J. Coloproctol. (Rio J.) vol.36 número2

jcoloproctol(rioj).2016;36(2):104–114

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Review

Article

Analysis

of

the

main

surgical

techniques

for

hemorrhoids

Magno

Otávio

Salgado

de

Freitas

,

Jaciara

Aparecida

Dias

Santos

,

Maria

Fernanda

Santos

Figueiredo

_,

_Cristina

_Andrade

_Sampaio

a_{Post-graduationPrograminPrimaryCareinHealth,SurgicalClinicDepartment,UniversidadeEstadualdeMontesClaros(Unimontes),}

MontesClaros,MG,Brazil

b_{UniversidadeEstadualdeMontesClaros(Unimontes),MontesClaros,MG,Brazil}

c_{ProgramofUndergraduateResearch,Fundac¸ãodeAmparoàPesquisadoEstadodeMinasGerais(FAPEMIG),BeloHorizonte,MG,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received24September2015 Accepted6December2015 Availableonline22March2016

Keywords:

Hemorrhoidectomy Hemorrhoids PPH

a

b

s

t

r

a

c

t

Introduction:Surgicaltreatmentofhemorrhoidaldiseaseisusedinabout5–10%ofcases whereconservativetreatmentshavenotbeeneffective.

Objective:Tolearnthesurgicaltechniquesusedinthetreatmentofhemorrhoidaldisease gradesIIIandIVinthelightofliterature.

Methods:Thisisanexploratorystudy,withanintegrativereviewofliteraturepublishedfrom 2009to2015fromdatabasesLILACS,SciELO,MEDLINE,PUBMEDandthePortalofCAPES, usingthefollowingdescriptors:“hemorrhoidectomy”and“hemorrhoids”,intheperiodfrom MarchtoMay2015.

Results:Nineteenarticleswereselected.Inthefourmoredescribedtechniques,thesurgical timerangedfrom19.58to52min,withrelapsesfrom5%,from17.5to35minandrecurrences of7.5%to8.2%,23–35minwas20%and22.5%relapse,12.5and13.2min,3.5%ofrelapses.

Conclusion:Conventionaltechniquesarestillthemostcommonlyperformedwithagood acceptanceonthelong-termresolutionandlowrecurrencerate.

©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Análise

das

principais

técnicas

cirúrgicas

para

doenc¸a

hemorroidária

Palavras-chave:

Hemorroidectomia Hemorroidas PPH

r

e

s

u

m

o

Introduc¸ão:Otratamentocirúrgicodadoenc¸ahemorroidáriaéutilizadoparacercade5a 10%doscasosemqueostratamentosconservadoresnãosurtiramefeito.

Objetivo:Conhecerastécnicascirúrgicasutilizadasnotratamentodadoenc¸ahemorroidária grauIIIeIVàluzdaliteratura.

∗ _{Correspondingauthor.}

E-mail:freitasmagno49@gmail.com(M.O.S.deFreitas).

http://dx.doi.org/10.1016/j.jcol.2015.12.008

jcoloproctol(rioj).2016;36(2):104–114

105

Métodos:Trata-sedeumestudoexploratório,comrevisãointegrativadaliteraturapublicada nosanosde2009a2015,dasbasesdedadosLILACS,SciELO,MEDLINE,PUBMEDenoPortal daCAPES;apartirdosseguintesdescritores:hemorroidectomiaehemorroidas,noperíodo demarc¸oamaiode2015.

Resultados: Foramselecionados19artigos.Nasquatrotécnicasmaisdescritas,otempo cirúrgicovarioude19,58a52minutoserecidivasde5%,de17,5a35minutoseasrecidivas de7,5%a8,2%,de23a35minutosehouvede20%a22,5%derecidivas,de12,5e13,2 minutose3,5%derecidivas.

Conclusão: Astécnicasconvencionaisaindasãoasmaisrealizadas,comboaaceitac¸ão quantoàresoluc¸ãoalongoprazoecombaixoíndicederecidivas.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este éumartigoOpenAccesssobalicençadeCCBY-NC-ND

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Hemorrhoidaldisease(HD)isaconditionthatafflictsabout 4.4%ofworldpopulation,andisthemostcommonanal dis-order.Theagedistributionshowsahigherincidenceamong patientsaged45–65yearswithdecreasedinvolvementafter 65years,andthefactthatmenaremorefrequentlyaffected thanwomen.1,2 _{Theprobablecauseoftheonset of} hemor-rhoids,accordingtothetheoryofThompson,1975,wouldbe theprolapsedanalvascularcushions,whichareconstituted bymusclefibers–atissueoffibroelasticconsistenceand vas-cularplexuseswitharteriovenousanastomoses.3

TheHDmaybeinternalorexternal,dependingonits rela-tionshiptothedentateline.HDisfurtherclassifiedintogrades rangingfromonetofour,withthreeandfourdegreesthemost seriousones.Thepossibleetiologiesofthedisease include prolongedeffort,pregnancy,constipation,heredity,increased intra-abdominal pressure with obstruction of the venous return,andprobablyaging.Thus,patientswithhemorrhoids may reportabright redbleeding throughthe rectum, anal pain,protrudingmasses,itching,burninganddiscomfort.4

