Rites of Passage Peri-Operatively.
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Official Journal of the American Society of Abdominal Surgeons, Inc.
This article originally appeared in the Winter 2012 / Spring 2013 issue of the Journal.
Our Experience in Treating Piles with THD
Dr. Faris Dawood Alaswad, M.D., M.B.CH.B., F.I.C.M.S., F.I.C.S., F.A.C.S., F.E.B.S.
Rites of Passage Peri-Operatively.
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Hemorrhoids are the most common anal disease. Depending on its symptoms, non invasive treatments such as band ligation, cryotherapy and sclerotherapy and invasive treatments such as a hemorrhoidectomy have been used to treat hemorrhoids.
Hemorrohoidectomy had been the most commonly used, but with the disadvantage of severe postoperative pain, longer recovery time and complications such as bleeding and anal stricture.
To overcome this disadvantage new treatment methods such as PPH or THD have been introduced.
THD has been reported to have a recurrence rate of less than 10%, and with 90% of patient satisfaction.
The simultaneous conduct of artery ligation and recto-anal repair has been recently introduced and has been reported to achieve good treatment outcomes.
PATIENTS AND METHODS
This is a prospective study conducted on 50 patients who underwent a one year follow up from among patients who had undergone THD operations in our hospital from Oct. 2011 to Oct 2012.
Evaluation of the procedural outcomes was done through outpatients visits conducted at 7, 30, and 90 days after discharge.
Recurrence was considered to have occurred in case of re bleeding or re-prolapsed.
Pre-operative symptoms, post operative pain, operation time and time to return to normal living were also examined.
The surgery was conducted on patients with grade 2-4 hemorrhoids. Patients who were diagnosed with concomitant anal diseases such as fistula, fissure, thrombotic hemorrhoid on preoperative examination were excluded from the surgery. All the patients underwent the surgery in the lithotomy position using a Doppler probe which was placed around 3-5 cm above the dentate line to locate the branches of the superior rectal artery. Subsequently a figure of eight suture was made using Vicryl 2-0 at the rectal mucosa where the artery had been confirmed. Recto Anal Repair (mucopexy) was conducted in a way that hemorrhoid mass was sequentially sutured from the artery ligation site to 5 mm of the upper dentate line by using the vicryl used for artery ligation and was firmly tightened in place on the rectal mucosa. This procedure was repeated at 6 sites (1, 3, 5, 7, 9, 11) o’clock.
The patients mean age was 51.7 +-13.2 years (range 22-87 years) and the patients consisted of 31 males and 19 females. The most common main symptom observed in the patients before surgery was prolapsed lesion (44) and bleeding (27) cases, defecation pain (11) cases, constipation (6) cases and fecal incontinence (2 cases) were also observed. There was significant overlap in symptoms.
The pre operative disease stages included grade 2 hemorrhoids in 6 patients, grade 3 in (34) patients and grade 4 in 10 patients according to Golligher classification. Five (5) patients had some previous hemorrhoid surgery at least once. Most patients had hemorrhoid symptoms for more than one year and some patients had them more than 30 years.
Anesthesia included general anesthesia in 41 patients, spinal anesthesia in 6 patients and local anesthesia in 3 patients. The patients were hospitalized on the day of surgery or on previous night before surgery.
The mean hospitalization period was 1 day. Most patients were discharged on the day of surgery. However 8 patients were discharged one day after the surgery and 2 patients discharged 2 days and one after 5 days.
The mean operation time was 35 (+/- 10 min). The number of blood vessels to which ligation was conducted was 6. Recto Anal Repair was conducted an average of 8 times along the circumference.
In a survey on the return to daily living, patients answered that they were able to return to their daily lives on average 2 days after the surgery.
The results of the follow up conducted one week after the surgery showed tenesmus in 10 patients, mild bleeding in 4 patients, voiding dysfunction in 3 patients and prolapse in one patient.
However serious complications requiring re-hospitalization were observed only in one case of secondary hemorrhage.
In a follow up study conducted one month after the surgery, 3 patients had tenesmus, 2 had bleeding and prolapse patients were noticed in 2 patients. When the (2) bleeding patients examined using anoscope it shows the cases to be anal fissure which is irrelevant to hemorrhoid surgery.
In the out patient’s visit 3 months after the surgery no patients complained from tenesmus, 2 patients had prolapsed and the two patients with bleeding fissure were treated conservatively and bleeding stopped.
In a follow up study conducted one year after the pre operative symptoms recurrence in 7 patients. 2 patients complained of defection bleeding, 5 patients complained of prolapse.
The score of surgery satisfaction one year after the surgery was 8 (+/- 2) points in a scale of 10, and 33 patients replied in a survey that they would recommend the surgery to other people.
