Updates on the Treatment of Hemorrhoidal Disease

1. Updates on the Treatment of Hemorrhoidal Disease WH Chan PYNEH Joint Hospital Surgical Grand Round April 2012

2. Hemorrhoids Diseased anal cushions Due to long standing raised intra-abdominal pressure or aging Internal vs external

3. Symptoms Prolapse Per rectal bleeding Pain Prevalence = 4.4 % - 30%

4. Goligher’s classification Objective description only. May not directly related to symptom

5. Management of hemorrhoids • Conservative • High fibre diet, Bulking agent, topical anaesthetic • Micronized purified flavonoids (Daflon) • Office procedures • Rubber band ligation, sclerotherapy • Infrared coagulation, cryotherapy, laser • Surgical procedures

6. Surgical Procedures • Excisional hemorrhoidectomy • Stapled hemorrhoidopexy (PPH) • Transanal hemorrhoidal dearterialisation (THD)

7. Excisional hemorrhoidectomy • Milligan-Morgan technique • Open hemorrhoidectomy • Developed in UK in 1937 • Excision of the hemorrhoids following transfixion at pedicles

8. Excisional hemorrhoidectomy • Ferguson technique • Closed hemorrhoidectomy • Developed in US in 1952 • Excision of hemorrhoids • Mucosal defect closed with absorbable sutures to facilitate wound healing

9. Methods of hemorrhoidectomy Closed vs Open Hemorrhoidectomy – Is there any difference? Dis Colon Rectum 2000; 43: 31-34 • Open vs close • Comparable in complication rate, bleeding, post-operative pain and long-term recurrence rate

10. Stapled hemorrhoidopexy First described by an Italian surgeon Longo in 1998 Procedure for Prolapse and Hemorrhoids

11. Circumferential rectal mucosectomy 4-5cm above dentate line Repositioning of the anal cushion (mucosal lifting) No excision of hemorrhoids

12. Complications of PPH • Common: • Tenesmus (14-50%)1 • Faecal or flatus incontinence (3-10%)1 • Per rectal bleeding (4.3% readmission, 0.4% need surgical hemostasis)2 • Pain (1.6% need readmission)2 • Urinary retention (4.9%, none need permanent urinary catheterization)2 • Postoperative complications after procedure for prolapsed hemorrhoids and stapled transanal rectal excision procedure M. Pescatori, G. Gagliardi. Tech Coloproctol 2008: 12: 7-19 2. Experience of 3711 stapled haemorrhoidectomy operations KH Ng, KS Ho, BS Ooi, CL Tang, KW Eu. British Journal of Surgery 2006; 93; 226-230

13. Rare complications of PPH • Rectal perforation • Pelvic sepsis • Anastomotic dehiscence • Rectovaginal fistula • Hemoperitoneum • Pneumoretroperitoneum

14. Doppler Guided Hemorrhoidal Artery Ligation Transanal hemorrhoidal dearterialization First described in 1995 by Morinaga

15. Doppler Guided Hemorrhoidal Artery Ligation Use Doppler probe to locate the hemorrhoidal artery Suture ligation to the hemorrhoidal artery

16. 1996 patients in 17 articles were analysed

17. Recurrence rate • For grade IV hemorrhoids: • 59.3% has residual prolapse • 26.7% relapse rate • excluded in many studies

18. Excisional hemorrhoidectomy vs PPH

19. Excisional hemorrhoidectomy vs PPH 25 randomized trials with 1918 procedures were reviewed (1991 to 2006)

20. Pain Significantly less pain in PPH

21. Recovery Earlier return to work and normal activities in PPH

22. Post excisional hemorrhoidectomy Post PPH Complete elimination of post operative wound care in PPH

23. Short term benefits of PPH Less post operative pain Earlier return of bowel function Earlier return to work and normal activities Similar complications Complete elimination of post-operative wound care

24. 15 randomized trials with 1201 patients were included Follow-up periods: 12 – 84 months

25. Prolapse recurrence rate is higher in PPH Same recurrence rate for bleeding Higher re-intervention rate in PPH

26. PPH vs THD

27. 3 randomized trials 80 patients in THD vs 70 patients in stapled hemorrhoidopexy

28. Significantly less pain in THD group

29. Similar complications

30. Similar recurrence rate

31. Summary • Hemorrhoid is a benign disease • Treatment is for symptom relief and patient expectation

32. Depends on: • Main symptom • Patient expectation • Grading of hemorrhoids

33. Symptoms • Prolapse: • Excisional hemorrhoidectomy • Bleeding: • Excisional hemorrhoidectomy/PPH/THD • External component: • Excisional hemorrhoidectomy

34. Patient expectation • Less post-op pain, faster convalescene • PPH and THD • Safety: • Similar post-op complications • PPH associated with tenesmus • PPH associated with rare but potentially fatal complications

35. Management of hemorrhoids Grade III and Grade IV Grade I and Grade II Bleeding only Prolapse +/- bleeding Conservative Office Procedure - Excisional hemorrohoidectomy - PPH/THD (less pain, faster recovery) Failed Excisional hemorrhoidectomy PPH/THD Patient’s symptoms and expectation are more important

36. Conclusion • Hemorrhoid is a benign disease • Management should aim at treating main symptoms and facilitate patient expectation • Need good pre-op communication in order to choose the best treatment and to achieve patient satisfaction

37. Thank you