Hemorroid Treatmant

Update in Hemorroid Treatment

Update in Hemorroid Treatment

Imam Sofii

Workshop Hemorroid PABI; Balikpapan, 19 Maret 2013

Imam Sofii

Workshop Hemorroid PABI; Balikpapan, 19 Maret 2013

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Introduction:Introduction:• Fibrovascular cushions (or hemorrhoids) are part of the

normal anatomy within the anal canal and are believed to be important in maintaining continence

• They are areas of vascular anastomosis in a supporting stroma of subepithelial smooth muscles.

• They contribute 15-20% of the normal resting pressure and feed vital sensory information.

• 3 main cushions are found:• L lateral • R anterior• R posterior

• But can be found anywhere in anus, prevalence is 4%• Miss labelling by referring physicians and patients is

common

Dentate line

Anal canal

Anatomical – Surgical

Entoderm (hindgut) columnar -

squamous dentata pulsated -

pulseless line sensated -

asensated

proctodeum (ectoderm)

Anal canal

Anatomical – Surgical

Entoderm (hindgut) columnar -

squamous dentata pulsated -

pulseless line sensated -

asensated

proctodeum (ectoderm)

Functional anatomy:Functional anatomy:

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The hemorrhoidal cushions consist of plexuses of large venous spaces, arterio-venous communications as corpus cavernosum recti (CCR) by Stelzner

The blood supply to the CCR is provided by the terminal branches of the superior rectal artery

The hemorrhoidal cushions consist of plexuses of large venous spaces, arterio-venous communications as corpus cavernosum recti (CCR) by Stelzner

The blood supply to the CCR is provided by the terminal branches of the superior rectal artery

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Functional anatomy:Functional anatomy:

It is a functional blood supply that fills this cavernous network

This structure plays an important role in continence by acting as a conformable plug, in order to ensure the complete closure of the anal canal. This mechanism contributes up to 15–20% of resting anal pressure

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The etiopathogenesis of the hemorrhoidal disease is multifactorial.

Two major theories: the sliding down theory and the vascular theory.

The first: pathological slippage of the normal anal lining, caused by the deterioration of supportive connective tissue and increased by the straining during defecation.

The second: the ‘‘vascular hyperplasia theory,’’ supposes that an abnormal behaviour of the arteriovenous shunt is responsible for the hypertension of hemorrhoidal plexuses, their consequent dilatation, and therefore their prolapse and bleeding.

Several studies have demonstrated “high resting anal pressure” in patients.

High pressure is caused by increased activity of the internal anal sphincter or the external anal sphincter or by increased vascular pressure within the anal cushions .

The etiopathogenesis of the hemorrhoidal disease is multifactorial.

Two major theories: the sliding down theory and the vascular theory.

The first: pathological slippage of the normal anal lining, caused by the deterioration of supportive connective tissue and increased by the straining during defecation.

The second: the ‘‘vascular hyperplasia theory,’’ supposes that an abnormal behaviour of the arteriovenous shunt is responsible for the hypertension of hemorrhoidal plexuses, their consequent dilatation, and therefore their prolapse and bleeding.

Several studies have demonstrated “high resting anal pressure” in patients.

High pressure is caused by increased activity of the internal anal sphincter or the external anal sphincter or by increased vascular pressure within the anal cushions .

Etiopathogenesis:Etiopathogenesis:

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Etiopathogenesis:Etiopathogenesis:

Anchoring tissue (AT)

Internal sphincter (IS)

Internal hemorrhoids (IH)

Parks’ ligament (PL) Anal canal (AC)

External hemorrhoids (EH)

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Clinical features Symptoms of hemorhhoids

History ( Full history required)

Haemorrhoid directed:•Pain : acute/chronic/ cutaneous•Lump : acute/ sub-acute•Prolapse; define grade•Bleeding: fresh, post defecation•Pruritis and mucus

General GI:•Change in bowel habit•Mucus discharge•Tenesmus/ back pain•Weight loss •Anorexia•Other system inquiry

Degree of prolapse through anus

•1st: bleed but no prolapse•2nd: spontaneous reduction•3rd: manual reduction•4th: not reducable