Currently, there are several therapeutic possibilities for the treatment of hemorrhoids, with the options ranging fromchangesineatinghabits,medicationsthatalleviatethe symptoms,theuseofoutpatienttechniquessuchas cryother-apy,sclerotherapy,laser photocoagulationand rubberband ligation,tosurgicalexcisiontechniquesforhemorrhoidal pro-lapsesaffectedbythedisease.5,6

Thesurgical treatmentis usedin about 5–10%of cases inwhichtheconservativetreatmenthadnoeffect;patients withsymptomaticoracuteGradeIIIorIVhemorrhoidswho havenotimprovedwithothertreatmentsareelectedforthe procedure.3

Surgicaltechniquesareoftendescribedasfivebasictypes: open and closed techniques, proposed byMilligan–Morgan andFerguson,respectively,andthesemi-closed,amputative, and stapled hemorrhoidopexy (PPH).5 _{Withregard torates} ofcomplications,hemorrhoidectomypresentsratesranging from3%to12%,and themostcommon complicationsare: urinaryretention,localpain,bleeding,analstenosis,perianal fistula,analincontinence,andrecurrence.7

Inlightofthis,consideration mustbegiventothemain surgicaltechniquesusedinthe treatmentofgradesIIIand

IVhemorrhoidaldisease,aswellasaspectsinherenttoeach techniquethatwouldinterfereinthebestprognosisforthe patient – postoperativepain, recurrence, surgical time and returntonormalactivity.However,littlehasbeendiscussed intheliteratureabouttheseissues,andevenlessinBrazilian literature.Thus,thisstudyaimstoevaluatethesurgical tech-niquesusedinthetreatmentofgradesIIIandIVhemorrhoidal disease,accordingtothepertinentliterature.

Method

Thisisanexploratorystudythatoutlined,fromanintegrative reviewofscientific literatureoncurrent surgical, the tech-niquesusedinthetreatmentofgradesIIIandIVhemorrhoidal disease.Thechoiceofthismethodwasduetothepossibility ofgrouping,evaluateandsynthesizetheresultsofresearchon aparticularsubjectinanorganizedandsystematicmanner, usingitwiththeobjectiveofobtainingamorecomprehensive understandingofthestudiesontheproposedtheme,besides workingasa synthesistoolforpublished andscientifically establishedstudies.8

In this research, publications available from 2009 to 2015 inthe databases LILACS (Literatura Latino-Americana edoCaribeem Ciênciasda Saúde), SciELO(Scientific Elec-tronicLibraryOnline),MEDLINE(MedicalLiteratureAnalysis and Retrieval System Online), PUBMED and CAPES Portal were surveyed. The search took place from March toMay 2015. Thedescriptors usedwere “hemorroidectomia [hem-orrhoidectomy]”, “hemorroidas [hemorrhoids]” and “PPH”. These descriptorswere chosenbecausetheyallowtocover andthereforeenabletheachievementofadiversifiedresult withrespecttosurgicaltechniques.

The titles and abstracts ofarticles were scrutinizedfor identificationofthosestudieswhichlookedattheproposed objective,consideringthefollowinginclusion criteria: stud-iespublishedinnationalandinternationaljournalswritten inEnglish,SpanishandPortuguese,andaccessedwithafree andfulltext.Reviewarticles,theses,editorials,letterstothe editorandstudieswherethemainfocuswasnottheanalysis ofsurgicaltechniquesusedingradesIIIandIVhemorrhoidal diseasewereexcluded.

106

articleswasproduced,andthechosenvariableswere:name ofthestudy,authorship/year,journal,studyobjective,study design and conclusions/recommendations. These variables were arrangedinthe collectioninstrument inthe order in whichtheywerefoundandselectedduringthesearch.

Results

and

discussion

Fromthedefinedstrategy,theliteraturesearchresultedin202 articles,ofwhich70werefoundinMEDLINE,63inPUBMED, 17inLILACS,38intheCAPESportal,and14inSciELO.After reading thetitles and abstractsofthesearticles, 47 poten-tiallyrelevantstudieswerefoundandthencarefullyreadin theirentirety.Ofthesearticles,19wereselected,becausethey strictlyfollowedtheinclusioncriteria.

Theanalysisofthe selectedmaterialwasperformed by meansofacriticalandqualitativereadingwhichallowedthe identificationofconvergences,enablingthefollowing group-ingbythematicaxes:conventionaltechniques(Fergusonand Milligan–Morgan),PPH(procedureforprolapsedhemorrhoid), THD(transanalhemorrhoiddearterialization)andLigaSureTM_; theseaxeswere alsodefined accordingto themainissues presentinthediscussionsandwiththestudyoutcomes: surgi-caltime,recurrence,postoperativepainandreturntoactivity. Aftertheinterpretationoftheresults,aknowledgesynthesis wascarriedout.

