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Rapid Responses: Rapid Responses published:
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Management of haemorrhoids
- Simon B Middleton, Richard E Lovegrove and Howard Reece-Smith (20 February 2008)
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Banding piles using a gastroscope
- David A Elphick, D Paul Hurlstone, Consultant Endoscopist (26 February 2008)
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Manual reduction?
- Paul A Kitchener (26 February 2008)
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Ligasure for management of haemorrhoids
- Cesar Augusto Guevara-Cuellar (1 March 2008)
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On hemorrhoids
- khalid alkhouly (8 April 2008)
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Simon B Middleton, Consultant Colorectal Surgeon Royal Berkshire Hospital, Reading, RG1 5AN, Richard E Lovegrove and Howard Reece-Smith
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Sir, We would like to congratulate Acheson and Scholefield on their review of the management of haemorrhoids.1 We would like to stress that although the grade of haemorrhoid was highlighted as being important in deciding the therapeutic approach, at our centre we have adopted an approach whereby symptomatology governs the therapeutic decision. For many patients, bleeding is the principle symptom, and we have used doppler guided haemorrhoidal artery ligation (DGHAL) since 2004 in those patients who have not have relief from injection of oily phenol in the outpatient clinic. Over this time we have had treated in excess of 400 patients. In 113 with long-term follow up there was a symptomatic recurrence rate of 19% at 30 months and a low complication rate. While this technique has proved effective in the control of bleeding, it is not effective in the treatment of prolapsed haemorrhoids, with recurrence of prolapse occurring in 64% at 30 months. Many patients experience prolapse of their piles which can lead to discharge of mucus, pruritus and occasionally seepage of stool. Contrary to the cover of the BMJ the article by Acheson and Scholefield did not highlight the most recent advance in haemorrhoidal treatment. Modification of the DGHAL transducer has allowed for the undertaking of DGHAL together with recto-anal repair (RAR). This technique was introduced at our unit in January 2007 in order to treat symptomatic prolapsed haemorrhoids. Since then we have treated 92 patients with a symptomatic relief rate of 82% at 3 months. Although the inclusion of a RAR makes this a more painful procedure than DGHAL, patient satisfaction is high. More recently we have been undertaking DGHAL with or without RAR under conscious sedation using midazolam and remifentanil. 48% of patients were entirely pain-free during the procedure, with the remaining 52% having a median pain score of 3 out of 10. It is therefore possible to obtain pain-free symptomatic relief of bleeding or prolapsed haemorrhoids in the day surgical setting. Competing interests: None declared |
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David A Elphick, SpR Gastroenterology Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, S10 2JF, D Paul Hurlstone, Consultant Endoscopist
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Acheson and Scholefield give an excellent review of the management of haemorrhoids, including the use of rubber band ligation 1. Gastroenterologists frequently encounter symptomatic haemorrhoids during colonoscopy or flexible sigmoidoscopy, yet many of these same physicians do not perform rubber band ligation, preferring to refer to surgical colleagues for this procedure. Many gastroenterologists are unfamiliar with the rigid band ligator traditionally used, and yet have significant experience with band ligation of oesophageal varices using a gastroscope. In keeping with previous reports 2, we suggest endoscopists skilled in variceal banding use a gastroscope to band haemorrhoids when they are diagnosed. This will speed treatment time and reduce the number of hospital visits these patients require. For skilled operators, band ligation of haemorrhoids using a flexible gastroscope is simple to perform and well tolerated. As with the rigid banding device, bands should be deployed proximal to the dentate line. Visualisation is generally much better with the retroflexed gastroscope than the rigid device, allowing more accurate placement of bands proximal to the engorged vascular cushions. As the procedure is significantly more expensive when carried out using the flexible gastroscope, it should probably only be performed when flexible lower gastrointestinal endoscopy is required as part of the diagnostic pathway. David A Elphick and D Paul Hurlstone,
1. Acheson AG and Scholefield JH. Management of haemorrhoids. BMJ 2008; 336: 380-3. 2. Cazemier M, Felt-Bersama RJ, Cuesta MA, Mulder CJ. Elastic band ligation of hemorrhoids: flexible gastroscope or rigid proctoscope? World J Gastroenterol 2007; 13(4): 585-7 Competing interests: None declared |
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Paul A Kitchener, retired physician 5 The Mead, London W13 8AZ
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I was surprised by the omission of manual reduction from the recommendations for the conservative management of third degree haemorrhoids. Competing interests: None declared |
