Kent and Medway Plicy Recmmendatin and Guidance Cmmittee Plicy Recmmendatin Plicy: PR 2017-11: Surgery fr haemrrhids Issue date: July 2017 Review date: July 2020 The Kent and Medway Plicy Recmmendatin and Guidance Cmmittee (PRGC) cnsidered natinal guidance and prfessinal sciety guidelines, the baseline psitin, ther CCG plicies, evidence relating t the impact f living with haemrrhids and predictrs f gd and pr utcmes fllwing surgery fr haemrrhids, and the views f lcal specialists. All decisins were made with reference t the Ethical Framewrk. This plicy des nt apply t referrals fr suspected cancer r ther serius pathlgies, r where urgent admissins are required. Initial management Minimally symptmatic haemrrhids may be safely bserved in primary care (see Table 1) Rutine referral fr assessment and treatment in secndary care may nly be cnsidered fr patients with persistent r highly symptmatic haemrrhids fr which cnservative measures (e.g. lifestyle changes and pharmaclgical treatment) have been tried and failed r are nt suitable Infrmatin n self-care, lifestyle changes and treatments, including a simple guide fr patients n the prs and cns f different treatment ptins fr haemrrhids is available n NHS chices. Criteria fr surgery 1 Surgery fr haemrrhids may nly be cnsidered where the fllwing criteria are met: AND Cnservative measures (e.g. lifestyle changes and pharmaclgical treatment) and nnsurgical treatment (e.g. rubber band ligatin, injectin sclertherapy r infrared phtcagulatin) have been tried and failed OR are nt suitable Haemrrhids are directly assciated with frequently re-ccurring persistent pain significantly affecting quality f life OR with frequently re-ccurring persistent bleeding See verleaf fr backgrund infrmatin and supprting ratinale. This plicy recmmendatin will be reviewed in light f new evidence r guidance frm NICE. Clinical Cmmissining Grups in Kent and Medway will always cnsider apprpriate individual funding requests (IFRs) thrugh their IFR prcess. Supprting dcuments NEL CSU HCiAG (2017) Surgery fr haemrrhids Scping reprt Equality Analysis Screening Tl Surgery fr haemrrhids (2017) 1 Surgical ptins include haemrrhidectmy, stapled haemrrhidpexy and haemrrhidal artery ligatin.
Table 1 Primary care management Ensure stls are sft and easy t pass If the persn is cnstipated, manage cnstipatin* If the persn is nt cnstipated: Advise adequate dietary fibre intake by eating a balanced diet cntaining whle grains, fruits, and vegetables; this shuld be dne gradually t minimise flatulence and blating. Advise that adequate fluid intake is particularly imprtant with an increased fibre diet t maintain sft, well-lubricated stls and t prevent intestinal bstructin. Give lifestyle advice t aid healing f the haemrrhid Advise n the imprtance f crrect anal hygiene. The anal regin shuld be kept clean and dry t aid healing and reduce irritatin and itching. Recmmend careful perianal cleansing with mistened twelettes r baby wipes, and t pat (rather than rub) the area dry. Advise against 'stl withhlding' and undue straining during bwel mvements, bth f which can wrsen the cnditin. Manage any symptms Cnsider recmmending simple analgesia (such as paracetaml) fr pain relief. Avid piid analgesics (such as cdeine) as they can cause cnstipatin, and avid nnsteridal antiinflammatry drugs (NSAIDs) if rectal bleeding is present*. Cnsider recmmending a tpical haemrrhidal preparatin t prvide symptmatic relief*. Minimise risk f recurrence Advise the persn that when the haemrrhid has healed, they shuld cntinue with dietary and lifestyle measures t reduce the risk f recurrence. Surce: Adapted frm NICE CKS n haemrrhids (last revised July 2016). *See lcal guidance and/r frmulary fr mre infrmatin, including guidance n prescribing medicines that are available ver the cunter.
