The following is an overview of certain diseases. It is ... · TREATMENT OF COMMON ANAL DISEASES: Peri-anal skin management No scratching/rubbing!!! Showers if possible instead of

The following is an overview of certain diseases. It is not a complete information

resource. Remember that the advice of your physician always takes precedent

over any of the following information.

The slides, information, written instructions and facts do not replace a discussion

with and examination by your physician. They may give you other instructions or

information specific to your needs. You should always consult a health care

professional for any symptoms or signs.

The information and pictures in this lecture may not be suitable for young

audiences.

WORKWORK--UP & TREATMENT UP & TREATMENT

OF HEMORRHOIDSOF HEMORRHOIDS

BYBY

John H. Winston, III, MD, MBAJohn H. Winston, III, MD, MBA

Colon and Rectal SurgeryColon and Rectal Surgery

INTRODUCTIONINTRODUCTION

COMMONCOMMON PERIANALPERIANAL SYMPTOMSSYMPTOMS::

Pain & tendernessPain & tenderness

Sharp / dull / cutting / burningSharp / dull / cutting / burning

Associated with bowel movementsAssociated with bowel movements

Constant / intermittent in frequencyConstant / intermittent in frequency

Associated with activityAssociated with activity

Associated with bleedingAssociated with bleeding

COMMON PERIANAL SYMPTOMSCOMMON PERIANAL SYMPTOMS::

BleedingBleeding

Frequency variesFrequency varies

Bright / dark / clotted in colorBright / dark / clotted in color

On paper / in bowl / on or in stoolOn paper / in bowl / on or in stool

Dripping or squirting can occurDripping or squirting can occur

Black, tarry stools imply other sourceBlack, tarry stools imply other source

Associated with bowel movementsAssociated with bowel movements

Associated with painAssociated with pain


OtherOther

FeverFever

SpasmSpasm

Constipation or difficult evacuationConstipation or difficult evacuation

Urinary difficultiesUrinary difficulties

Seepage / soilage / mucus dischargeSeepage / soilage / mucus discharge

Pruritis / itchingPruritis / itching

SwellingSwelling

DrainageDrainage


Office evaluationOffice evaluation

Physical examination:Physical examination:

Inspection of perineum

Palpation

Digital rectal exam

Endoscopy

PositioningPositioning

LightingLighting

InstrumentationInstrumentation

COMMON PERIANAL SYMPTOMSCOMMON PERIANAL SYMPTOMS:: Office endoscopyOffice endoscopy

Colonoscopy or flex. sig. with Colonoscopy or flex. sig. with

contrast enema to rule out contrast enema to rule out

synchronous diseasesynchronous disease

Rigid sigmoidoscopyRigid sigmoidoscopy to assess to assess

levellevel

AnoscopyAnoscopy to evaluate anal canalto evaluate anal canal

Labs & radiology to rule out other Labs & radiology to rule out other

diseasesdiseases

PROCTOSCOPIC WORKPROCTOSCOPIC WORK--UPUP

• Good for most diseases

• Definitive. Gives lot’s of information

• Allows for biopsy if needed

• Easy to use

• Readily available

• Determines level, position & size of tumors

or other disease

COMMON REGIMENSCOMMON REGIMENS

TREATMENT OF COMMON ANAL DISEASESTREATMENT OF COMMON ANAL DISEASES::

Bowel managementBowel management

1.1. Have one stool per day. Use Have one stool per day. Use ColaceColaceTMTM BIDBID

2.2. Use Use 30cc MOM30cc MOM in the morning if no stool the in the morning if no stool the previous day. Repeat once if neededprevious day. Repeat once if needed

3.3. If not effective take If not effective take 4 Dulcolax4 DulcolaxTMTM tab.stab.s PO. Use PO. Use 1 quart apple juice1 quart apple juice PO immediately afterPO immediately after

TREATMENT OF COMMON ANAL DISEASESTREATMENT OF COMMON ANAL DISEASES: :

Diet & fluid managementDiet & fluid management

30 gm.s fiber each day30 gm.s fiber each day

–– Increase fruits & vegetables.Increase fruits & vegetables. Two servings each meal.Two servings each meal.

–– Use MetamucilUse MetamucilTMTM or or KonsylKonsylTMTM as directed.as directed.

