skin-covered external element of the hemorrhoids to be excised is
grasped with an artery forceps and drawn downward and outward to expose the
lower pole of the mucosal-covered part of the hemorrhoid. The mucosal compo-
nent of each hemorrhoid is then grasped with a second artery clip and drawn out
to expose the whole of the hemorrhoid to be removed. The hemorrhoid to be
removed is dealt with by grasping both artery clips attached to the hemorrhoid in
the palm of one hand, while a v-shaped incision is made in the perianal skin,
round the lower border of the hemorrhoid. This incision is deepened and extended
across the mucocutaneous junction of the anal canal. The hemorrhoidal mass is
then carefully separated from the underlying ring of external sphincter muscle at
the anal margin and internal sphincter within the anal canal. In this manner, a
hemorrhoidal pedicle is developed, with its base in the upper anal canal. The
sphincter muscles should be in view and preserved throughout this dissection. The
anal mucosa on each side of the pedicle is incised to narrow the pedicle, prior to
suture ligation. The hemorrhoidal pedicle is transfi xed with a heavy absorbable
suture and ligated, before being excised with scissors. The procedure is repeated
at each of the other hemorrhoid sites. Care is taken throughout the procedure to
maintain adequate mucocutaneous bridges between each of the excision sites.
Failure to do this can lead to a large circumferential wound, which will heal with
considerable stenosis. The idea is to leave three pear-shaped wounds on the anal
margin. More recent developments of this technique have involved new
22
J.G. Williams
technologies to excise the hemorrhoid. This includes diathermy, lasers, and ultra-
sonic (harmonic) dissectors. None of these alternatives appear to offer any special
advantage over conventional excision with a pair of scissors, and they add to the
cost of the procedure.
The Milligan-Morgan operation is still widely practiced in the UK. Properly per-
formed, it produces good results and has stood the test of time. A study of the longer
term results of this operation shows that after at least 5 years follow-up, two-thirds
of patients are happy with the results of the operation. However, in this cohort of
over 400 patients, one-third reported anal incontinence, one-fourth of whom could
date the onset of incontinence to the operation [
10 ] .
Closed (Ferguson) Hemorrhoidectomy
The rationale behind the Ferguson operation is based on some of the perceived dis-
advantages of the Milligan-Morgan operation. This includes removing vascular
hemorrhoidal tissue with minimal amounts of anoderm, limiting postoperative dis-
charge and speeding up healing by closing the defects in the anal canal and limiting
the potential for stenosis, which may complicate healing by second intention of
large anal wounds.
The procedure is performed in the prone jackknife position under general,
regional, or local anesthetic supplemented with mild sedation. A selection of anal
retractors is necessary to perform the procedure. A Pratt bivalve speculum is useful
for identifying the hemorrhoidal complexes to be removed. Excision of the hemor-
rhoid is performed with either a Fansler operating anoscope or Hill-Ferguson anal
retractor of appropriate size.
The retractor is positioned in the anal canal in line with the hemorrhoidal tissue
which is to be removed. The anal skin adjacent to the outer margin of the hemor-
rhoid is grasped with a strong tissue forceps and drawn toward the center of the
anal canal. Dissecting scissors are then used to incise the perianal skin and com-
mence excision of the hemorrhoid, which is achieved by pressing the belly of the
scissors outward onto the internal sphincter, which is protected by being kept taut
by the presence of the anal retractor (Fig. 2.2 ). In contrast to the open technique,
the excision proceeds to a higher level in the anal canal, beyond the anorectal junc-
tion and top of the internal sphincter. The hemorrhoid is simply excised at the apex
of the dissection, without developing and suture ligating the pedicle. Bleeding
from the edge of the mucosa is controlled initially with cautery. Any residual
excess hemorrhoidal tissue beneath the cut edge of the mucosa on each side can be
excised to minimize recurrence, but care is taken not to excise any more anoderm.
The resulting defect is closed with a running absorbable suture (Fig. 2.3 ): 3/0 poli-
glecaprone 25 ( Monocryl
®
) on a small needle works well. Suturing commences at
the apex, where the rectal mucosa is fi xed to the underlying muscle to prevent fur-
ther prolapse. The anal mucosa can be fi xed to the internal sphincter by including
small bites of the muscle, but some authors contend that this increases pain and
increases the likelihood of wound separation in the postoperative period. Suturing
23
2 Hemorrhoids
Fig. 2.2 First stage of a
“closed” Ferguson
hemorrhoidectomy. The
Fansler operating proctoscope
is in place, and the
hemorrhoid is being excised
off the anal sphincters with
scissors to the apex of the
hemorrhoid
Fig. 2.3 The hemorrhoid has
been excised, and the
resulting defect is closed with
a running absorbable suture,
taking bites of each cut edge
of the anal mucosa and a
small bite of underlying
sphincter muscle
24
J.G. Williams
continues out onto the perianal skin to produce a longitudinal suture line (Fig. 2.4 ).
