Novel approach to advanced hemorrhoidal disease Novel Approach to Advanced Hemorrhoidal Disease Pravin J. Gupta Gupta Nursing Home, Nagpur, India Abstract metodele standard existente. Este descrisã o nouã tehnicã, ºi anume ablaþia prin radiofrecvenþã a hemoroizilor, urmatã Background. There have been many attempts to find a de fixarea prin suturã a masei hemoroidale. Material ºi less painful surgical method of treating hemorrhoids as metodã. Acest studiu nerandomizat, retrospectiv, descrie against those available in standard surgical procedures. A evoluþia clinicã a 1650 pacienþi trataþi prin aceastã procedurã novel technique of hemorrhoidal ablation by radiofrequency într-o perioadã de 5 ani. Pentru ablaþia hemoroizilor s-a utilizat is described, which is followed by suture fixation of the un generator de radiofrecvenþã cu frecvenþã dualã. Rezultate. hemorrhoidal mass. Material and methods. This non- Durata intervenþiei a fost de 6 pânã la 8 minute. Durata randomized, retrospective study describes the clinical spitalizãrii a fost de 9 ore. Complicaþiile postoperatorii outcome of the procedure performed in 1650 patients over a imediate au inclus retenþia de urinã, infectarea plãgii ºi period of 5 years. An Ellman dual frequency radiofrequency tromboza perianalã. Perioada medie de incapacitate de muncã generator was used for ablation of hemorrhoids. Results. a fost de 10 zile. Complicaþiile tardive au inclus dezvoltarea The operation time ranged between 6 to 8 minutes. Mean papilelor anale ºi recurenþa la 2% din pacienþi. Concluzie. hospital stay was 9 hours. The immediate postoperative Procedeul utilizat poate fi considerat ca alternativã pentru complication included retention of urine, wound infection procedurile convenþionale chirurgicale. Acest procedeu de and perianal thrombosis. The mean period of incapacity for îngrijire de o zi este simplu de efectuat, permite pacienþilor work was 10 days. Late complications included development de a reveni la activitatea normalã într-o scurtã perioadã de of anal tags, anal papillae and recurrence in 2% patients. timp având dureri mai reduse ºi mai puþine complicaþii There was no incidence of anal stricture or continence postoperatorii. disorder. Conclusion. The procedure advocated by the author can be opted as an alternative to conventional surgical procedures. This day care procedure is simple to perform, Introduction allows the patients to return to normal activities in a short span of time with lesser pain and has fewer postoperative Hemorrhoidectomy is frequently associated with complications. significant postoperative pain. The surgeons are always on the lookout for new techniques to reduce this pain and such Keywords attempts are constantly being evaluated to achieve the Radiofrequency hemorrhoidectomy - harmonic scalpel- ultimate. Circumferential mucosectomy with a stapler, ligasure closed diathermic hemorrhoidectomy with high frequency device, and the doppler guided hemorrhoidal artery ligation have significantly modified the classical indications for surgical Rezumat treatment of hemorrhoids. Apart from reduction of pain, surgical techniques have Premize. Au existat multe încercãri de a se gãsi o metodã evolved to solve complications such as postoperative chirugicalã mai puþin dureroasã de a trata hemoroizii decât bleeding, stenosis and recurrence. Use of harmonic scalpel Romanian Journal of Gastroenterology (1), ligasure (2) and closed (3) methods of hemorrhoidectomy December 2005 Vol.14 No.4, 361-366 have been proposed to tackle the shortcomings often Address for correspondence: Pravin J.Gupta associated with conventional procedures. Gupta Nursing Home Attempting at a similar aim, we used a combination D/9, Laxminagar Nagpur - 440022, India technique of radiofrequency ablation and suture fixation of E-mail: firstname.lastname@example.org the hemorrhoidal mass for prolapsing hemorrhoids in our 362 Gupta hospital over the last seven years (4). We found the to which different electrodes could be attached to meet the procedure to be quicker, less painful, and equally effective requirement of the procedure (2). A ball electrode, which is when compared with other types of surgical procedures for meant for coagulation of the tissue, was used