TheresultsarelistedinTable1,inwhichthetitleofthe study,authorship,journal,studyobjective,studydesignand conclusions/recommendationsareidentified.

Intheanalysisoftheselectedarticles,wefoundfour stud-iesthatcomparedconventional(openandclosed)techniques

versusPPHtechnique;fourstudiesthatevaluatedPPH tech-nique;twopublicationsthatanalyzedPPHversusTHD;four articles that addressed only conventional techniques; four studies that also analyzed conventional techniques versus

LigaSureTM_{; andonestudy thatsinglyexaminedTHD} tech-nique. The number and percentage of productsrelated to theyearofpublicationwerealsoconsideredinthisstudy,as describedinTable2.

Itwasobservedthattheperiodwiththehighestnumber ofpublicationswastheyear2013:6(31.5%)articles.Theyears 2011,2014and2015producedonearticleeach(5.3%).Thus,itis clearthattherewasadecreaseinthenumberofpublications inthelast year,showingadecreased concernwithrespect totheissueathand.Regardingthecountryoforiginofthe publications,itwasclear(Table3)thatBrazilandChilehad thehighestnumberofpublications:3(15.7%)each.

Itwas foundthatthe fourmostwidelyusedtechniques were:conventional,PPH,THDandLigaSureTM_.

Conventionalsurgicaltechniques

Themostcommonlyusedconventionaltechniqueswerethe open(Milligan–Morgan)andtheclosed(Ferguson)technique. Theopentechniqueisconsideredthegoldstandardforthe surgicaltreatmentofgradeIVhemorrhoidaldisease.Initially, thistechniquewasproposedbySalmonin1830and popular-izedsince1937byMilliganandMorgan;basicallyitconsists oftheexcisionofthehemorrhoidaltissuewithligationand

dissectionofthevascularpedicle,leavingthewoundopento healbysecondaryintention.6

Ontheotherhand,theclosedtechniqueisconsideredas aclassicalprocedure;itwasdescribedintheliteratureby Fer-gusonin1931andpublishedin1959byJamesFergusonand RichardHeaton.Thistechniqueischaracterizedbythe exci-sionofthehaemorrhoidaltissue,followedbytheligationof the vascular pedicle, but withsutures appliedtodissected andresectedareas.Thesurgicalprocedureincludesareduced surgicaltime,besidesprovidingthepatientwithlessscar for-mationandpreservationofanalsensitivity.6

Surgicaltimeandreturntonormalactivity

AccordingtodatadescribedinFig.1,thesurgicaltimeofthe conventional techniquerangedfrom 19.58to52min.Thus, the comparativestudybetweenLigaSureTM _{versusFerguson} techniques,carriedoutinthesurgerysectoroftheRegional HospitalofRancagua,inChile,9_{showedthattheclosed} tech-nique showed a surgical time of 24.3±7min. In contrast, thecomparisonbetweenthesesametechniquesdescribedby theDepartmentofSurgery,BanarasHinduUniversity,India, showedasurgicaltimeforFerguson’stechniqueof29min.10

Ontheotherhand,thecomparativestudybetween hem-orrhoidectomytechniquebylaserversusconventional open techniquethatwasheldinAlokaHospital,Kosovo,showed a surgical time of 26.74min.2 _{The investigation developed} inChinawiththeopentechnique(Milligan–Morgan)gotthe shortersurgicaltime,whichwas19.58±2.71min.11_Thelonger surgicaltimehasbeenreportedinaBrazilianstudythat com-paredtheconventionaltechniqueandPPHinahospitalinSão Paulo,withtheconventionaltechnique,ittookapproximately 52minandlasted PPH 31minwithstatistical significance.7 Alongsurgicaltimecanexposethepatienttoahigherrisk ofinfectionasthepatientloseshis/herfirstprotective bar-rier(skin)againstmicroorganisms,withperianalandperineal sepsisasapotentialcomplication.12

With respecttothe return toactivity,patients returned afterperiodsfrom21daysto10weeks.InthestudyofKhanna etal.,10_{thisperiodwasof21days.Intheircomparativestudy} between theclosed and semi-closed techniquesperformed intheOutpatientSurgeryDepartmentoftheHospitalBarros LucoTrudeauinChile,Azolasetal.13_{pointoutthatthereturn} wasinabout30days.Inhispublication,Roldós14_describes thatthereturntonormallifeforhispatientsoccurredwithin an interval of29 days. Marianelliet al.7 _{described intheir} studythatthereturntonormalactivityoccurredin10weeks. A meta-analysisthat examined theresultsofcomparisons ofconventional hemorrhoidectomy versusLigaSureTM _in10 articles,showedthattheuseofLigaSureTM _{wasstatistically} superior in many ways, including less operating time and postoperativepain,fasterreturntoactivityandlowerrateof complications.1

Painandrecurrences

j

coloproctol

(rio

j).

