Haemorrhoidal disorders -What is the optimal treatment?

Transcription

1 Haemorrhoidal disorders -What is the optimal treatment? Per-Olof Nyström, M.D., Ph.D. Professor of Surgery Karolinska Institutet and Karolinska University Hospital Huddinge Stockholm, Sweden

2 The methods to treat haemorrhoids Pile destruction Pile excision Sclerosing injections Rubber Band Ligation Infrared coagulation Radiofrequency coagulation Haemorrhoid artery ligation HAL Excision of haemorrhoid pedicles, Milligan, Ferguson with scissors, diathermy, Ultracision, Ligasure or staplers Pile pexy Stapled haemorrhoidopexy (anopexy), Longo Suture haemorrhoidopexy Transanal haemorrhoid dearterialisation THD with suture haemorrhoidopexy

3 1. What is the nature of symptomatic haemorrhoids? 2. What is the anatomical problem? 3. What are the patient's complaints? 4. Will restoration of anatomy cure the symptoms? 5. Would patient settle for partial or temporal cure?

4 1. Haemorrhoids is mucoanal prolapse! 2. Can we agree on a simple classification? 3. What are the cardinal symptoms? 4. How well is the disease cured?

5 Do you need to reduce a prolapsing haemorrhoid with your hand at defecation? Patient self-reported Multicentre trial 125/ % Own case series 61/ % Perianal block trial 41/ % Mucosal prolapse

6 Are there anal skin tags or folds? Surgeon assessed Multicentre trial 130/ % Own case series 67/ % Perianal block trial 37/ % Anodermal prolapse

7

8

9

10

11

12

13

14

15

16

17 Goligher 1 Lunnis 2 Morgado 3 Thomson 4 Grade 0 - Non prolapsing anal cushings - - Grade I Merely project into the lumen of the anal canal Non prolapsing Small haemorrhoid Bleeding haemorrhoidal disease Bleeding Grade II Grade III Piles may appear externally whilst the patient is straining but return spontaneously Protrude during defecation, remain prolapsed until they are digitally replaced within the anus Prolapsing intermediate haemorrhoids Prolapse but return spontaneously. Bleed frequently Large haemorrhoids that prolapse and need aid to reduce. Bleed frequently and often profusely Prolapsing haemorrhoidal disease Thrombotic haemorrhoidal disease Prolapse at defecation (with or without bleeding) with spontaneous return to anal canal Prolapse (with or without bleeding) requiring replacement. Grade IV Skin-covered components, cannot be properly returned to the anal canal. Very large haemorrhoids. Prolapse, which is permanent and irreducible. Bleed profusely. Mixed haemorrhoidal disease -

18

19 Proportion of Grade IV prolapse in randomized trials Boccasanta Palimento Shalaby Ortiz Ho Ganio Correa-Rovelo Pavlidis Kairaloma Senagore Rowsell Percent

20

21 Does patient reduce a prolapsing haemorrhoid with the hand when passing a motion? No Yes Surgeon assessment of prolapse at proctoscopy Acute thrombosed and prolapsed haemorrhoids No Yes Grade 1 Grade 2 Grade 3 Grade 4 Anodermal prolapse with tags and polyps: A - None B One or few tags C - Circumferential

22 Pre-operative and postoperative anatomical grading of mucoanal prolapse Preop % Postop % Percent N=270 1A 1B 1C 2A 2B 2C 3A 3B 3C Grade Gerjy et al. Colorectal Dis 2008

23 Preop and postop symptoms of mucoanal prolapse by anatomical grade (N=257) (prolapse score excluded) Symptom score preop Symptom score postop Points 4 Points A 2B 2C 3A 3B 3C 0 2A 2B 2C 3A 3B 3C Grade Grade Gerjy et al. Colorectal Dis 2008

24 Questions How often do you have pain from the anus? How often do you have itching or discomfort of the anus? Never Answers Less than once per week 1-66 times per week Every day (always) How often do you have bleeding when passing a motion? How often do you soil your underclothes (soiling from the anus)? How often do you reduce a prolapse with your hand when passing a motion?

25 Symptom load at baseline. Patients randomised to Milligan-Morgan or Anopexy, N=180 Number points

26 Symptom load at 1 year after surgery. Patients randomised to Milligan-Morgan or Anopexy. Number points

27 Daily average pain (VAS summed over 14 days) 140 VAS Anopexi p=0.004 Milligan Percentile STOPP trial

28 Daily peak pain (VAS summed over 14 days) Anopexi p=0.001 Milligan VAS Percentile STOPP trial

29 STOPP-trial: Continence scores: Soiling (p=0.0001), gas (p=0.13), loose stool (p=0,03), solid stool (p=0,17). No difference between Anopexy vs M-M: pre p=0,39, post p=0, Preoperative 40 Postoperative p= Count Count Points Points

30 Prolapse grade 3, n= 12 Sympton score 5 points, n= Incontinence score 6 points n= patients with complete follow-up at 1-6 years after surgery Gerjy et al Fueglistaler et al. DCR 2007;50:204

31 1. Reasonable treatment with low risk 2. Low pain profile 3. Short recovery 4. Preserved continence 5. Day surgery 6. Local anaesthetic block 7. Acceptable long-term outcome

32

33

34 Replacing the cut edge of rectal mucosa involves suturing it to a few fibres of the proximal portion or shelving edge of the external sphincteric muscle. Nesselrud JP. Surg Clin N Amer 1954 & Rev Surg 1966 Milligan et al. Lancet 13 Nov. 1937

35 Mucoanal prolapse

36

37

38

39 Stapled anopexy from the inside

40 Gerjy et al. Colorectal Dis 2007;9:754-7.

41 Doppler-Guided Transanal Haemorrhoidal Dearterialisation Minor postoperative pain Few postoperative complications Can be done under conscious sedation Day-surgery May be repeated

42 Ligation 2-3 cm Liniea dentata Doppler signal THD proctoscope Doppler probe

43 THD Modified for mucosal prolapse

44 Preoperative Postoperative 3 v postoperatively Curtesy Dr. Lenander

45 Nyström et al. Tech Coloproctol 2004;8:23-6. Gerjy et al. DCR 206;2006;49: Marti. Ann Chir 1993;47: Gabrielli et al. DCR 2001;44: Ropivacain 5mg/ml ml

46

47

48 A. Denies need for manual reduction No external component B. Affirms manual reduction Minimal external component C. Affirms manual reduction Significant external component D. Major external component Denies need for manual reduction

49 (Hans Memling, Garlandio)

50

51 STOPP-trial: Disease-related QoL, Q32: personal inconvenience (p=0.0001). Q33: social constraints (p=0.0001). Points 2 1,6 Anopexy Milligan Pre-post: p= ,2 0,8 0,4 0 Preop 2-4 months 1 year

52

53