for the hemorrhoids (5). procedure. Radiofrequency coagulation is a method of tissue ablation using a frequency as high as is used for radio Preparation of the patient broadcasting. The alternating current passes down from an Patients were asked to consume 30 ml of Lactulose uninsulated electrode tip of the radiofrequency device to (Duphalac) on the night before the procedure. They were the targeted tissue and generates changes in the direction admitted on the morning of the day of surgery. An informed of ions within the tissue fluid. The tissue is heated by electric consent was obtained. resistive heating (6). During contact with the radio waves, Patients were operated under a short-term general water in the tissue gets vaporized when the temperature anesthesia or caudal block. A standard perioperative regime reaches close to 1000 C. However, as the temperature is kept included an intravenous dose of 1g of Ceftriaxone sodium. under control at 100 0 C, it causes little charring and Operative technique carbonization. This tissue vaporization also results in The procedure was performed with the patient in a significant hemostasis without actually burning the tissue lithotomy position. With the help of straight artery forceps, (7). After subjecting the hemorrhoids to the radiofrequency the three skin tags corresponding the three principle sites waves, the ablated mass is fixed to the underlying tissue of hemorrhoids, namely at 3,7 and 11oclock were held and with absorbable suture material within the anal canal. retracted out to view the hemorrhoids and work on them. Starting at the pedicle, the whole pile mass was coagulated by evenly rotating the ball electrode of the Material and methods radiofrequency device over the hemorrhoidal mass. The This study comprises a consecutive series of 1650 output power intensity of the radio surgical unit was patients with grade III or IV hemorrhoids that were advised adjusted to achieve shrinkage of the tissues while avoiding a hemorrhoidectomy and who consented to undergo this a spark. The gradual change of hemorrhoids to a dusky mode of treatment. The procedure was carried out at Gupta white color (blanching) indicated a satisfactory coagulation Nursing Home, Nagpur, India, over a period of 7 years. The necrosis. patient demographics and presentation symptoms are Following this maneuver, the ablated hemorrhoidal mass described in Table I. was over sewn with 1-0 chromic catgut on 40mm needle (No. 4246 Ethicon UK). Beginning from the most distal end Table I Patient demographics and presentation symptoms of the hemorrhoid from the dentate line, the suturing was (n=1650) carried towards the pedicle in a continuous locking manner. A knot was tied at the hemorrhoidal pedicle to secure this Males (%) 1137 (69) plication. All the hemorrhoids were dealt with in a similar Parks classification n (%) fashion. The skin components found associated with grade Grade III 1344 (81) Grade IV 306 (19) IV hemorrhoids were excised. Mean age of the patients yrs (range) 32 (5-91) Data collection and postoperative care Presenting symptoms n (%) Postoperative pain was controlled using tablets Bleeding 1592 (96) Pain 933 (57) containing Tramadol hydrochloride 37.5mg and Paracetamol Pruritus 464 (28) 325 mg (Tab Ultracet, Janssen Cilag, India) twice daily, never Discharge 307 (19) more than three per day and only until the pain persisted. Severe anemia needing pre-operative 159 (10) Patients were asked to take 20 ml of Lactulose (Duphalac) at blood transfusion bedtime for a month. They were advised to take a warm sitz bath twice a day. A detailed clinical evaluation by noting down complete Patients were assessed in the afternoon and were history and per rectal and anoscopic examination was carried discharged if there were no complaints like severe pain or out. Patients complaining of lower gastrointestinal tract urinary retention. Patients with urinary retention were symptoms like frequency of stool, passage of mucus or discharged only when they could pass urine of their own. abdominal pain underwent endoscopy to exclude proximal Pain was assessed using a visual analogue scale (0-10). pathology. Patients were given a diary in which they were asked to Patients operated for