2

0

1

6;

3

6(2)

:104–114

107

Table1–Distributionofthestudiesselected,accordingtothestudyname,authorship,journal,studyobjective,studydesignandconclusions/recommendations, 2009–2015.

Studyname Authorship Journal Studyobjective Studydesign Conclusions/recommendations Evaluaciónfuncionaly

encuestade satisfaccióndelos pacientesoperadosde hemorroidescon técnicadePPH

Heine,Cápona,López, Larach,Larach,Kronberg, etal.(2010)

RevistaChilenadeCirugía Knowingtheevolutionand perceptionofpatients operatedforhemorrhoids withthePPHtechniquein themediumterm.

Investigativestudy Mostpatientsfavorablyassessed thehemorrhoidectomytreatedby PPHintermsofresolutionof postoperativesymptoms, functionalstatus,andoverall satisfactioninthemediumterm. Surgicalcomplications

in2840casesof hemorrhoidectomyby Milligan–Morgan, Fergusonand combinedtechniques

Santos,Coutinho,Meyer, SampaioandCruz(2012)

JournalofColoproctology Reviewandupdate87cases ofsurgicalcomplications fromaseriesof2840 patientsundergoing hemorrhoidectomyusing Milligan–Morgan,Ferguson andmixedtechniquesover theperiodof46yearsof professionalactivityinthis specialty(1965–2011).

Originalarticle Theacceptanceofthesurgical indicationforhemorrhoidectomy was25.7%,beingmorecommon andbetteracceptedbywomen thanbymen.Thisoperationwas performedmoreofteninpatients inthefourth,fifthandthird decadesoflifeandtheoverall incidenceofsurgical

complicationswas3.0%.Themost commoncomplicationswereanal stenosisandseverebleeding,with nodifferencebetweensurgical techniques.

Hemorroidectomia convencionalversus

Hemorroidopexia Mecânica(PPH). Estudoretrospectivo de253casos

Marianelli,Machado, Almeida,Baraviera, Falleiros,Lolli,etal.(2009)

RevistaBrasileirade Coloproctologia

Reviewtheexperienceof thecoloproctologyservice, HSPM-SP,insurgical treatmentofhemorrhoidal disease.

Documentarystudy Themostwidelyusedmethodfor thesurgicaltreatmentof hemorrhoidswasconventional hemorrhoidectomy.Itwasalso observedthatmechanical hemorrhoidopexy(PPH)showed shorteroperativetimeandfaster postoperativerecovery.Moreover, therewasagreatertendencyto latecomplicationsand recurrences,withthepatientsin needofanewsurgeryinthe conventionalhemorrhoidectomy group.

Hemorroidectomía cerraday

semicerrada:Estudio prospectivo aleatorizado

Azolas,Villalón,Danilla, Hasbún,Gaticaand Salamanca(2010)

RevistaChilenadeCirugía Comparetheresultsof closedversusthe half-closedsemicerrada hemorrhoidectomyin termsofpain, complications,surgical timeandhealing.

108

j

coloproctol

(rio

j).

2

0

1

6;

3

6(2)

:104–114

Table1–(Continued₎

Studyname Authorship Journal Studyobjective Studydesign Conclusions/recommendations Estudiocomparativo

entre

hemorroidectomía cerradadeFergusony hemorroidectomía comLigaSureTM

Jaramillo,Beltrán,Bozzo, andLarracheaeGonzález (2011)

RevistaColombianade Cirurgia

Compareconventional hemorrhoidectomy, representedbyFerguson techniqueversus

hemorrhoidectomywith LigaSureTM_.

Originalarticle Thehemorrhoidectomywith LigaSureTM_{significantlyshortens}

thesurgicaltime,being comparableintermsof postoperativepainandof complicationswithFerguson hemorrhoidectomy. Nuevatécnica

quirúrgicaparael tratamientodela enfermedad hemorroidal

Roldós(2010) RevistaCubanadeCirurgia Reducethemorbidityof surgicaltreatmentofthe disease.

Originalarticle Theproposedtechniqueprovides anewoptiontoimprove

postoperativemorbidityofsurgical treatmentinpatientswith hemorrhoidaldisease.New randomizedcontrolledtrialson hemorrhoidectomytechniquesare needed.

AnálisisyResultadosde laOperaciónde Fergusonemel Tratamientodela Enfermedad Hemorroidal

Ferrari,Jamier,Barrionuevo andAndrada(2013)

RevistaArgentinade Coloproctologia

Prospectivelyevaluatethe resultsobtainedfroma seriesof

hemorrhoidectomy proceduresperformedwith Fergusontechnique.

Originalarticle Thehemorrhoidectomywiththe Fergusontechniqueresultedinan appropriateandeffective procedureforthetreatmentof gradeIIorIIIhemorrhoidal disease,withalowrateof postoperativecomplications. Procedimientopara

hemorroidescon prolapsodemucosa: TécnicadeLongo. Reportepreliminar.