Origin in relation to Dentate line

1. Internal: above DL2. External: below DL3. Mixed

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Pathological Habitual

1. Chronic diarrhea (IBD)2. Colon malignancy3. Portal hypertension4. Spinal cord injury5. Rectal surgery6. Episiotomy7. Anal intercourse

1. Constipation and straining2. Low fiber, high fat/spicy diet3. Prolonged sitting in toilet4. Pregnancy5. Aging6. Obesity7. Office work8. Family tendency

Clinical features Risk factor:Clinical features Risk factor:

Clinical features Investigation:Clinical features Investigation:

Lab: CBC / Clotting profile/ Group and save Proctography: if rectal prolpse is suspected Colonoscopy: if higher colonic or sinister pathology is

suspected

Lab: CBC / Clotting profile/ Group and save Proctography: if rectal prolpse is suspected Colonoscopy: if higher colonic or sinister pathology is

suspected

The diagnosis of hemorrhoids is based on clinical assessment and proctoscopy

Further investigations should be based on a clinical index of suspicion

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Clinical features Complication:Clinical features Complication:

Thrombosed external haemorrhoids

1. Ulceration2. Gangrene3. Fibrosis4. Thrombosis5. Sepsis and abscess formation6. Incontinence

Thrombosed internal haemorrhoids

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TreatmentTreatment

Varies from simple reassurance to operative hemorrhoidectomy.

Treatments are classified into three categories: • Dietary and lifestyle modification and medication. • Non (para) operative/office procedures.• Operative hemorrhoidectomy.

Varies from simple reassurance to operative hemorrhoidectomy.

Treatments are classified into three categories: • Dietary and lifestyle modification and medication. • Non (para) operative/office procedures.• Operative hemorrhoidectomy.

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Dietary and lifestyle modifications:Dietary and lifestyle modifications:

The main goal of this treatment is to minimize straining at stool.

Achieved by increasing fluid and fiber in the diet, recommending exercise, and perhaps adding fiber agents to the diet such as psyllium.

If necessary, stool softeners may be added.

The main goal of this treatment is to minimize straining at stool.

Achieved by increasing fluid and fiber in the diet, recommending exercise, and perhaps adding fiber agents to the diet such as psyllium.

If necessary, stool softeners may be added.

TreatmentTreatment

"you don't defecate in the library so you shouldn't read in the bathroom".

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Rubber Band LigationRubber Band Ligation

Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids.

Complications include bleeding, pain, thrombosis and life threatening perineal sepsis.

Successful in two thirds to three quarters of all individuals with first and second degree hemorrhoids.

Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids.

Complications include bleeding, pain, thrombosis and life threatening perineal sepsis.

Successful in two thirds to three quarters of all individuals with first and second degree hemorrhoids.

Treatment Office Treatments:Treatment Office Treatments:

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Infrared CoagulationInfrared Coagulation

Generates infrared radiation which coagulates tissue protein and evaporates water from cells.

It is most beneficial in Grade I and small Grade II hemorrhoids.

Generates infrared radiation which coagulates tissue protein and evaporates water from cells.

It is most beneficial in Grade I and small Grade II hemorrhoids.

Treatment Office Treatments:Treatment Office Treatments:

Bicap Electrocoagulation

It works, in theory, similar to photocoagulation or to rubber banding.

The probe must be left in place for ten minutes.

Poor patient tolerance minimized the effect of this procedure.

It works, in theory, similar to photocoagulation or to rubber banding.

The probe must be left in place for ten minutes.

Poor patient tolerance minimized the effect of this procedure.

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SclerotherapySclerotherapy

Injection of an irritating material into the submucosa in order to decrease vascularity and increase fibrosis.

Injecting agents have traditionally been phenol in oil, sodium morrhuate, or quinine urea.

Injection of an irritating material into the submucosa in order to decrease vascularity and increase fibrosis.

Injecting agents have traditionally been phenol in oil, sodium morrhuate, or quinine urea.

Treatment Office Treatments:Treatment Office Treatments:

Manual anal dilatation was first described by Lord .

Cryotherapy was used in the past with the belief that freezing the apex of the anal canal could result in decreased vascularity and fibrosis of the anal cushions.