Key pints and ratinale What are haemrrhids? Haemrrhids (als knwn as piles) are abnrmally swllen vascular mucsal cushins that are present in the anal canal. They can be classed as internal r external, depending n their rigin in relatin t the dentate line. The dentate line is situated 2cm frm the anal verge and marks the transitin between the upper and lwer anal canal. External haemrrhids riginate belw the dentate line and are cvered by mdified squamus epithelium (anderm), which is richly innervated with pain fibres. External haemrrhids can therefre be itchy and painful. Internal haemrrhids arise abve the dentate line and are cvered by clumnar epithelium, which have n pain fibres. Internal haemrrhids are therefre nt sensitive t tuch, temperature, r pain (unless they becme strangulated). Internal haemrrhids are further graded by degree f prlapse. Peple can have internal and external haemrrhids at the same time. Haemrrhids may be asymptmatic. Bright-red, painless rectal bleeding with defecatin is the mst cmmn symptm. Other pssible symptms include anal itching r irritatin; a feeling f rectal fullness, discmfrt, r f incmplete evacuatin n bwel mvements; siling; and anal pain (with prlapsed, strangulated internal haemrrhids, r thrmbsed external haemrrhids). Hw are haemrrhids managed? Primary care management includes lifestyle and dietary advice, use f laxatives, tpical preparatins and simple analgesia. Secndary care treatments fr haemrrhids may be nnsurgical r surgical, depending n the severity f symptms and the degree f prlapse. Nnsurgical interventins include rubber band ligatin, sclersant injectins, infrared cagulatin r electrtherapy. Surgical prcedures include haemrrhidectmy, stapled haemrrhidpexy r haemrrhidal artery ligatin. What des natinal guidance say? There is n NICE clinical guidance n the management f haemrrhids r indicatins fr surgery. Hwever, NICE have issued guidance n the safety and efficacy f a number f prcedures fr haemrrhids. Accrding t the Ryal Cllege f Surgens (RCS) and Assciatin f Clprctlgy f Great Britain and Ireland (ACPGBI) cmmissining guide n rectal bleeding (2013; under revisin): Minimally symptmatic haemrrhids may be safely bserved in primary care Patients with symptmatic haemrrhids shuld be given advice abut tpical treatment, ral fluid intake, high-fibre diet and fibre supplementatin Rutine referral shuld be cnsidered fr patients with persistent r highly symptmatic haemrrhids At present surgery is reserved fr bleeding r prlapsing haemrrhids that have nt respnded t utpatient treatment. What des current lcal guidance say? Currently there is n Kent and Medway wide plicy n access t surgical interventins fr haemrrhids. West Kent CCG and east Kent CCGs appear t have plicies n surgery fr haemrrhids, but they d nt appear t have been fully implemented r have supprting ratinale. What is the ratinale fr PR2017-11? PR2017-11 is bradly cnsistent with recmmendatins made in the RCS and ACPGBI cmmissining guide n rectal bleeding (2013). What is the impact f implementing PR2017-11? Due t an absence f suitable data, it has nt been pssible t quantify the impact f implementing PR2017-11 n activity and expenditure. Hwever, the establishment f eligibility criteria fr surgery fr haemrrhids and guidance n initial management f this cnditin, including rutine referral criteria, is likely t lead t mdest reductins in activity and expenditure fr surgery fr haemrrhids. Althugh CCGs in West Kent and east Kent have a plicy n surgery fr haemrrhids (dcumented in their LPP+ list), the impact f implementing the PRGC plicy recmmendatin is unlikely t be substantially different t the rest f Kent and Medway as it appears that the LPP+ plicy has nt been fully implemented.