–– 1 bowl of 1 bowl of AllAll--BranBranTMTM or other bran cereal each morningor other bran cereal each morning

1.5 1.5 -- 2.0 liters of fluid/day2.0 liters of fluid/day

–– Two 8 oz. glasses with each meal.Two 8 oz. glasses with each meal.

–– 1 small 1 small (500cc) bottle(500cc) bottle when out of house.when out of house.

–– Increase intake on hot or active days.Increase intake on hot or active days.

TREATMENT OF COMMON ANAL DISEASESTREATMENT OF COMMON ANAL DISEASES:: PeriPeri--anal skin managementanal skin management

No scratching/rubbing!!!No scratching/rubbing!!!

ShowersShowers if possible instead of baths. if possible instead of baths. No soapNo soap on on periperi--anal skin. anal skin. Use handUse hand not washcloth.not washcloth.

If soap must be used, use soaps for sensitive skin like If soap must be used, use soaps for sensitive skin like Dove™Dove™

Use a Use a hair dryerhair dryer on cool setting to dry perineumon cool setting to dry perineum

A & DA & DTMTM, , DestinDestinTMTM or petroleum jelly to perineum or petroleum jelly to perineum TID & after stools. Use a ¼ TID & after stools. Use a ¼ cotton ball & cotton ball & MaxipadMaxipad™™..

Use Use baby wipes baby wipes or plain lotion on toilet paperor plain lotion on toilet paper

TREATMENT OF COMMON ANAL DISEASESTREATMENT OF COMMON ANAL DISEASES::

Pain ControlPain Control

Use aggressive pain control using narcotics if Use aggressive pain control using narcotics if

needed needed

Use nonUse non--steroidal antisteroidal anti--inflammatory drugs like inflammatory drugs like

Ibuprofen or AcetominophenIbuprofen or Acetominophen

Take Take warm bathswarm baths, not “sitz” baths, not “sitz” baths

Reduces spasmReduces spasm

Enhances blood flowEnhances blood flow

SUMMARY of INTRODUCTIONSUMMARY of INTRODUCTION

• History & physical will reveal most diagnoses

– Physicians should ask the right questions

– Anoscopy & rigid sigmoidoscopy performed by a skilled practioner is key

– A specialist may find a different diagnosis !

• There are general treatments for all anal diseases / symptoms

– Treat the inflammation

– Protect & care for the skin

• Getting the correct diagnosis is key to recommending the appropriate treatment !

HEMORRHOIDSHEMORRHOIDS::

Incidence & PrevalenceIncidence & Prevalence

Close to 50% of people 50 or older are affectedClose to 50% of people 50 or older are affected

National Institues of Health data (1983 National Institues of Health data (1983 -- 1987)1987)

–– Incidence: 1 million new casesIncidence: 1 million new cases

–– Prevalence: 10.4 million peoplePrevalence: 10.4 million people

–– Hospitalizations: 316,000Hospitalizations: 316,000

–– Physician office visits: 3.5 millionPhysician office visits: 3.5 million

–– Prescriptions: 1.5 millionPrescriptions: 1.5 million

4.4 % of US population seen by physician for 4.4 % of US population seen by physician for

symptomatic hemorrhoidssymptomatic hemorrhoids

49/100,000 of US population undergo 49/100,000 of US population undergo

hemorrhoidectomy annuallyhemorrhoidectomy annually


IntroductionIntroduction

•• EVERYONEEVERYONE has them !!!

• Exact cause unknown

• Cause bleeding, bleeding, massmass,, itching, burning, mass, pain, seepage/soilageain, seepage/soilage

• Probably serve to help continence


PurposePurpose Normal part of anatomyNormal part of anatomy

Aid in fecal continenceAid in fecal continence

–– Contribute to 15Contribute to 15--20% of resting anal pressure20% of resting anal pressure

–– Ensure complete closure of anal canal by acting as a Ensure complete closure of anal canal by acting as a

plug or as a compressible liningplug or as a compressible lining

–– Engorge with intraEngorge with intra--abdominal hypertension further abdominal hypertension further

closing anal canalclosing anal canal

Protect sphincters/anus from the trauma of Protect sphincters/anus from the trauma of defecationdefecation

EXTERNAL HEMORRHOIDSEXTERNAL HEMORRHOIDS: :