Manual anal dilatation was first described by Lord .

Cryotherapy was used in the past with the belief that freezing the apex of the anal canal could result in decreased vascularity and fibrosis of the anal cushions.

Other Office Treatments:

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HemorrhoidectomyHemorrhoidectomy

Milligan-Morgan Ferguson Parks Whitehead-Toupet Ligasure

Milligan-Morgan Ferguson Parks Whitehead-Toupet Ligasure

Treatment Surgical Treatments:Treatment Surgical Treatments:

Milligan-Morgan

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Ferguson

Treatment Surgical Treatments:Treatment Surgical Treatments:

Ferguson

Parks

Ferguson Ferguson

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Treatment Surgical Treatments: Ligasure

Treatment Surgical Treatments: Ligasure

Diatermy (Loder-Phillips, 1993)

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Stapled hemorrhoidopexy Terminology: Stapled hemorrhoidectomy Circular stapled

hemorrhoidectomy Circular stapled anoplasty PPH Stapled prolapsectomy Transverse mucosal

prolapsectomy Longo procedure

Stapled hemorrhoidopexy Terminology: Stapled hemorrhoidectomy Circular stapled

hemorrhoidectomy Circular stapled anoplasty PPH Stapled prolapsectomy Transverse mucosal

prolapsectomy Longo procedure

Treatment Surgical Treatments:Treatment Surgical Treatments:

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Stapled hemorrhoidopexyStapled hemorrhoidopexy

Surgical rationale Excision of cylinder of rectal mucosa → replacement of hemorrhoids in anal canal

Vascular interruption → shrinkage of prolapsed component

Avoidance of anal wound reduces pain

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Transanal Hemorrhoid Dearterialization (THD) Hemorrhoid Arterial Ligation (HAL) Doppler Guided Hemorrhoid Arterial Ligation (DGHAL)

Transanal Hemorrhoid Dearterialization (THD) Hemorrhoid Arterial Ligation (HAL) Doppler Guided Hemorrhoid Arterial Ligation (DGHAL)

Close to anorectal jungtion (+ 2 cm).

Almost 6 sectors there are artery (99,3-99,7%).

The artery are into the submucosa (98,3-100%).

The artery are very superfisial (2.4-1.9 cm)

Close to anorectal jungtion (+ 2 cm).

Almost 6 sectors there are artery (99,3-99,7%).

The artery are into the submucosa (98,3-100%).

The artery are very superfisial (2.4-1.9 cm)

Treatment Surgical Treatments:Treatment Surgical Treatments:

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Increased arterial inflow and/or a decreased venous outflow

Hypertension of CCR

Dilatation of the hemorrhoidal cushions favorsprolapse during defecation or straining

Weakening and the subsequent tearing of the Parks and Treitz ligaments

Further dilatation and increasing of the prolapse

Rupture of artero-venous shunts

Bleeding (spontaneous or during defecation)

Rasionale:

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Evaluation:Evaluation: Every procedure could be

postoperative evaluation i.e:

Pain Pruritus Bleeding Soiling Incontinence to gas Oedema Thrombosis Pile/prolaps Spingter tone

Every procedure could be postoperative evaluation i.e:

Pain Pruritus Bleeding Soiling Incontinence to gas Oedema Thrombosis Pile/prolaps Spingter tone

The American Journal of Surgery 183 (2002) 519–524

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Rational decition:Rational decition:

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Hemorrhoidal Disease: A Comprehensive Review

J Am Coll Surg Vol. 204, No. 1, January 2007

27The ASCRS Textbook of Colon and Rectal Surgery 2007

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Arch Surg. 2009;144(3):266-272

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Arch Surg. 2009;144(3):266-272

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Comparison of operative outcomes and postoperative complications in patients

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33The American Journal of Surgery (2012) 204, 684–688

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Symptom questionnaire

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SH vs Convs (Cochrane review)SH vs Convs (Cochrane review) All RCT from 1998-2006: SH vs Convs.

SH patients significantly more like to have recurrent in long-term followup 1year or more (7 trials, 537 pts; OR=3,85; 95%CI=1,47-10,07; p=0,006).