hemorrhoids in the past or having note the severity of the pain immediately after defecation acute thrombosed hemorrhoids were excluded from the and then again after 6 hours every day. They were asked to study. note the total number of analgesics consumed on each day. A radiofrequency generator Ellman Dual Frequency 4 Patients were followed after 1 week, 2, 4 and 12 weeks MHz (Ellman International, Oceanside, New York) was used from the procedure to assess the duration of post operative to ablate the hemorrhoids. The unit is provided with a handle pain, time to return to work, wound healing and early Novel approach to advanced hemorrhoidal disease 363 complications like bleeding, perianal thrombosis, seepage Table III Immediate postoperative complications after and continence disorder. Wound healing was observed by radiofrequency ablation and fixation of hemorrhoids inserting a pediatric anoscope during the follow-up after 2 Retention of urine 78 (4.7) weeks. They were subsequently followed up to 36 months Severe hemorrhage requiring to ascertain late complications such as continence dis- re-admission 24 (1.4) Pruritus Ani 76 (4.6) turbance, recurrence of hemorrhoids or their symptoms and Perianal thrombosis 68 (4.1) development of external skin tags, if any. Wound infection 4 (0.2) Values are n (%) Results Hemorrhage. 24 patients returned with massive bleeding The time needed for coagulation of each hemorrhoid between the 8 and 11 th postoperative day. They were was about 20 to 40 seconds depending on the size of the readmitted. 13 of them responded to conservative treatment hemorrhoidal mass. All the hemorrhoids were dealt with in a in the form of local compression and haemostatics. However, single sitting and the entire procedure took about 6-8 minutes in the remaining 11, the bleeding points needed to be secured to perform. under anesthesia. All of them had an uneventful recovery The outcome of the procedure is described in Table II. thereafter. Pruritus. Itching in and around the anus was reported Table II Postoperative events after radiofrequency ablation and by 76 of the patients. Antihistaminic medication relieved fixation of hemorrhoids them of this complaint. Perianal thrombosis. 68 patients developed thrombosis Hospital stay 9 hrs (3.4) Post defecation pain score in 1st week 4.3 (2.8) of the external hemorrhoidal tissue in the immediate Pain score at rest in 1st week 2.2 (1.3) postoperative period. The patients were reassured and were Total analgesic requirement in first 2 21 tablets (4) asked to apply cold compresses over the swollen part. This postoperative weeks problem was solved over the next two weeks. Return to work 10 days (4.3) Wound healing time 17 days Incontinence. 3% of patients complained of incontinence for flatus in the first two weeks. It was self-limiting. None of Values are mean (SD) unless otherwise noted the patients had any complaint of incontinence of feces. Pain. In the first week, the mean post defecation pain Wound infection. Four patients operated for Grade IV score was 4.3 while it was 2.2 at rest, i.e. at 6 hours after hemorrhoids with removal of skin components complained defecation. In the second week, the post defecation pain of increase in the intensity of pain and purulent discharge score was 2.7 and pain score at rest was 1.3. The mean total in the 2nd week. Digital examination revealed localized analgesic requirement for the first two weeks was 21 tablets. suppuration in the wound. The infection subsided in 3 of There was more pain in patients who underwent excision of them with use of oral metronidazole and application of skin components of the hemorrhoids. metronidazole ointment. The fourth patient developed an Bleeding. 37% of patients complained of post defecation abscess requiring drainage under anesthesia. The wound bleeding, amounting from a mere smearing of the stool to healed uneventfully thereafter. small drops at the first follow-up at 1week. 4% of these Late complications continued to have minor bleeding up to 2 weeks. While 11 These were assessed at the follow-up between 30 and patients had bleeding in the form of stool streaking for as 36 months of the procedure. The follow-up was made in long as 4 weeks, the remaining patients did not have any person at the hospital. 