AnatomyAnatomy

• Below the dentate line

• Covered by modified squamous epithelium

or special skin

• Arise from inferior hemorrhoidal artery

• Usually accompany internal hemorrhoids

• Make skin tags

INTERNAL HEMORRHOIDSINTERNAL HEMORRHOIDS: :

AnatomyAnatomy

• Above the dentate line

• Covered by columnar / transitional

epithelium or special skin

• Arise from superior hemorrhoidal artery

• Four (4) degrees


PathogenesisPathogenesis

Several theories of pathology existSeveral theories of pathology exist

Associated with:Associated with:

–– advanced age advanced age

–– diarrhea/constipationdiarrhea/constipation

–– PregnancyPregnancy

–– pelvic tumorspelvic tumors

–– prolonged sittingprolonged sitting

–– increased intraincreased intra--abdominal pressureabdominal pressure

All results in easily traumatized tissue leading to All results in easily traumatized tissue leading to bleedingbleeding

INTERNAL HEMORRHOIDSINTERNAL HEMORRHOIDS::

Banov ClassificationsBanov Classifications

STAGESTAGE SIGNSSIGNS SYMPTOMSSYMPTOMS

1 •“Bleeding”??

•No prolapse

•No pain, itching

•Bleeding

•No prolapse

•No discomfort

2 •Bleeding

•Usually prolapse

•Spontaneous reduction

•Bleeding

•Prolapse

•Pruritis, mild discomfort

3 •Bleeding

•Readily prolapse

•Manual reduction

•Bleeding

•Prolapse

•Pruritis, moderate discomfort

4 •Bleeding

•Permanent prolapse

•Non-reducible

•Bleeding

•Prolapse

•Pruritis, Pain

•Incontinence

Published in 1985; Used by the American Society of Colon and Rectal SurgeonsPublished in 1985; Used by the American Society of Colon and Rectal Surgeons

Grade I and IIGrade I and II

Office TreatmentsOffice Treatments

• Rubber Band Ligation

• Infrared Coagulation

• Sclerotherapy

• Bicap/ultroid

Surgical TreatmentsSurgical Treatments

• Ferguson (Closed)

• Milligan Morgan (Open)

• RF (LigaSure)

• Stapled (PPH)

• Ultrasonic

• Cautery

• Laser

Grade I, II, ~IIIGrade I, II, ~III


ManagementManagement

Grade III & IVGrade III & IV

Dietary / Lifestyle ChangesDietary / Lifestyle Changes

• Ointments & Creams

• Suppositories

• Fiber Diet & Water

• Stool softeners

• Bulk agents

• Sitz baths


Stage 1Stage 1


Stage 2 or Stage 3Stage 2 or Stage 3


Stage 4 Stage 4 –– hemorrhoid crisishemorrhoid crisis

HEMORRHOIDS:HEMORRHOIDS:

Medical TreatmentMedical Treatment

Diet changes & fluidsDiet changes & fluids

Stool softeners & LaxativesStool softeners & Laxatives

Warm bathsWarm baths

Eliminate strainingEliminate straining

Salves and ointmentsSalves and ointments

Topical Therapies for Hemorrhoidal Disease

AGENT MODE OF ACTION BENEFITS COMMENTS

Pramoxine HCl Rapidly acting local

anesthetic

Local symptom relief Protective coating over

inflamed tissue

Viscous Lidocaine Local anesthestic Local symptom relief Poor tissue adherence

Hydrocortisone

acetate

(suppository)

Topical anti-inflammatory

agent

Useful in internal

hemorrhoids

Reaches tissue farther

in anal canal unlike

topicals

Phenylephrine HCl Local vasoconstriction May be affective when

other local anesthetics

fail

May exacerbate

hypertension

Diphenhydramine Antihistamine Reduces itching Treats only symptoms

5-ASA Local anti-inflammatory

effect

Reduces pain &

bleeding

•Fewer SE than topical

steroids

•Not commonly used

Dennison AR, et al. Am J Gastroenterology 1999.