Hemorrhoids are the most common disease among anal diseases and is known to be caused by anal cushion descent or abdominal congestion of the internal hemorrhoid venous plexus. Various treatment methods have been developed and used to date.2 Hemorrhoidectomy has been the standard treatment method and has been used for a long time. It is a good method to eliminate the pathophysiological factors of hemorrhoids, but has disadvantages of having an approximately 10% postoperative complication rate3 requiring time for treatment, and requiring significant time to return to normal daily activities. To overcome these disadvantages, new operation methods have beendeveloped to minimize postoperative pain and to return to daily living as soon as possible.4 The PPH, which was first introduced by Longo et al in 1993, is a surgery method that effectively blocks the blood flow of the upper rectal artery into the hemorrhoid by segment ally resecting the rectal mucosa with a regular form and suturing them automatically and that fixes the descended rectal mucosa by uplifting it. It has advantages of less postoperative pain, shorter hospitalization period, and simpler procedure.5 However, it has disadvantages in that it may cause serious complications such as bleeding, perforation, abscess formation, peritonitis, and fecal incontinence unless the resection plane is precisely sutured.5-7 In addition, a long-term follow up study reported that recurrence rate was higher for the PPH than for a hemorrhoidectomy.8
Doppler guided hemorrhoid artery ligation, which was first introduced by Morinaga et al.9 in 1995, is a surgical method that ligates and contracts hemorrhoid mass after detecting the upper rectal artery branches connected to each hemorrhoid through a Doppler signal, and compared to a conventional hemorrhoidectomy,10 no difference in the recurrence of preoperative symptoms was reported to have been found in a one-year follow up study. A 3-year follow up study including grade 4 hemorrhoids reported good out comes such as a 12% recurrence rate and fewer complications.1, 2, 3 However, artery ligation alone has limitations in the removal of the remaining anal mucosa and the treatment of a severely prolapsed hemorrhoid. Accordingly, the early apparatus was recently modified to simultaneously conduct artery ligation and Recto Anal Repair. Thus it had an effect of fixing the upper anal canal upward after as what is done in PPH method.
In this study artery ligation and recto anal repair each was conducted an average of mean six times. The mean operation time was approximately 35 minutes. No significant differences in the operation times and the number of artery ligations and recto anal repairs were found among the patients. Meanwhile, in other studies,4, 5, 6 the number of artery ligation was, on average, 5-10; particularly, the number of recto anal repairs was a minimum of 1 and a maximum of 5 which was less than the number recto anal repairs conducted in this study.8,9,10 The reason for this difference is attributed to differences in the surgery methods. In this study, during artery ligation, the recto anal repair was simultaneously conducted in such a manner that the prolapsed hemorrhoid mass on the Doppler probes groove was sequentially sutured. Meanwhile in other studies each artery ligation was conducted for the entire anal canal in advance, and several prolapsed hemorrhoids were than separated followed by recto-anal repair.
In a follow up study conducted 7 days after the surgery approximately 20% of the patients suffered from tenesmus, which was higher than the frequency reported in anotherstudy.9 This is likely attributable to the fact that the number of recto anal repairs was higher in this study. A further comparative study is required to obtain more evidence. In a follow up study conducted one year after the surgery recurrence including rebleeding, was observed in 7 patients (14%). Which was higher recurrence rate than that shown in other studies.4, 7, 9 The recurrence rates were 10% 6% and 30% for grade 2, grade 3, and grade 4 hemorrhoids, respectively. When only prolapsed was considered, recurrence occurred in 10% of the patients. In this case, no significant difference in recurrence rate was found between this study and other studies. However, the direct comparison is not really reliable as each study had different recurrence criteria. Only prolapsed was defined as recurrence in one study1 whereas prolapsed or bleeding was defined as recurrence in this study. In addition symptoms requiring surgery were defined as recurrence in another study.3 Thus an accurate comparison may be difficult. Faucheron et al 1, 4, 6 conducted a follow up study of approximately 34 months after a study conducted on 100 patients with grade 4 hemorrhoids and reported a 9% recurrence rate. This rate is significantly lower than the 38% recurrence rate for grade 4 hemorrhoids of this study. This difference is likely attributable to the different criteria of grade 4 hemorrhoids. In this study, prolapsed hemorrhoids that were prolapsed over the entire anus were mainly included in the criteria of grade 4 hemorrhoids, but in the study conducted by Faucheron et al,6 partially prolapsed hemorrhoids were mainly included. A study conducted by Szmulowicz et al7 also reported that 65% of recurrent patients had large-sized hemorrhoids prolapsed over the entire anus. A follow-up study conducted for more than one year showed that THD was a safe and effective treatment method for most hemorrhoids except grade 4 hemorrhoids with severe prolapsed.5, 6, 7
This study has a limitation in that it was conducted with a restricted number of surgeons in a single institution. However as this technique is currently being used in other medical institutions in addition to the authors hospital a long term large scale multicenter study could be conducted to compare this technique with other surgery methods in the future.
THD treatment of most hemorrhoids except hemorrhoid with severe prolapsed achieved a satisfactory outcome without significant pain and complications. A further longterm large scale multicenter follow up study is required. Furthermore a study on the treatment of hemorrhoids associated with other anal diseases is required.
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3. Milligan ET, Morgan CV, Jones LE. Surgical anatomy of the anal canal and the operative treatment of hemorrhoida. Lancet. 1937:2:1119-1124.
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10. Maw A, Emu KW, Seow-Choen F. Retroperitoneal sepsis complicating stapled hemorrhoidectomy; report of a case and review of the literature. Dis colon rectum. 2002;45; 826-828.
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