Mederos,Pintoand Manzaneda(2009)

RevistaMedicaHerediana Evaluatetheefficacyand safetyofPPHinpatients withgradesIIIandIV hemorrhoidswithrectal mucosaprolapse.

Originalarticle HemorrhoidectomybyPPHis effectiveintreatingsymptomsof gradeIIIandIVhemorrhoidswith prolapseofthemucosa,atleastin theshortandmediumterm. Hemorroidectomíacom

LigaSureTM_vs.

diatermia

convencional:Análisis retrospectivo monocéntrico

Papis,Parodi,Herrerías, Sánchez,Gómez,Sierra, etal.(2013)

ActaGastroenterologica Latinoamericana

Comparethesurgical outcomesbetweenthe hemorrhoidectomy performedaccordingto Milligan–Morgantechnique withuseofLigaSureTM_and

thatperformedwith conventionaldiathermy.

Originalarticle Thehemorrhoidectomyperformed withLigaSureTM_provedtobea

safetechnique,withalowrateof postoperativepainandfewer complications.

Milligan–Morgan hemorrhoidectomy withanalcushion suspensionand partialinternal sphincterresection forcircumferential mixedhemorrhoids

Lu,Shi,Wang,Wu,Liuand Wen(2013)

WorldJournalof Gastroenterology

Identifyamoreeffective treatmentprotocolfor mixedcircumferential hemorrhoids.

j

coloproctol

(rio

j).

2

0

1

6;

3

6(2)

:104–114

109

Table1–(Continued₎

Studyname Authorship Journal Studyobjective Studydesign Conclusions/recommendations Clinicalobservationson

thetreatmentof prolapsing hemorrhoidswith tissueselecting therapy

Wang,Zhang,Zeng,Zhang, Zhu,Liu,etal.(2015)

WorldJournalof Gastroenterology

Comparetheeffectsand postoperative

complicationsbetweenthe tissuefromstapled therapeuticsand Milligan–Morgan hemorrhoidectomy.

Originalarticle Therapywiththeuseofastapler forsevereprolapsedhemorrhoidis asatisfactorytechniquefor obtainingfasterrecovery,lower complicationratesandhigher operatingsafety.

Laser

Hemorrhoidoplasty Procedurevs.Open Surgical

Hemorrhoidectomy:a TrialComparing2 Treatmentsfor HemorrhoidsofThird andFourthDegree

Maloku,Gashi,Lazovic, IslamiandJuniku-Shkololli (2014)

ActaInformaticaMedica Comparethelaser procedureforsymptomatic hemorrhoidswithanopen surgicalprocedurein outpatientcare

Originalarticle Thelaserprocedurefor hemorrhoidswasmoreeffective thanopensurgical

hemorrhoidectomy.Postoperative painandsurgicaltimeareonly twoindicatorsforthisdifference.

Comparisonof LigaSureTM

Hemorrhoidectomy withConventional Ferguson’s Hemorrhoidectomy

Khanna,Khanna,Bhadani, SinghandKhanna(2010)

IndianJournalofSurgery CompareLigaSureTM

hemorrhoidectomyversus

conventionalFerguson’s ‘closed’hemorrhoidectomy forthetreatmentofgrade IIIandIVhemorrhoids.

Originalarticle TheLigaSureTM

hemorrhoidectomyisasafeand effectiveprocedure,withless bloodloss,postoperativepain,and complicationscomparedwith conventionalhemorrhoidectomy. Technically,itismuchsimpler,by obviatingtheuseofsuturesand hemostasis.

Milligan–Morgan Hemorrhoidectomyvs

Stapled

Hemorrhoidopexy.

Kashani,Mehrvarz,Nzeini andErfanian(2012)

TraumaMonthly Evaluateandcomparethe resultsofthesetwosurgical proceduresintermsof recovery,improvementof symptomsandincidenceof complications

Originalarticle Bothtechniquesareeffective methodsforthetreatmentof gradeIIIandIVhemorrhoidsand areassociatedwitharecoveryrate over95%.Overall,theresultsare thesameforbothtechniques.Low postoperativepainwastheonly advantageofstaplingtechnique

110

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j).

2

0

1

6;

3

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:104–114

Table1–(Continued)

Studyname Authorship Journal Studyobjective Studydesign Conclusions/recommendations Comoo

Coloproctologista BrasileiroVêaDoenc¸a Hemorroidária–Análise deDadosColhidosde QuestionárioDirigido aosEspecialistas FiliadosàSociedade Brasileirade Coloproctologia

Cruz,Alvarenga, Constantino,Andrade, Gomes,Faria,etal.(2009)

RevistaBrasileirade Coloproctologia

Analyzetheresponsesto anextensivequestionnaire with52questionsabout hemorrhoidaldisease(HD)

Originalarticle Themainsurgicalindicationfor hemorrhoidaldiseasewasthe intensityofsymptoms(64.47%), withapreferenceforthe Milligan–Morganopentechnique (65.79%).

