THE RATIONAL TREATMENT OF INTERNAL HEMORRHOID BASED ON ITS PATHOGENESIS

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1 THE RATIONAL TREATMENT OF INTERNAL HEMORRHOID BASED ON ITS PATHOGENESIS Ignatius Riwanto Dept. of Surgery, Digestive div. Diponegoro Medical Faculty ACUTE CARE SURGERY BANDUNG FEBRUARY 2018

2 HEMORRHOID The symptomatic enlargement and distal displacement of the normal anal cushions World J Gastroenterol 2012 May 7; 18(17): Discontinuous series of cushions 3 main cushions: left lateral, right anterior, right posterior Anal cushion secured by Parks ligament (ficibroelast network coming from int. sphincter, muscularis propia) and Treitz s muscle (coming from muscularis mucosa of the rectum) Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002, Sardinha. Hemorrhoids. Surg.Clin N Am

3 PATHOGENESIS OF HEMORRHOIDAL DISEASE Plexus hemorrhoidalis: normal condition without symptom. Congested plexus hemorrhoidalis gives symptoms. The patogenesis of hemorrhoidal disease (symptomatic hemorrhoid) is not completely understood, there are 2 theories: 1. vascular theory 2. increase the laxity of the hemorrhoidal support tisue. Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002, Sardinha. Hemorrhoids. Surg.Clin N Am

4 VASCULAR THEORY Hemorrhoids are varicose dilatations of the radicles of the hemorrhoidal veins Internal hemorrhoid: varicose enlargement of the veins of superior hemorrhoidal plexus. External hemorrhoid: varicose enlargement of the veins of inferior plexus. Netter FH (1987)

5 HEMORRHOID VS RECTAL VARICES DUE TO PORTAL HYPERTENSION 1. Corman et al. Hand book of colon and Rectal Surgery Sato et.al. Endoscopic Procedures in Colon and Rectum downloaded Oct No increased incidence of hemorrhoid in patients with portal hypertension. Rectal varices enlarged portal-systemic collateral through middle and inferior hemorrhoidal vein (1) Hemorrhoid and rectal varices are different disease entity. (1) Treatment Rectal Varices: (2) - Portal shunt - Endoscopic Injection Scleroterapi - Endoscopic band Ligation

6 INCREASE LAXITY OF THE HEMORRHOIDAL SUPPORT TISSUE Chronic straining weaken and increase the laxity/ destroys of hemorrhoidal support tissue (muscularis mucosae, m Treitz, Lig. Park sliding downward of part of the anal canal lining. Anal prolapse stretching of the upper and midle hemorroidal vessels and formation of kinks + closing pressure of the anal sphincter creates an obstacle to the venous flow, creating predisposition to thrombosis Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002, Abramowitz et al. Gastroenterologie June-July 2001.

7 ARTERIO-VENOUS SHUNT IN HEMORRHOID

8 VASCULAR STRUCTURE IN NORMAL ANAL CUSHION Normal: a sphincterlike structure, formed by thickened tunica media containing 5-15 layers of smooth muscle cells, between the vascular plexus within the sub epithelial space of the anal transitional zone World J Gastroenterol 2012 May 7; 18(17):

9 VASCULAR STRUCTURE IN HEMORRHOID Hemorrhoids: remarkably dilated, thin-walled vessels within the submucosal arteriovenous plexus, with absent or nearly-flat sphincter-like constriction on the vessels smooth muscle sphincter helps in reducing the arterial inflow, thus facilitating an effective venous drainage World J Gastroenterol 2012 May 7; 18(17):

10 THE VASCULAR NATURE OF HEMORRHOIDS (F. AIGNER ET AL., 2006, GASTROINTEST SURG.) Study Groups Caliber of the vessels (SRA) Flow in the vessels (SRA) 41 patients with 1.87 mm 33.9 cm/s symptomatic hemorrhoids 17 healthy volunteers 0.92 mm 11.9 cm/s 10

11 THE VASCULAR NATURE OF HEMORRHOIDS (F. AIGNER ET AL., 2006, GASTROINTEST SURG.) strong evidence that the arterial blood supply is of relevance in the development of hemorrhoidal cushions. Vascular dilation and increased blood flow suggest that there might exist an increased arterial inflow rather than a venous stasis or outflow problem supporting the development of hemorrhoids. 11

12 MORPHOLOGY AND HEMODYNAMICS OF THE ANORECTAL VASCULAR PLEXUS The anorectal vascular plexus was characterized by a network of submucosal vessels with multiple thickened venous vessels separated by distinct sphincter-like constrictions Flow differences in peak velocities of afferent vessels, control group : 6.8 +/- 1.3 cm/s hemorrhoidal disease: /- 1.5 cm/s; P = Acceleration velocities of afferent vessels, control group: 51 +/- 4 ms hemorrhoidal disease: 94 +/- 11 ms; P = Conclusion: Coordinated filling and drainage of the anorectal vascular plexus is regulated by intrinsic vascular sphincter mechanisms. Both morphological and functional failure of this vascular system may contribute to the development of hemorrhoidal disease. Int J Colorectal Dis Jan;24(1):105-13