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY Refractory 2Refractory 2ndnd degree hemorrhoidsdegree hemorrhoids Symptomatic 3Symptomatic 3rdrd & 4& 4thth degree hemorrhoids degree hemorrhoids Rectal mucosal prolapse Rectal mucosal prolapse Low grade hemorrhoids with other associated disease(s)Low grade hemorrhoids with other associated disease(s) Failure of conservative treatment Failure of conservative treatment Patient requestPatient request


Surgical TreatmentSurgical Treatment

ExcisionExcision

Radiofrequency (Ligasure™)Radiofrequency (Ligasure™)

Harmonic energyHarmonic energy

Stapling (PPH™)Stapling (PPH™)

DilationDilation

Rubber band ligation Rubber band ligation

Sclerotherapy/injectionSclerotherapy/injection

Infrared Infrared

photocoagulationphotocoagulation

Bipolar diathermy Bipolar diathermy

coagulationcoagulation

Laser Laser

CryotherapyCryotherapy

Essential elements of surgical Essential elements of surgical

treatment of hemorrhoidstreatment of hemorrhoids

1.1. Ligation of arterial flowLigation of arterial flow

2.2. Excision of redundant mucosa & dilated Excision of redundant mucosa & dilated

hemorrhoidal blood vesselshemorrhoidal blood vessels

3.3. Remodeling of anal lining or anodermRemodeling of anal lining or anoderm

4.4. Induction of inflammation & fibrosisInduction of inflammation & fibrosis

PROCEDURE FOR PROLAPSE & HEMORRHOIDSPROCEDURE FOR PROLAPSE & HEMORRHOIDS::

BEFORE AFTERBEFORE AFTER

PROCEDURE FOR PROLAPSE & HEMORRHOIDSPROCEDURE FOR PROLAPSE & HEMORRHOIDS: Advantages : Advantages -- Less PainLess Pain

Roswell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled hemorrhoidectomy): randomized, controlled trial. LanceRoswell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled hemorrhoidectomy): randomized, controlled trial. Lancet, t, Vol. Vol. 355, Mar 4, 2000;779355, Mar 4, 2000;779--781.781.

11 patients in each group

Prospective, randomized

P=0.003

PROCEDURE FOR PROLAPSE & HEMORRHOIDS: Advantages PROCEDURE FOR PROLAPSE & HEMORRHOIDS: Advantages -- quicker recoveryquicker recovery

Stapled vs. Excision Hemorrhoidectomy, LongStapled vs. Excision Hemorrhoidectomy, Long--term Results of a Prospective Randomized Trial, Hetzer N, Demartines N, Handschin AEterm Results of a Prospective Randomized Trial, Hetzer N, Demartines N, Handschin AE, ,

Archives of Surgery 2002Archives of Surgery 2002

6.7

20.7

0

5

10

15

20

25

Days off

Work

PPH Hemorrhoidectomy

Procedure

INTERNAL HEMORRHOIDS:

Surgical Options -- Ligasure™

• A form of excisional hemorrhoidectomy

• Safe and effective alternative

• Rapid and nearly bloodless

• No differences compared with standard surgery in post-op

– Pain

– Complications


Rubber Band LigationRubber Band Ligation

• Most common office procedure

• Band placed using suction or atraumatic clamp

• Band draws in excess hemorrhoid tissue,

causes scar & fixation of lining of anal canal to

prevent prolapse

• Band must be placed above dentate line or

severe anal pain will result

– 240 pts. Prospective study w/ 32 month follow up

– Results:

• Grade 1 - 100 % success rate

• Grade 2 - 97% success rate



– Better results & no difference in complications

with multiple bands vs. single band


Rubber Band Ligation Rubber Band Ligation –– ResultsResults

Rev Esp Enferm Dig. 2003 Feb;95(2):110-4, 105-9

J Med Assoc Thai. 2002 Mar;85(3):345-50

– Delayed hemorrhage: 1% at 1-2 weeks

– Thrombosis of external hemorrhoids: 3%

– Rectal tenesmus or cramps: 11%

– Mild anal pain 7.4% (esp. with multiple bands)

– Pain with urination: 4.3%

– Transient anal bleeding (3.7%) usually 5-7days

– Rectal sepsis:

• Rare complication associated with immunosupression

• Symptoms: Fever, urinary retention, significant pain

HEMORRHOIDSHEMORRHOIDS:: Rubber Band Ligation Rubber Band Ligation -- ComplicationsComplications

Instruments forInstruments for

Rubber Band LigationRubber Band Ligation

ANOSCOPE

RUBBER BAND LIGATOR


Laser treatmentLaser treatment

• A form of excisional hemorrhoidectomy

• A large prospective study showed no

difference1

• Prospective, randomized study showed higher

cost & prolonged healing2

• ASCRS Standards of Practice tasks force does

not support its use. 11 Senagore et al, 1993; Senagore et al, 1993; 2 2 Wang et al, 1991Wang et al, 1991