Change sheet Reasn fr review: Currently there is n Kent and Medway wide plicy n access t surgical interventins fr haemrrhids. West Kent CCG and east Kent CCGs appear t have plicies n access t surgery fr haemrrhids (dcumented in their LPP+ list), but they d nt appear t have been fully implemented r have dcumented ratinale. Kent and Medway CCGs have indicated that they wuld like t agree a single area-wide plicy n this tpic t ensure equity f access acrss the regin. Changes made t current plicy: West Kent CCG and east Kent CCGs plicy n haemrrhidectmy* Surgical therapy is indicated fr the fllwing: 4th degree (irreducible) haemrrhids (with significant external cmpnent) OR Haemrrhids which bleed spntaneusly (nt assciated with defecatin) > 5 times in 1 week fr >3/52 weeks f the year OR Bleeding haemrrhids which can lead t irn deficiency anaemia withut any ther cause OR Excessive pst-defaecatry bleeding (after mst bwel mvements, cluring the tilet bwl red) OR Pain r discmfrt directly frm haemrrhids significantly affecting quality f life PRGC plicy recmmendatin (PR2017-11) This plicy des nt apply t referrals fr suspected cancer r ther serius pathlgies, r where urgent admissins are required. Initial management Minimally symptmatic haemrrhids may be safely bserved in primary care. Rutine referral fr assessment and treatment in secndary care may nly be cnsidered fr patients with persistent r highly symptmatic haemrrhids fr which cnservative measures (e.g. lifestyle changes and pharmaclgical treatment) have been tried and failed r are nt suitable. Infrmatin n self-care, lifestyle changes and treatments, including a simple guide fr patients n the prs and cns f different treatment ptins fr haemrrhids is available n NHS chices. Criteria fr surgery Surgery fr haemrrhids may nly be cnsidered where the fllwing criteria are met: Cnservative measures (e.g. lifestyle changes and pharmaclgical treatment) and nn-surgical treatment (e.g. rubber band ligatin, injectin sclertherapy r infrared phtcagulatin) have been tried and failed OR are nt suitable AND Haemrrhids are assciated with frequently reccurring persistent pain significantly affecting quality f life OR with frequently re-ccurring persistent bleeding Red=deletin, green=additin. *Althugh West Kent CCG implement the Kent and Medway CCGs schedule f plicy statements fr health care interventins and referral and treatment criteria (RaTC), they have further agreed directly with Maidstne and Tunbridge Wells NHS Trust (MTW) clinicians, guidance fr apprpriateness f certain surgical prcedures (including access t surgical interventins fr haemrrhids); this list is currently referred t as the LPP Plus. East Kent CCGs (Ashfrd CCG, Canterbury and Castal CCG, Suth Kent Cast CCG, Thanet CCG) have adpted the West Kent CCG LPP+ list. Hwever, crrespndence with cntracting clleagues suggests that the LPP+ is nt included within the cntract between East Kent CCGs and East Kent Hspitals University NHS Fundatin Trust (EKHUFT). Similarly, cnsultant surgens frm MTW and EKHUFT wh respnded t a stakehlder questinnaire did nt identify any cnsistently applied frmal eligibility criteria fr access t surgery fr haemrrhids suggesting the LPP+ plicy n haemrrhids is nt used (widely) in clinical practice. Medway CCG, Dartfrd, Gravesham and Swanley CCG and Swale CCG d nt have a plicy n surgery fr haemrrhids. Ratinale fr PR2017-11: PR2017-11 is bradly cnsistent with recmmendatins made in the Ryal Cllege f Surgens (RCS) and Assciatin f Clprctlgy f Great Britain and Ireland (ACPGBI) cmmissining guide n rectal bleeding (2013; under revisin). The West Kent CCG and east Kent CCGs plicy n haemrrhidectmy des nt appear t have a supprting ratinale.
Estimated impact f implementing PR2017-10: Due t an absence f suitable data, it has nt been pssible t quantify the impact f implementing PR2017-11 n activity and expenditure. Hwever, the establishment f eligibility criteria fr surgery fr haemrrhids and guidance n initial management f this cnditin, including rutine referral criteria, is likely t lead t mdest reductins in activity and expenditure fr surgery fr haemrrhids. Althugh CCGs in West Kent and east Kent have a plicy n surgery fr haemrrhids (dcumented in their LPP+ list), the impact f implementing the PRGC plicy recmmendatin is unlikely t be substantially different t the rest f Kent and Medway as it appears that the LPP+ plicy has nt been fully implemented.