13 INERVATION OF ANAL CANAL SKIN & MUCOSA Pain sensation is passing through free nerve ending Anal canal rich of free nerve ending Every intervention to treat hemorrhoid that hitting anal canal will produce pain. Conserve anal cushion & anal canal skin: reduce pain significantly holding the anal canal function (protect anal canal skin, support the continent & sampling mechanism)

14 EXCISIONAL OF HEMORRHOIDAL TISSUE (CONVENTIONAL HEMORRHOIDECTOMY) GRADE III & IV MOSTLY REMOVING PRIMARILY ANAL CUSHION INTACT MUCOSAL BRIDGE IS IMPORTANT TO PREVENT STRICTURE RISK OF SPHINCTER INJURY NEED WOUND CARE PAINFUL

15 PROBLEM & COMPLICATIONS OF CONVENTIONAL HEMORRHOIDECTOMY Problem: Post-operative pain Complications: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5%), incontinence (2-12%). MINIMALLY INVASIVE: REDUCE PAIN & COMPLICATIONS Schubert ET AL. World J Gastroenterol 2009

16 MINIMALLY INVASIVE SURGERY FOR GRADE III-IV HEMORRHOID STAPPLER HEMORRHOIDOPEXY HEMORRHOID ARTERY LIGATION & RECTO-ANAL REPAIR ANAL CUSHION PRESERVING HEMORRHOID SURGERY

17 STAPPLER HEMORRHOIDOPEXY o PECK 1986, DEVELOPED BY LONGO o BASED ON THE THEORY OF INCREASE LAXITY OF HEMORRHOIDAL SUPPORT TISSUE o CIRCULAR REMOVAL OF THE RECTAL MUCOSA PROXIMAL TO HEMORRHOIDAL TISSUE UPWARD MOVEMENT OF THE PROLAPSING HEMORRHOID o IS TARGET TO CUT ALL THE RECTAL ARTERY IS ALWAYS ACHIEVED?

18 HEMORRHOID ARTERY (HA) NETWORK Color duplex imaging examination Determine the location of HA above the anorectal junction (AAJ) and the depth AAJ (cm) HA detected (%) External rectal (%) Intramusc uler (%) Ratto et.al. Br J Surg. 2012;99: Submucos a (%)

19 HEMORRHOID ARTERY INTERRUPTION IN STAPPLED HEMORRHOIDECTOMY (SH) Doppler hemorrhoid artery detection before and one month after SH in 45 Hemorrhoid patients. Preoperatively: 100% three main branches of the artery (3,7,11,o'clock), 67 % fourth, 16 % a fifth and 13 % a sixth could be identified. One month postoperatively: in 80 % of all branches, 16 % of the cases two main vessels, 4 % only one main vessel could be identified. Zentralbl Chir Jan;127(1):19-21.

20 DOPPLER GUIDED HEMORRHOID ARTERY LIGATION (HAL) & RECTOANAL REPAIR HAL: first reported by Morinaga (Japan) 1995 Because the arteries carrying the blood inflow are ligated, internal pressure of the plexus of hemorrhoid is decreased, shrink and become smaller. HAL: high prolapse recurrence in grade IV 2005 RAR (Recto-Anal Repair) RAR = Proctoplasty/ mucopexy is lifting the hemorrhoid back to where the belong for grade III-IV. The American Journal of Surgery, 2006

21 STEP FOR RECTO-ANAL REPAIR (RAR) [MUCOPEXY]

22 MUCOPEXY/ RECTO-ANAL REPAIR Z suture above marker including rectal muscle Continues submucosal suture through marker until the base of hemorhoid Distance 0,5 cm PDF 02, 5/8

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25 EYE-OPERATIVE FIELD LEVEL TWO NEDLE HOLDER TECHNIQUE THREAD TRACTION TO CHECK ARTERIAL OCCLUSION AND MUSCLE INVOLVEMENT

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27 DG HAL-RAR VS CLOSED HEMORRHOIDECTOMY

28 A SYSTEMATIC REVIEW COMPARING TRANSANAL HAEMORRHOIDAL DE-ARTERIALISATION (THD) TO STAPLED HAEMORRHOIDOPEXY (SH) IN THE MANAGEMENT OF HAEMORRHOIDAL DISEASE 3 RCT 150 patients 80 THD and 70 SH patients. Baseline homogen (P = 0.40) Statistically equivalent in success rate (P = 0.19), operation time (P = 0.55), postoperative complications (P = 0.11) and recurrence (P = 0.46) THD significantly less postoperative pain P < compared to SH. Tech Coloproctol Feb;16(1):1-8 (Abstract).