81% of the patients attended the bleeding right from the very first defecation. follow-up. They were questioned about complaints, if any. Bowel movements. More than 86% of the patients could Per rectal examination and anoscopy was carried out in all pass stools within 24 hours of the procedure. The defecation the patients irrespective of whether they had any complaints was painful but smooth and easy. or not. Duration of incapacity to work. The mean time to return External skin tags. 94 patients had small external skin to work was 10 days. Patients operated for grade IV tags. hemorrhoids took a period of 2 weeks before they could Recurrence. 37 patients had non-prolapsing resume their routine. hemorrhoids with intermittent bleeding. Hemorrhoidal Wound healing time. The wounds were found to be banding or infrared coagulation was carried out to relieve healed at a mean of 17 days, which ranged between 14 and them of the complaints. Nine patients complained of 35 days. hemorrhoidal prolapse with spontaneous reduction. The Complications. The complications encountered in the prolapse, however, was not accompanied by any bleeding first two weeks of the procedure are shown in Table III. or soiling. They were asked for a regular follow-up. Retention of urine. 108 male patients had retention of In another 47 patients, anoscopy showed presence of urine in the immediate postoperative period. 56 of them were anal papillae. Few of these patients complained of symptoms relieved after a warm sitz bath. The remaining 52 patients like pruritus and post defecation dyscomfort. Symptomatic required catheterization once. treatment resolved their complaints. 364 Gupta None of the patients was found to have stricture or of the hemorrhoidal tissue reduced the bulk of the pile mass. narrowing of the anal canal. Similarly, no soiling or inconti- Gaj and his associates (17) have proposed a technique of nence was reported by any of the patients (Table IV). transfixed correction of grade III hemorrhoids. Table IV Late complication of the procedure of The operation of hemorrhoids is aimed at the removal of radiofrequency ablation and fixation of hemorrhoids the dilated veins, ligation of hemorrhoidal arteries and fixation of the anal mucosa to the underlying muscle to prevent prolapse and to obliterate submucous space (18). Skin tags n (%) 94 (5.6) Anal papillae n (%) 47 (2.8) The procedure adapted by us fulfills all the above Recurrence of bleeding n (%) 24 (1.4) requirements in the sense that the pathological enlargement Recurrence of prolapse n (%) 9 (0.5) of the hemorrhoidal plexus is reduced by radiofrequency ablation and the distal displacement of the hemorrhoids is repositioned back by plication while ensuring simultaneous Discussion ligation of hemorrhoidal vessels (19). With radiofrequency ablation, the fixation of mucosa to Radiofrequency instrumentation has been in use in oral, the underlying structure obliterates the space of vascular ophthalmic, plastic and restorative surgery for a long time. components, and thus helps in reducing postoperative It is recommended for ablation of hepatic tumors due to its bleeding. As the ablation is restricted above the dentate coagulative properties (8). Its use has been documented for line, the postoperative pain is much less. The combined proctological procedures like hemorrhoidectomy (9) and procedure thus ensures complete control of the anal fistulotomy (10). hemorrhoidal disease (20). The notable characteristic of radiofrequency coagulation The probable causes of secondary hemorrhage in is its property in achieving immediate reduction of vascular patients operated with this technique were premature components of the hemorrhoids (11) which is followed by slughing of the hemorrhoids with bleeding from the raw fixation of the mucosa to the underlying tissue as healing area, infection and straining during defecation. occurs in the process by cicatrisation (12). The results of our procedure are comparable with the Suturing or fixation of the hemorrhoids is a well-known results of open and closed hemorrhoidectomy and method. El-Meguid (13) innovated a Pile Suture method, hemorrhoidectomies performed with harmonic scalpel or