Transanal haemorrhoidal dearterialisationwith mucopexyversus

stapler

haemorrhoidopexy:a randomizedtrialwith long-termfollow-up

Lucarelli,Picchio, Caporossi,DeAngelis,Di Filippo,etal.(2013)

AnnalsoftheRoyalCollege ofSurgeonsofEngland

Comparethelong-term resultsoftransanal hemorrhoidal dearterialization(THD)

versusmucopexyand stapledhaemorrhoidopexy (SH)inthetreatmentof gradeIIIandIV hemorrhoids.

Originalarticle TherecurrencerateafterTHDwith mucopexyissignificantlyhigher thanafterlong-termSH,although theresultsweresimilarwith respecttothecontrolofsymptoms andpatientsatisfaction.

Resultadosauma ˜no trasdesarterialización hemorroidalguiada pordoppler

Gomez-Rosado, Sanchez-Ramirez, Capitan-Morales, Valdes-Hernandez, Reyes-Diaz,Cintas-Catena, etal.(2012)

CirugiaEspa ˜nola Evaluatethesafetyand efficacyofthistechnique (Doppler-guided hemorrhoidal dearterialization)after 1-yearfollow-up.

Originalarticle Doppler-guidedhemorrhoidal dearterializationappearstobe effectiveafteroneyear,withalow complicationrate.

Stapled

hemorrhoidectomy; resultsofa prospectiveclinical trialinSaudiArabia

GurayaandKhairy(2013) JournalofClinicaland DiagnosticResearch

Evaluatetheeffectiveness ofstapled

hemorrhoidectomy(SH)in termsofcureofsymptoms andcontrolof

postoperativepain.

Originalarticle SHisasafe,fastandconvenient surgicaloptiongradeIIIandIV hemorrhoids,withalow complicationrate,minimal postoperativepain,andearly dischargefromhospital. Stapled

hemorrhoidopexye Initialexperience fromageneral surgerycenter

Jaiswal,GuptaandDavera (2013)

MedicalJournalofArmed ForcesofIndia

Knowingtheinitial experienceofahospital service,regardingstapling technique.

jcoloproctol(rioj).2016;36(2):104–114

111

Conventional technique

Surgical time 19.58-52 min

Pain

VAS scale

Day 0-Day 1-Day 7

6.5/5.4/4.1

Return to normal

activity 21 days-10 weeks

Recurrences 5%

Fig.1–Distributionofstudiesaccordingtosurgicaltime,pain,returntoactivityandrecurrencesintheconventional

technique,2009–2015.

pain,itrangesfrom0to10(where0isrelatedtoatotalabsence ofpainand10beingthemaximumlevelofbearablepain).15

Onaverage,painondayzeroreceivedagrade=6.5 (mod-erate);onday1,5.4(moderate);andonday7,4.1(light),with 5%ofrecurrences.Jaramilloetal.9_{observedintheirstudythat} painonday0receivedagrade=6.1;onday1,4.8;andonday7, 6.3.Therewerenorecurrences.Intheirstudy,Khannaetal.10 foundthatthepaininVASscaleatday0=8.6;onday1=6.4; andonday7=1.6,with5%ofrecurrences.Therecurrencerate wasconfirmedbythestudybyKashanietal.16_{;thesefindings} comparedPPHversusMilligan–Morgantechniqueinahospital inIran;however,thepaingradewas=4.6ondayzeroand=2.3

Table2–Distributionofthesampleaccordingtothe yearofpublication,2009–2015.

Year n %

2009 3 15.8

2010 4 21

2011 1 5.3

2012 3 15.8

2013 6 31.5

2014 1 5.3

2015 1 5.3

Total 19 100

Table3–Distributionofthesampleaccordingthe countryoforiginofthestudies,2009–2015.

Year n %

SaudiArabia 1 5.3

Argentina 1 5.3

Brazil 3 15.7

Chile 3 15.7

China 2 10.52

Cuba 1 5.3

Spain 2 10.5

India 2 10.5

Iran 1 5.3

Italy 1 5.3

Kosovo 1 5.3

Peru 1 5.3

Total 19 100

onday7.Luetal.11_{onlyratedthepainasmild,moderateor} severe,andtherateofrecurrencewasnotevaluated.

Animportantpointinrelationtoconventionaltechnique isalowerrecurrenceratethat,asdescribedintheliterature, rangesfrom3.1to31%.7_{Inthisstudy,therecurrenceratewas} alsolowerincomparisonwithTHDtechniquesandPPH,which suggestsbetterefficiency/effectivenessofthetechnique,from Ceratoetal.3_{pointofview,whocorroboratethesefindings,} emphasizingthatthecurrentmeta-analyzesandcohort stud-iescomparingPPHversusconventionalsurgeryshowedhigher recurrenceinpatientswhoweretreatedwithPPH.

