Novel Approach to Advanced Hemorrhoidal Disease

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					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:      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 11o’clock 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,
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