29 MULTICENTER TRIAL DOPPLER-GUIDED THD 803 patients mean follow-up of mo. Overall success rate of 90.7% recurrence of hemorrhoidal prolapse 6,3% bleeding 2,4% both recurrence and bleeding 0,6% Ratto C, Colorectal Dis 2015; 17: O10-O19

30 IS DOPPLER ASSISTED TO DETECT ARTERY REALLY NEEDED? Theoretically artery arteries are located in six of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9 and 11 o clock Avital S (2012): one-third of the population has at least one artery in an even-numbered clock position. DOPPLER-ASSISTED LOCALIZATION IS IMPORTANT IN CORRECTLY LOCATING THE ARTERIES Avital S. et al. Tech Coloproctol 2012; 16: 61-65

31 DOPPLER FREQUENCY & ITS ABILITY TO DETECT ARTERY DGHAL and THD equipment operate at 7-8 MHz can only detect deep arteries 2-3 cm above the dentate line, the terminal branches of the superior rectal arteries become superficial (2 mm deep) and thin (0.6-2 mm). A new Doppler-guided uses a 20 MHz Dopplertransducer, accurate in detecting superficial arteries at approximately 2 cm above the dentate line larger number of arteries (12 instead of 6) can be detected. World J Gastrointest Surg 2016 January 27; 8(1): 1-4

32 LASER VS SUTURE LIGATION SUTURE LIGATION LOCATED ABOVE (1 CM) OF THE EXACT POINT WHERE THE DOPPLER SIGNAL LOCATES THE ARTERY. LASER FIBER IS PLACED IN CONTACT WITH THE MUCOSA EXACTLY AT THE SAME POINT WHERE THE DOPPLER SIGNAL LOCATES THE ARTERY. DIODE LASER ENERGY DELIVERED AT 980 NM OF WAVELENGTH CAUSES SHRINKAGE OF THE MUCOSA AND SUBMUCOSA TO A DEPTH OF 4 MM

33 PERSONAL EXPERIENCE August June 2017: 122 cases October 2014: 61 cases have been evaluated and reported on ICS meeting in Bali entitle: Factors Affecting Post-operative Pain after Hemorrhoid Artery Ligation and Recto-anal Repair (HAL-RAR) of Internal Hemorrhoid Sigit Adi Prasetyo, Ignatius Riwanto Dept. of Surgery, Diponegoro Medical Faculty

34 METHOD & RESULT Method. A series of 61 grade II-IV internal hemorrhoid patients, underwent HAL-RAR in St Elizabeth Hospital, Semarang Indonesia, period of August March 2014 were analyzed prospectively. Result. After multivariate analysis variables that significantly influence post operative pain on 24 hours were removing of internal thrombosis, removing of anal papilla hypertrophy and anal laceration, on 48 hours were removing of external thrombosis, removing of anal papilla hypertrophy and anal laceration and on 7 days were the same with on 24 hours. 2 prolapsing on week 2 but disappear after 8 weeks FU.

35 CONVENTIONAL SURGERY THE ONLY OPTION Prolapsing fibrotic grade IV internal hemorrhoid Strangulated grade IV internal hemorrhoid Big circular grade IV internal hemorrhoid Multiple thrombus and excesive combination with external (skin component) in grade IV hemorrhoid

36 COMBINATION EXCISIONAL HEMORRHOIDECTOMY AND HAL-RAR Prominent grade IV internal hemorrhoid Impossible to be operated with minimally invasive Morgan Milligan may left prominent normal skin-mucosa bridge Addition with HAL-RAR for prominent mucosal bridge improve the result

37 COMBINATION HAL-RAR & MINIMAL MUCOCUTANEOUS EXCISION If during HAL-RAR, there is still: some prolapse Excessive skin component mini mucocutanous excision (MME) Skin tag/ hypertrophy of anal papilla excision. Colorectal Dis Feb;12(2):

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39 POST-OPERATIVE INFORMATION AFTER HAL-RAR Slight post-operative pain Slight post operative bleeding is normal Some patients: Temporary urinary retention Feeling need to pass a stool, that last for up to two weeks Fecal impaction/ constipation Some prolapsing Beeson: July

40 POST-OPERATIVE INSTRUCTION AFTER HAL-RAR Analgetics: paracetamol & ibuprofen Eating bulk fiber and laxative (lactulosa) to prevent fecal impaction/ constipation Warm water sitz bath several time to reduce discomfort Bath the area with water to soothe and keep it clean It is important not to tray sit in the toilet to pass feces that actually not there. No strenuous activity for the next two weeks No lifting of item over than 5 kg for the next two weeks No exercise beyond a gentle walk for the next two weeks Both man and woman should abstain sexual intercourse for two weeks after operation. Beeson: July

41 SUMMARY (1) Problem with conventional hemorrhoidectomy are severe pain and complications that stimulate surgeon to find method of hemorrhoid surgery than painless and lower complication. Histologically there is a arteriovenous shunt in anal cushion and there are rectal artery enlargement and diminishing of sphincter like muscle in hemorrhoid patient, destruction of supportive tissue in anal cushion

42 SUMMARY (2) Surgery for hemorrhoid nowadays change from removing the pile that more painful to ligating the hemorrhoid artery and lifting the anal cushion to its position (HAL-RAR) that more painless, and preserve the anal cushion function Post-operative information and instruction should be addressed to the patients to understand the problem and to prevent complication

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