INTERNAL HEMORRHOIDS:INTERNAL HEMORRHOIDS:

Infrared CoagulationInfrared Coagulation

Commonly an office procedureCommonly an office procedure

No anesthesia neededNo anesthesia needed

Mild or no discomfortMild or no discomfort

Best for lowBest for low--grade internal hemorrhoidsgrade internal hemorrhoids


Infrared CoagulationInfrared Coagulation

• Infrared radiation coagulates tissue protein

• Destruction depends on intensity & duration

of treatment

• Decreases hemorrhoidal blood flow

• Does not treat excess redundant tissue

• Requires more treatments than RBL

• Less painful than ligation

OVERVIEW:

Pros & cons of treatment options TREATMENT OPTION PROS CONS

Over the counter topical

medications

• Convenient to carry

anywhere

• Affordable

• Patient has some control

• Immediate symptom relief

• Messy, unpleasant to apply

• Extremely high recurrence

• No permanent effect

• Relief is limited for advanced cases

Sitz baths • Provides some relief on

contact

• Affordable

• Patient has some control

• Time-consuming

• Not portable

• Relief temporary

Dietary • Inexpensive

• Useful for other diseases

• Easy to comply

• Inconvenient

• Requires lifestyle changes

• Long-term success is unlikely

Sclerotherapy • Simple

• Office procedure

• Relatively painless

• Long term success is sparsely reported

• Indicated where bleeding is main

symptom

• Requires an injection

Infrared Coagulation


• Minimal discomfort

• Minimal tissue loss

• May require several visits

• Expensive

• Not performed commonly

OVERVIEW: Pros & cons of treatment options

TREATMENT OPTION PROS CONS

Procedure for

Prolapse and

Hemorrhoids (PPH)

• Places hemorrhoid in normal

position

• 30-45 minute procedure

• Recovery is less painful

• Return to normal activity in 2-3

days

• Performed under local, regional,

or general

• Rare & possibly unknown risks

• Rectal wall damage can result

• Anal incontinence

• Persistence of skin tags

• Persistent urgency

• Cost of stapler??

• Stapler misfires???

Rubber Band Ligation

• Lowest recurrence rate of all office

procedures

• Versatile

• Rare complications

• Removes hemorrhoid


• Cheap

• Painful, depending on location of

banding

• Multiple visits

• Hard to remove bands

• Ineffective against external disease

• High recurrence rate

Excisional

Hemorrhoidectomy

• Removes hemorrhoid

• Lowest recurrence rates overall

• Durable

• Time proven

• Performed under local, regional,

or general

• Painful recovery

• 2-3 weeks to return to normal activity

• Possibility of wound infection

• Short-term incontinence

• Cost of postoperative care?

CONCLUSIONS:CONCLUSIONS:

HemorrhoidsHemorrhoids

• Hemorrhoids are very common

• Other diseases can be confused for

hemorrhoids

• There are alternatives for treatment

• Some can be treated with less invasive, less

painful techniques

• Office treatment is possible

ANAL FISSURESANAL FISSURES

ANAL FISSURES

• Usually young, adult

males

• Due to crack in poorly

perfused anal epithelium

• Distal to the dentate line

• Pain!!, minimal bleeding,

itching

ANAL FISSURESANAL FISSURES::

PathophysiologyPathophysiology

DECREASED DECREASED

BLOOD FLOW BLOOD FLOW

& ISCHEMIA& ISCHEMIA

TRAUMA TO TRAUMA TO

ANODERMANODERM

INTERNAL INTERNAL

SPHINCTER SPHINCTER

SPASMSPASM

ANAL PAINANAL PAIN

START

COMMON ANAL FISSURE SIGNSCOMMON ANAL FISSURE SIGNS

• Sentinel skin tag

• Hypertrophic papilla

• Exposed internal sphincter

• Spastic internal sphincter

ANAL FISSURES:

Non-surgical treatment • Diet changes

• Stool softeners & Laxatives

• Fluids

• Warm baths

• Analpram HC 2.5%

• Pain medications

• Diltiazem cream

• Topical N2O donor

• Nifedipine

• Botulinum toxin

ANAL FISSURES:

Nitroglycerin

• Glyceryl trinitrate is a NO2 donor

• Controversial for chronic fissures

• 30% can get headaches

• Considered first-line definitive medical

therapy

FISSURES: Surgical treatment

• Internal sphincterotomy

• Excision

• Botox injection into the sphincter

• Anoplasty / flap

• Manual dilation – not done in U.S.