Relapsescausetheoccurrenceofmultipledisorders,since thepatientwillhavetoundergoanewsurgicalprocedure. Evi-denceoflesserpainaftersurgeryandfasterrecoverytimes forpatientssubmittedtoPPHwasalsoobserved,whenthis techniquewascomparedwiththeconventionaltechnique.3

Studies suggest that in comparison with the conven-tionaltechnique,theuseofLigaSureTM_{techniquemaybenefit} patientsintermsoflesspostoperativepainandfewer compli-cations,sincetheintenseandprolongedpostoperativepain, caused by removal of hemorrhoids always constitutes an importantconcernforbothsurgeonsandforpatients.17

Procedureforprolapsedhemorrhoid(PPH)

ThistechniquewasdescribedbyLongoin1993asanew sur-gicaloptionforthetreatmentofhemorrhoidaldisease;with PPH,anannulusofmucosaandsubmucosaisremovedwith theuseofacircularstaplerabovethedentateline,with fixa-tionthehemorrhoidalpadforcorrectionoftheprolapse.18

PPHshowedasurgicaltimevariationof17.5–35min.Not allstudiesassessedpainbyVASscale;insomearticlespain wasdescribedasmildortolerable;theaverageinthosestudies thatusedtheVASscalewas:ondayzero,grade5(moderate); onday1,grade3(mild);andonday7,grade2.4(light).The returntonormalactivitytookplaceinaperiodfrom7days to6weeks,witharecurrenceraterangingfrom7.5%to8.2% (Fig.2).

Surgicaltimeandreturntonormalactivity

112

PPH technique

Surgical time

Return to normal activity

Recurrences Pain

17.5-35 min

VAS scale

Day 0-Day 1-Day 7

5/3/2.4

7 days-6 weeks

7.5-8.2%

Fig.2–Distributionofstudiesaccordingtosurgicaltime,pain,returntoactivityandrecurrencesinthePPHtechnique,

2009–2015.

foundasurgicaltimeof31min,withatimeofreturnto activ-ityof6weeks.Wang etal.,20_{intheircomparativestudy of} Milligan–MorganversusPPHtechniquesconductedina hospi-talinChina,notedasurgicaltimeof18.3min;however,these authorsdidnotevaluatethereturntoactivity.

ThestudysolelyonPPHtechniqueconductedbyMederos etal.18 _{ina hospitalinPeruhad theshortersurgicaltime,} 17.5min;andinthestudybyGurayaandKhairy,12_theduration ofthesurgicalprocedurewas21.7min,andasintheseother citedstudies,thereturntoactivityhasnotbeenevaluated.

Painandrecurrences

InstudiesusingtheVASscale,theaveragepainondayzero wasgrade5;onday1,grade3;andonday7,grade2.4,with recurrenceof7.5–8.2%.Thus,Kashanietal.16_demonstrated thatthemostintensepaingotgrade4onday0and1.7onday 7,withrecurrenceof7.5%.Wangetal.18_{obtainedgrade5on} day0;grade3onday1;andonsubsequentdays,anaverageof 2.4;therecurrencewasnotevaluated.InthestudybyLucarelli etal.,19_{theaverageofthethreesituationsofpainassessment} intheVASscalewas=3,witharecurrenceof8.2%.

AswasseenwiththeapplicationoftheVASscale, postop-erativepainwaslower,particularlyonday7,comparedwith theconventionaltechnique.Thisfindingmayalsobe associ-atedwithanearlierreturntonormalactivityandwithabetter well-beingofthepatient,alsointhe immediate postopera-tiveperiod.However,althoughPPHpresentsalargenumber ofcomplications,generallytheoverallindexissimilartothat oftheconventionaltechnique.3

However,althoughPPHpresentsalargenumberof compli-cations,generallytheoverallpercentageissimilartothatof theconventionaltechnique.Inaddition,PPH“isnoteffective forbulkyexternalhemorrhoids,orforthethrombosedones”.3

LigaSureTM

ThistechniquewasdescribedbyJoelSayfan2001;init,one usesabloodvesselsealanttoolknownasLigaSureTM_.21

Using LigaSureTM_{, surgical times ranged from 12.5 to} 13.2min.Onaverage,theEVAscaleondayzerowas5.5 (mod-erate);onday1,3.9(slight);andonday7,2.1(light).Patients returnedtoactivityafter7days;3.5%ofthemrelapsed(Fig.3).

Surgicaltimeandreturntonormalactivity

InthestudyconductedbyKhannaetal.,10_{thesurgicaltime} was12.5minandthereturntoactivityoccurredin7days.In thestudybyJaramilloetal.,9_{thesurgicaltimewas13.2min,} and the return to activity also took place in 7 days. The LigaSureTM _{techniqueshowedthesmallestvariationin} sur-gicaltime;therefore,thisisanoptimalsurgicaloptionwith regardtothecontrolofpost-operativeinfections,aswellas promotinganearlierreturntopreoperatoryroutine.