After the fi rst (and usually largest) hemorrhoid has been excised, the anal canal is
reinspected with the bivalve retractor to identify the next hemorrhoid to be excised.
The procedure is repeated until all hemorrhoids (usually three) have been dealt
with. Invariably, less tissue is removed at each subsequent site, and again, care is
taken to preserve as much anoderm as possible to allow the wounds to be closed
without tension.
Parks described a variation of this closed technique, where hemorrhoidal tissue
is excised from the submucosal plane after raising mucocutaneous fl aps within the
anal canal from a longitudinal incision over the hemorrhoid. Few surgeons perform
this submucosal hemorrhoidectomy.
Open Versus Closed Hemorrhoidectomy: Which Technique Is Superior?
Whether to perform an open hemorrhoidectomy or a closed procedure is largely
a matter of surgeon preference and training. A number of trails comparing the
two techniques have been published (Table 2.3 ); however, the results of these
trials vary, and most trials suffer from small numbers and short follow-up. A
recently published Swedish multicenter trial [ 11 ] randomized 115 patients to
Fig. 2.4 Completed suture line
at the end of the
haemorrhoidectomy. The
procedure is repeated for each
haemorrhoid to be excised
25
2 Hemorrhoids
Table 2.3 Studies comparing open and closed techniques for hemorrhoidectomy
Author
Number
Follow-up
Parameters compared
Open Closed Pain Healing Morbidity Leakage
Ho et al. [
26 ] 34 33 8.7 months No difference Open No difference
Not tested
Hosch et al. [
27 ] 17 17 12 weeks No difference No difference Closed Not tested
Carapeti et al. [
28 ] 17 18 6 weeks No difference No difference No difference Not tested
Arbman et al. [
29 ] 39 38 1 year No difference Closed No difference No difference
Gençosmanoglu et al.
[
30 ]
40 40 <40 months Open Closed Open Not tested
Arroyo et al. [
31 ] 100 100 1 year Closed Closed No difference Not tested
You et al. [
32 ] 40 40 3 weeks Closed Closed No difference Not tested
The table indicates which technique has a more favourable outcome for the parameters measured.
26
J.G. Williams
undergo open hemorrhoidectomy and 110 patients to closed hemorrhoidectomy.
There was no difference in level of pain postsurgery or in rate of complications.
Similarly, at 1 year postsurgery, a similar proportion of patients in each group
had experienced recurrent hemorrhoidal symptoms (15.6% vs. 17.6%). However,
closed hemorrhoidectomy was associated with an improvement in incontinence
score at 1 year, which was not observed after Milligan-Morgan hemorr-
hoidectomy, and patients were more likely to be satisfi ed after the Ferguson
procedure.
Ligasure
®
Hemorrhoidectomy
The principles of Ligasure hemorrhoidectomy are similar to those of closed hem-
orrhoidectomy and involve excision of the excess hemorrhoidal tissue after fi rst
achieving sealing and hemostasis with a bipolar electrothermal sealing device
( Ligasure: Tyco Healthcare UK Limited, 154 Fareham Road Gosport, Hampshire
PO13 0AS ). This device uses a very high frequency current, providing hemostasis
by denaturing collagen and elastin from the vessel wall and surrounding connec-
tive tissue. It is postulated that sealing of hemorrhoidal tissue in between the
Ligasure forceps is achieved with minimal collateral thermal spread and limited
tissue charring through use of active feedback control over the power output, which
should result in diminished postprocedural pain as compared to conventional surgi-
cal techniques.
The operation is performed under general or regional anesthesia. An anal retrac-
tor is inserted into the anal canal, and the external part of the hemorrhoid to be
removed is grasped with a pair of forceps and lifted into the anal canal. The jaws of
the Ligasure instrument are closed across the base of the hemorrhoid, and the
machine is activated until sealing occurs. The jaws are opened, and a thin strip of
coagulated tissue is visible at the base of the hemorrhoid. The hemorrhoidal tissue
above this seal is excised, and the process is repeated up the anal canal until the
hemorrhoid has been completely removed, leaving a thin strip of coagulated and
sealed anoderm along the length of the anal canal. The process is repeated for each
hemorrhoid to be removed.
The technique has been assessed in a number of randomized trials, most of
which suffer from small numbers and relatively short follow-up. A recent
Cochrane review [ 12 ] concluded that some of the claims in favor of Ligasure
hemorrhoidectomy are valid. Pain and analgesic requirement during the fi rst 7
days are less after this procedure than following conventional excision, but the
difference is lost by day 14. Hospital stay is similar, and there is no difference in
complication rates, with similar incidence of postoperative bleeding and inconti-
nence. As yet, there are insuffi cient data to assess any superiority of one tech-
nique over the other as regards long-term outcome and recurrence of hemorrhoidal
symptoms. Thus, it would appear that there are some short-term advantages to
Ligasure hemorrhoidectomy that need to be offset against the extra expense of
the procedure.
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