SUMMARY: FissuresSUMMARY: Fissures

• Pain with defecation is the dominant symptom

• Often confused for hemorrhoids

• Fissures are common

• Most can be treated medically

– 90% success rate

– Should consider avoiding surgery

CONCLUSIONS: FissuresCONCLUSIONS: Fissures

• Common disorders often present to any physician’s office first

• Most can be treated medically as an outpatient

• A good history & physical are the most important aspect of care

• Referral to a specialist should be considered in complex & recurrent cases

REFERENCESREFERENCES

Senagore, MD. “Surgical Management of Hemorrhoids.” Senagore, MD. “Surgical Management of Hemorrhoids.” Journal of Journal of

Gastrointestinal SurgeryGastrointestinal Surgery; Vol. 6, No. 3, 2002.; Vol. 6, No. 3, 2002.

M. HulmeM. Hulme--Moir and D.C. Bartolo. “Disorders of the AnorectumMoir and D.C. Bartolo. “Disorders of the Anorectum--

Hemorrhoids.” Hemorrhoids.” Gastroenterology ClinicsGastroenterology Clinics Vol. 30, No. 1: March 2001.Vol. 30, No. 1: March 2001.

Thomson WBF. “The nature of haemorrhoids”. Thomson WBF. “The nature of haemorrhoids”. Br J SurgBr J Surg 1975;62:542.1975;62:542.

Gass OC, Adams J. “Hemorrhoids: Etiology and pathology”. Gass OC, Adams J. “Hemorrhoids: Etiology and pathology”. Am J SurgAm J Surg

79:4079:40--43, 1950.43, 1950.

Smith LE. Hemorrhoids. A review of current techniques and management. Smith LE. Hemorrhoids. A review of current techniques and management.

Gastroenterol Clin North AmGastroenterol Clin North Am 1987; 6:791987; 6:79--91.91.

PerezPerez--Miranda M, GomezMiranda M, Gomez--Cedenilla A et al. Effect of fiber supplements on Cedenilla A et al. Effect of fiber supplements on

internal bleeding hemorrhoids. internal bleeding hemorrhoids. HepatogastroenterologyHepatogastroenterology 1996;43:15041996;43:1504--1507.1507.

Dennison AR, et al. “The management of Hemorrhoids.” Dennison AR, et al. “The management of Hemorrhoids.” Am J Am J

GastroenterologyGastroenterology, 1999: 475, 1999: 475--481.481.


Murie JA, Mackenzie I, Sim AJ. “Rubber band ligation and Murie JA, Mackenzie I, Sim AJ. “Rubber band ligation and

hemorrhoidectomy ofr second and third degree hemorrhoids: A hemorrhoidectomy ofr second and third degree hemorrhoids: A

prospective clinical trial.” prospective clinical trial.” Br J SurgBr J Surg 1980;70:541980;70:54--56.56.

Arroyo et al. “Open versus closed dayArroyo et al. “Open versus closed day--case haemorrhoidectomy: is case haemorrhoidectomy: is

there any difference?Results of a prospective randomised study.” there any difference?Results of a prospective randomised study.” Int J Int J

Colorectal Dis.Colorectal Dis. 2004 Jul;19(4):3702004 Jul;19(4):370--3.3.

Wolff BG, Culp CE. “The whitehead hemorrhoidectomy. An unjustly Wolff BG, Culp CE. “The whitehead hemorrhoidectomy. An unjustly

maligned procedure.” maligned procedure.” Dis Colon RectumDis Colon Rectum. 1988 Aug;31(8):587. 1988 Aug;31(8):587--90. 90.

Koblstadt CM, Weber J, Prohm P. “Stapler hemorrhoidectomy. A new Koblstadt CM, Weber J, Prohm P. “Stapler hemorrhoidectomy. A new

alternative to conventional methods.” alternative to conventional methods.” Zentralbl ChirZentralbl Chir. .

1999;124(3):2381999;124(3):238--43. 43.