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Cesar Augusto Guevara-Cuellar, Assistant Professor University of Valle 25360
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Although there are many options for to dissect out the hemorrhoids when open haemorrhoidectomy is performed, there is growing evidence that Ligasure vessel sealing device is an optimal option for this procedure. In a recent meta-analysis that compared Ligasure versus conventional haemorrhoidectomy in 525 patients Tan et al found a significant reduction in operative time, blood loss and pain the day after the operation measured by the visual analog scale (1). A randomised multicenter clinical trial recently published that compared Milligan Morgan haemorrhoidectomy using Ligasure versus conventional diathermy found significant difference in severity of postoperative anal pain, lower requirement of rescue analgesics and return to work and normal activities in patients with Ligasure (2). Concomitant use of Plantago ovata could increase these benefits and diminish hospital stay and tenesmus (3). (1) Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Meta- analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg. 2007;142:1209-18; (2) Altomare DF, Milito G, Andreoli R, Arcanŕ F, Tricomi N, Salafia C, Ligasuretrade mark Precise vs. Conventional Diathermy for Milligan-Morgan Hemorrhoidectomy: A Prospective, Randomized, Multicenter Trial. Dis Colon Rectum. 2008 Jan 30 [Epub ahead of print] (3) Kecmanovic DM, Pavlov MJ, Ceranic MS, Kerkez MD, Rankovic VI, Masirevic VP. Bulk agent Plantago ovata after Milligan-Morgan hemorrhoidectomy with Ligasure. Phytother Res. 2006 Aug;20(8):655-8. Competing interests: None declared |
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khalid alkhouly, General Surgeon 10 Woodland Hill, Perth Andover, NB, E7H 5H5
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Editor: Evaluation of Hemorrhoids and Rectal Bleeding The evaluation of hemorrhoids should include a problem-specific history and physical examination. In patients with rectal bleeding, a family medical history is needed to evaluate the possibility of colorectal neoplasm. The physical examination should typically include visual inspection of the anus, digital rectal examination, and anoscopy. A complete colon evaluation with colonoscopy or barium enema with flexible sigmoidoscopy may be indicated for patients with rectal bleeding. The primary concern is the possibility of colorectal neoplasia, inflammatory bowel disease, colitis, diverticular disease, and angiodysplasia. A careful history and physical examination are the cornerstones of appropriate use of endoscopic procedures, which may include proctoscopy and/or flexible sigmoidoscopy. More endoscopic evaluation with complete colonoscopy or flexible
sigmoidoscopy combined with barium enema is indicated for those who
fulfill certain criteria in the following criteria: *Adapted from the Multi-Society Task Force on Colorectal Cancers Thrombosed External Hemorrhoids External hemorrhoids may thrombose spontaneously, possibly secondary to straining at stool or heavy lifting. There is little scientific data comparing treatment options for external hemorrhoidal thrombosis. Clinical experience leads to the recommendation that local excision of the external component under local anesthesia could be done within 48 to 72 hours of onset of symptoms. This can be performed in the office but may require treatment in the operating room because of large size, extension, or patient anxiety. Simple incision and evacuation of the clot should be avoided, because the lesion is typically made up of multiple small intravascular thromboses rather than a single hematoma. It may results in rethrombosis and even extension to a circumferential hemorrhoidal thrombosis. However, those patients who have been present for more than 72 hours often can be treated conservatively if the pain is not too severe. In this circumstance, avoidance of constipation, patient analgesia, and sits baths. Rubber band ligation versus excision Hemorrhoidectomy For mildly prolapsed or bleeding internal hemorrhoids, rubber bands can be applied snugly around the base of each major hemorrhoid during one or more office visits. The bands should be positioned above the anal canal, otherwise great pain or post treatment discomfort is expected. The long-term results are good, rarely; band ligation is complicated by severe perianal sepsis or prolonged pain, fever, and urinary retention. Rubber band ligation should be the primary treatment used for grade II hemorrhoids, and excision Hemorrhoidectomy reserved for patients who failed after repeated rubber bands or grade III hemorrhoids. However, despite the disadvantages of excision Hemorrhoidectomy, patient satisfaction and patient's acceptance of the treatment modalities seems to be similar. Rubber band ligation can be adopted as the choice of treatment for grade II hemorrhoids with similar results but with out the side effects of excision Hemorrhoidectomy while reserving excision Hemorrhoidectomy for grade III hemorrhoids or recurrence after rubber band ligation. Competing interests: None declared |
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