SH was associeted higher recurrence rate (5 trials; 417 pts; OR=3,60; 95%CI=1,24-10,49; p=0,02).

A significantly complained prolapse symptom (8 trials; 798 pts; OR=2,96; 95%CI=1,33-6,58; p=0,008).

Giordano et al: SH was associeted higher recurrence rate (14 trials; 1063 pts; OR=5,5; p<0,001) and undergo to correct recurrent prolapses (10 trials; 824 pts; OR=1,9; p<0,002).

All other clinical parameters showed trends favoring SH.

Fasten et al: recurrent prolapses can be successfully treated with redo PPH more than 90%.

All RCT from 1998-2006: SH vs Convs.

SH patients significantly more like to have recurrent in long-term followup 1year or more (7 trials, 537 pts; OR=3,85; 95%CI=1,47-10,07; p=0,006).

SH was associeted higher recurrence rate (5 trials; 417 pts; OR=3,60; 95%CI=1,24-10,49; p=0,02).

A significantly complained prolapse symptom (8 trials; 798 pts; OR=2,96; 95%CI=1,33-6,58; p=0,008).

Giordano et al: SH was associeted higher recurrence rate (14 trials; 1063 pts; OR=5,5; p<0,001) and undergo to correct recurrent prolapses (10 trials; 824 pts; OR=1,9; p<0,002).

All other clinical parameters showed trends favoring SH.

Fasten et al: recurrent prolapses can be successfully treated with redo PPH more than 90%.

Hemorrhoids; Shackelford’s surgery of the Alimentary Tract;2013: 1889-92

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Giardano et al: 16 (17) met inclusion creteria were observasional study (low-very low study).

Of the 1996 pts involved (majority grade II or III disease): early postoperative pain 18,5%; residual protrusion, bleeding, and fever incidence > 3%.

Folloup of 1year or more 6 (17): prolapse incidence 10,8%; bleeding 9,7%; pain on defecation 8,7%.

Giardano et al: 16 (17) met inclusion creteria were observasional study (low-very low study).

Of the 1996 pts involved (majority grade II or III disease): early postoperative pain 18,5%; residual protrusion, bleeding, and fever incidence > 3%.

Folloup of 1year or more 6 (17): prolapse incidence 10,8%; bleeding 9,7%; pain on defecation 8,7%.

HAL HAL

Hemorrhoids; Shackelford’s surgery of the Alimentary Tract;2013: 1889-92

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Hemorrhoids are part of the normal anatomy within the anal canal.

Multifactorial etiopathogenesis: pathological slippage of the normal anal lining, vascular hyperplasia theory, high resting anal pressure.

The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy.

Three categories treatment: 1) Dietary and lifestyle modification and medication 2) Non (para) operative/office procedures. 3) Operative haemorrhoidectomy.

Pain is the most frightening complication for the most patient.

Hemorrhoids are part of the normal anatomy within the anal canal.

Multifactorial etiopathogenesis: pathological slippage of the normal anal lining, vascular hyperplasia theory, high resting anal pressure.

The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy.

Three categories treatment: 1) Dietary and lifestyle modification and medication 2) Non (para) operative/office procedures. 3) Operative haemorrhoidectomy.

Pain is the most frightening complication for the most patient.

Conclusion:Conclusion:

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Early diagnosis and prompt treatment can reduce the complication and recurrence.

The management of symptomatic haemorrhoid should be directed at the symptom complex of the individual patient.

For many specific cases, more than one procedure and modification is needed.

Recently, Stapled haemorrhoidectomy and Hemorrhoid Arterial Ligation with or without mucosopexy may prove to be an effective, less painful technique to manage prolapsed hemorrhoid.

Early diagnosis and prompt treatment can reduce the complication and recurrence.

The management of symptomatic haemorrhoid should be directed at the symptom complex of the individual patient.

For many specific cases, more than one procedure and modification is needed.

Recently, Stapled haemorrhoidectomy and Hemorrhoid Arterial Ligation with or without mucosopexy may prove to be an effective, less painful technique to manage prolapsed hemorrhoid.

Conclusion:Conclusion:

43makasih