Palimento D, et al. “Stapled and open hemorrhoidectomy: randomized Palimento D, et al. “Stapled and open hemorrhoidectomy: randomized

controlled trial of early results.” controlled trial of early results.” World J Surg.World J Surg. 2003 Feb;27(2):2032003 Feb;27(2):203--7. 7.


Senapati A Nicholls RJ. “A randomized trial to compare the results of Senapati A Nicholls RJ. “A randomized trial to compare the results of

injection sclerotherapy with a bulk laxative alone in the treatment of bleeding injection sclerotherapy with a bulk laxative alone in the treatment of bleeding

hemorrhoids.” hemorrhoids.” Int J Colorectal DisInt J Colorectal Dis 1988:3:1241988:3:124--6.6.

Bayer, I, Myslovaty, B and Picovsky BM. “Rubber band ligation of Bayer, I, Myslovaty, B and Picovsky BM. “Rubber band ligation of

hemorrhoids: Convient and economic treatment.” hemorrhoids: Convient and economic treatment.” J. clin. GastroenterolJ. clin. Gastroenterol., .,

23:50, 1996.23:50, 1996.

Wrobleski, DE, Corman ML, et al. “LongWrobleski, DE, Corman ML, et al. “Long--term evaluation of rubber ring term evaluation of rubber ring

ligation in hemorrhoidal disease.” ligation in hemorrhoidal disease.” Dis. Colon RectumDis. Colon Rectum, 23:478, 1980., 23:478, 1980.

MacRae HM, McLeod RS. “Comparison of hemorrhoid treatment modalities: MacRae HM, McLeod RS. “Comparison of hemorrhoid treatment modalities:

A metaA meta--analysis.” analysis.” Dis Colon RectumDis Colon Rectum 38:68738:687--694, 1995.694, 1995.

Iwagaki, H, Higuchi Y, et al. “The laser treatment of hemorrhoids: Results of a Iwagaki, H, Higuchi Y, et al. “The laser treatment of hemorrhoids: Results of a

study on 1816 patients. study on 1816 patients. Jpn J SurgJpn J Surg 1989;19:658.1989;19:658.

Smith LE, Goodreau JJ, Fouty WJ. “Operative hemorrhoidectomy versus Smith LE, Goodreau JJ, Fouty WJ. “Operative hemorrhoidectomy versus

cryodestruction.” cryodestruction.” Dis Colon Rectum.Dis Colon Rectum. 1979 Jan1979 Jan--Feb;22(1):10Feb;22(1):10--6.6.


Lienert M, Ulrich B. “DopplerLienert M, Ulrich B. “Doppler--guided ligation of the hemorrhoidal arteries. guided ligation of the hemorrhoidal arteries. Report of experiences with 248 patients.” Report of experiences with 248 patients.” Dtsch Med Wochenschr.Dtsch Med Wochenschr. 2004 Apr 2004 Apr 23;129 (17):94723;129 (17):947--50.50.

Morinaga, K, Hasuda K et al. “A novel therapy for internal hemorrhoids: Morinaga, K, Hasuda K et al. “A novel therapy for internal hemorrhoids: Ligation of the hemorrhoidal artery with a newly devised instrument Ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter.” (Moricorn) in conjunction with a Doppler flowmeter.” Am J GastroenterolAm J Gastroenterol 1995; 90:610.1995; 90:610.

Konsten J, Beaten CGMI. “Hemorrhoidectomy vs. Lord’s method: 17 year Konsten J, Beaten CGMI. “Hemorrhoidectomy vs. Lord’s method: 17 year followfollow--up of a prospective, randomized trial.” up of a prospective, randomized trial.” Dis Colon RectumDis Colon Rectum 2000;43:5032000;43:503--6.6.

Schouten WR, van Vroonhoven TJ:Lateral sphinterotomy in the treatment of Schouten WR, van Vroonhoven TJ:Lateral sphinterotomy in the treatment of hemorrhoids: A clinical and manometric study.” hemorrhoids: A clinical and manometric study.” Dis Colon RectumDis Colon Rectum 29:86929:869--872, 1986.872, 1986.

Madoff, Robert and James Fleshman. “American Gastroenterological Madoff, Robert and James Fleshman. “American Gastroenterological association technical review on the diagnosis and treatment of hemorrhoids.” association technical review on the diagnosis and treatment of hemorrhoids.” Gastorenterology Gastorenterology May 2004, vol. 126, No 5.May 2004, vol. 126, No 5.

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