Painandrecurrence

Khanna et al.10 _{report that the pain in VAS scale on day} zero=4.9; on day 1=3.8; and on day 7=1.4; recurrences occurred in3.5%ofcases.Jaramilloetal.9 _{reportedthat,in} theirstudy,thepaininVASscaleonday0=6.1;onday1=4.1; andonday7=2.8.Norecurrenceswerereported.

ThehemorrhoidalresectionwithLigaSureTM_isanoptimal alternative,byallowingsurgicaltimereduction,ofthe anal-gesicsneededinthefirst24h,andofpostoperativepain.21,22 Thepresenceofseverepainwithinthefirst24haftersurgery maypromoteurinaryretentionandconstipation.10

Compared with conventional hemorrhoidectomy, the LigaSureTM _{method attenuates postoperative pain and the} needtoprescribeparenteralanalgesia,sincethereisa mini-malthermalexpansionandalsobythelackofsutures.3

Hemorrhoidaltransanaldearterialization(THD)

DescribedbyMorinagaetal.in1995inordertobeanew sur-gicalapproachinthetreatmentofhemorrhoids,THD“usesa kitwithanoscopethatreachestheupperportionofthedistal rectum,wherewithaDopplerdevicepinpointstheterminal branchesofthehemorrhoidalarteriesinpositions1,3,5,7,9 and11hintherectalcircumference”.Thesevesselsare cran-iocaudallyconnected[...]“totheupperandlowerportionsof

the ligationand areattached; withthis,prolapsereduction andfixationoccur”.3

jcoloproctol(rioj).2016;36(2):104–114

113

Surgical time

Pain

Return to normal activity LigaSure™

technique

Recurrences

12.5 and 3.2 min

VAS scale Day 0-Day 1-Day 7

5.5/3.9/2.1

7 days

3.5%

Fig.3–Distributionofstudiesaccordingtosurgicaltime,pain,returntoactivityandrecurrencesintheLigaSureTM

technique,2009–2015.

THD technique

Surgical time 23-25 min

VAS scale Day 0-Day 1-Day 7

5.5/3.0/1.4

7-14 days

20-22.5% Pain

Return to normal activity

Recurrences

Fig.4–Distributionofstudiesaccordingtosurgicaltime,pain,returntoactivityandrecurrencesintheTHDtechnique,

2009–2015.

Surgicaltimeandreturntonormalactivity

InthestudybyLucarellietal.,19_{thesurgicaltimewas35min} andthereturntoactivitytookplacein14days.Ontheother hand,inthestudybyGomez-Rosadoetal.,22_performedina clinicinSpainandthatevaluatedonlyTHD,thesurgicaltime wasabout23min,andthereturntoactivitytookplacein8 days.

ComparedwithLigaSureTM_{,THDshowedarelativelylonger} surgicaltime; however,this surgicaltime issimilartothat for PPH, and shorter than that for the conventional tech-nique,suggestingthat THDisagoodoption. Thereturn to activityoccurred inashortertimewhencomparedto con-ventionaltechniquesandPPH.Inaddition,THDhasthebest cost-benefit ratio, as well as a less intense postoperative painversusPPH.Thediseaserecurrencewassimilarforboth techniques.3

Painandrecurrence

Thevariationinobservedpainwassimilartothatfoundby Gomez-Rosadoet al.,22_{and therecurrenceratewasaround} 22.5%.;ontheotherhand,thestudy conductedbyLucarelli etal.19_{demonstratedanaveragepaingradeofapproximately} 4(light)intheevaluateddays, with20%recurrencerate. A studycomparing THDversus PPHfortreatmentofgradeIII hemorrhoidal disease concluded that both techniques are comparable.THDhasthebestcost-effectiverate,aswellas alessintensepainversusPPH.Recurrenceratesweresimilar.1 Incontrast,thestudy demonstrateshigherrecurrencerates forTHDtechnique.

ItwasobservedthatafterthepublicationofThompson’s studiesin1975onthepathophysiologyofthisdisease, sev-eralsurgicaloptionshaveemerged,inanattempttocorrect thechangesinthevascularcushionsandsupportingtissue ofthesestructures.Therefore,surgicaltreatmentshouldbe basedonsymptoms,disease classification,andselectionof individual patients,soonecanofferthe bestsurgical tech-niqueforeachcase.Thus,anaspectexceedinglyimportant, tobeexaminedbythesurgeon,isthepropercareofthepain postoperatively,sincepaincanbeahindrancetotheuseofa particulartechnique,evenwhenmoremodernandefficient.3

Conclusion

Conventional techniquesare still the most practiced,with goodacceptanceastothelong-termresolutionandtothelow recurrencerate,despiteaperiodofslowerrecoveryandmore intensepain.Thelatesttechniques,asTHDandLigaSureTM_, showgoodresultsingradeIIIdisease,withshortersurgical timesandlesspain,butwithunsatisfactorylong-termresults. Thusnewstudiesarerequiredforasaferevaluation.

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environmentthatarecrucialtoagoodunderstandingofthe hemorrhoidectomy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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