where three interrupted sutures were used to fix the ligasure (Table V). hemorrhoidal cushions. By a similar technique, Bhansali and The main disadvantages of this procedure is Kale (14) achieved comparable results. Patnaik and Mangual development of external hemorrhoidal thrombosis in the (15) have described this technique as a better alternative to plicated segment of the hemorrhoid, persistence of anal skin the standard hemorrhoidectomy. Serdev (16) advocated a tags in patients with grade IV hemorrhoids and development method of pile stitch, quite similar to the technique we of anal papillae or tags at the site of hemorrhoid ablation. adopted in our procedure. He used absorbable sutures, which The complication rate with our procedure is less when were placed above the dentate line to attach the cushion compared with the above-mentioned surgical procedures back to the internal sphincter. He claimed that this obliteration (Table VI). Table V Comparative evaluation of postoperative events in various surgical procedures for advanced hemorrhoids Milligan and Ligasure Harmonic Closed Radiofrequency abla- Morgan hemor- scalpel1 hemor- tion and fixation hemor- rhoidectomy hemor- rhoidectomy of hemorrhoids rhoidectomy (2,26,28) rhoidectomy (3, 9,29,30) (3,25,28,29,30) (21,22,26,31) Operative time 30-58 minutes 11-25 minutes 10-30 minutes 30-37 minutes 6-8 minutes Hospital stay 2.76-5 days 1-5 days 1 day 1-3 days < 1 day Time to return to work 17-62 days 5-14 days 7-21 days 10-15 days 10days Wound healing time 28- 45 days 14-22 days 25-30 days 25-30 days 17days Table VI Comparative evaluation of complications in various surgical procedures for advanced hemorrhoids Milligan and Morgan Ligasure Scalpel Closed Radiofrequency abla- hemorrhoidectomy hemorrhoidectomy hemorrhoidectomy hemorrhoidectomy tion and fixation (22,24,29) (2, 26,27,32) (22, 23,31) (9, 29,33) of hemorrhoids Secondary bleeding 3-10% 9% 2% 1.8% 1.4% Retention of urine 5-15% 5% 2% 12-40% 4.7% Skin tag formation 10-15% 0-3% 1-4% 8% 5.6% Recurrence 2-5% 5-12% 3-5% 7% 2% Novel approach to advanced hemorrhoidal disease 365 It was observed that patients having grade IV hemor- 11. Gupta PJ. Novel technique: radiofrequency coagulation - a rhoids complained of greater intensity of pain for longer treatment alternative for early-stage hemorrhoids. Med Gen duration in our series. Few of them also had wound infection. Med 2002; 4: 1. More patients with grade IV hemorrhoids had residual anal 12. Gupta PJ. Radioablation of advanced grades of hemorrhoids with radiofrequency. Curr Surg 2003; 60: 452-458. skin tags. 13. Farag AE. Pile suture: a new technique for the treatment of The rationale behind using an absorbable material such hemorrhoids. Br J Surg 1978, 65: 293-295. as chromic catgut for plication was that the time needed for 14. Bhansali A, Kale PC. Plication of hemorrhoids. Indian J Surg absorption of the catgut was almost identical to the time 1982; 49: 78-80. needed by the ablated and plicated hemorrhoidal mass to 15. Patnaik SP, Mangual R. Plication: a new method of treating get fixed to the underlying tissue. piles without knife. Antiseptic 1996; 93: 206-209. It is however admitted that no direct comparison to the 16. Serdev N. The surgical treatment of hemorrhoids. Their suturing traditional methods of hemorrhoidectomy is undertaken, so ligation without excision. Khirurgiia (Sofiia) 1990; 43: 65- one cannot know whether this method truly yields improved 68. outcomes. The comparison to previously published data 17. Gaj F, Trecca A, Garbarino M, Flati G. Transfixed stitches for cannot be taken as a direct evaluation, because the literature- the treatment of haemorrhoids. Chir Ital 2004; 56:699-703. 18. Holzheimer RG. Hemorrhoidectomy: indications and risks. based data presented may have been derived from Eur J Med Res 2004; 9: 18-36. substantially different patient populations. Nonetheless, the 19. Gupta PJ. Randomized trial comparing in-situ radiofrequency comparison does speak about the efficacy of the procedure ablation and Milligan-Morgan hemorrhoidectomy in prolapsing advocated by us in treating advanced hemorrhoidal disease. hemorrhoids. J Nippon Med Sch 2003; 70: 393-400. 20. Gupta PJ. A comparative study between radiofrequency ablation Conclusion with plication and Milligan-Morgan hemorrhoidectomy in grade III hemorrhoids. Tech Coloproctol 2004; 8:163-168. Radiofrequency ablation and plication of hemorrhoids 21. Armstrong DN, Ambroze WL, Schertzer ME, Orangio GR. is a safe, effective, and swift method for treatment of pro- Harmonic Scalpel vs. electrocautery hemorrhoidectomy: a lapsed hemorrhoids. The procedure causes minimal pain and prospective evaluation. Dis Colon Rectum 2001; 44: 558-564. chances of complications are perceptibly less. The wound 22. Tan JJ, Seow-Choen F. Prospective, randomized trial comparing healing is quick, allowing an early return to normal activity. diathermy and Harmonic Scalpel hemorrhoidectomy. Dis Colon Rectum 2001; 44: 677-679. 23. Armstrong DN, Frankum C, Schertzer ME, Ambroze WL, References Orangio GR. Harmonic scalpel hemorrhoidectomy: five hundred consecutive cases. Dis Colon Rectum 2002; 45: 354-359. 1. Ramadan E, Vishne T, Dreznik Z. Harmonic scalpel 24. Sielezneff I, Salle E, Lecuyer J, Brunet C, Sarles JC, Sastre B. hemorrhoidectomy: preliminary results of a new alternative Early postoperative morbidity after hemorrhoidectomy using method. Tech Coloproctol 2002; 6:89-92. the Milligan-Morgan technic. A retrospective study of 1,134 2. Milito G, Gargiani M, Cortese F. Randomised trial comparing cases. J Chir (Paris) 1997; 134: 243-247. LigaSure haemorrhoidectomy with diathermy dissection 25. Bikhchandani J, Agarwal PN, Kant R, Malik VK. Randomized operation. Tech Coloproctol 2002; 6: 171-175. controlled trial to compare the early and mid-term results of 3. You SY, Kim SH, Chung CS, Lee DK. Open vs. closed stapled versus open hemorrhoidectomy. Am J Surg 2005; hemorrhoidectomy. Dis Colon Rectum 2005; 48:108-113. 189:56-60. 4. Gupta PJ. Plication of hemorrhoids after radiofrequency 26. Kwok SY, Chung CC, Tsui KK, Li MK. A double-blind, ablation: an alternative to hemorrhoidectomy. Ann Saudi Med randomized trial comparing Ligasure and Harmonic Scalpel 2002; 22: 267-268. hemorrhoidectomy. Dis Colon Rectum 2005; 48:344-348. 5. Gupta PJ. Radiofrequency ablation and plication of hemorrhoids. 27. Basdanis G, Papadopoulos VN, Michalopoulos A, Apostolidis S, Tech Coloproctol 2003; 7: 45-50. Harlaftis N. Randomized clinical trial of stapled hemor- 6. Wedman J, Miljeteig H. Treatment of simple snoring using rhoidectomy vs. open with Ligasure for prolapsed piles. Surg radio waves for ablation of uvula and soft palate: a day-case Endosc 2004. surgery procedure. Laryngoscope 2002; 112: 1256-1259. 28. Timerbulatov VM, Mekhdiev DI, Kalanov RG, et al. Appliance 7. Brown J.S. Radiosurgery. In Minor Surgery - a Text and Atlas. of LigaSure generator in hemorrhoidectomy. Khirurgiia 3rd ed, London. Chapman and Hall: 1997; 324-325. (Mosk) 2004; 9:44-46. 8. Weber JC, Navarra G, Jiao LR, Nicholls JP, Jensen SL, Habib 29. Uba AF, Obekpa PO, Ardill W. Open versus closed haemor- NA. New technique for liver resection using heat coagulative rhoidectomy. Niger Postgrad Med J 2004; 11:79-83. necrosis. Ann Surg 2002; 236: 560-563. 30. Arroyo A, Perez F, Miranda E, et al. Open versus closed day- 9. Filingeri V, Gravante G, Baldessari E, Grimaldi M, Casciani CU. case haemorrhoidectomy: is there any difference? Results of a Prospective randomized trial of submucosal hemorrhoidectomy prospective randomised study. Int J Colorectal Dis 2004; with radiofrequency bistoury vs. conventional Parks operation. 19:370-373. Tech Coloproctol 2004; 8:31-36. 31. Khan S, Pawlak SE, Eggenberger JC, et al. Surgical treatment of 10. Filingeri V, Gravante G, Baldessari E, Casciani CU. Radio- hemorrhoids: prospective, randomized trial comparing closed frequency fistulectomy vs. diathermic fistulotomy for sub- excisional hemorrhoidectomy and the Harmonic Scalpel mucosal fistulas: a randomized trial. Eur Rev Med Pharmacol technique of excisional hemorrhoidectomy. Dis Colon Rectum Sci 2004; 8:111-116. 2001; 44:845-849. 366 Gupta 32. Lawes DA, Palazzo FF, Francis DL, Clifton MA. One year 33. Kosorok P, Mlakar B. Haemorrhoidectomy as a one-day surgical follow up of a randomized trial comparing Ligasure with open procedure: modified Ferguson technique. Tech Coloproctol haemorrhoidectomy. Colorectal Dis 2004; 6:233-235. 2005; 9:57-59.