Selective hemorrhoidal dearterialization with high mucopexy in the surgical treatment of hemorrhoidal disease

The doppler-guided transanal hemorrhoidal dearterialization technique associated with mucopexy is a noninvasive surgical option used to treat hemorrhoidal disease (HD). Objective: To compare and analyze the results using a variation of the doppler-guided transanal hemorrhoidal dearterialization technique with the technique of selective hemorrhoidal dearterialization with high mucopexy in the treatment of HD. Method: A total of 292 patients who underwent surgical treatment for grade II, III and IV HD from March 2012 to December 2017 were studied. From this total, 110 (37.6%) patients underwent a conventional doppler-guided transanal hemorrhoidal dearterialization with mucopexy (CD), and 182 (62.3%) underwent selective hemorrhoidal dearterialization with highmucopexy (SHeLF). In the group of patients undergoing CD, 4 patients (3.64%) had grade II HD, 82 (74.55%) grade III, and 24 (21.82%) grade IV. In the group submitted to SHeLF, 18 (9.89%) patients had grade II HD, 86 (47.25%) had grade III, and 65 (35.71%) had grade IV. The same surgeon operated all patients under spinal anesthesia. In patients undergoing CD, six arterial branches have been dearterialized, while in patients undergoing SHeLF, the hemorrhoidary nipples submitted to a dearterialization were selected (from 1 to 5) by intraoperative evaluation followed by high rectal mucopexy. In the postoperative period, the following parameters were evaluated: pain, tenesmus, bleeding, and recurrence. Moderate results to severe pain was a postoperative complaint reported by 13 (11.82%) patients undergoing CD, and by 19 (10.44%) undergoing SHeLF. Intense tenesmus was reported by 26 (23.64%) patients undergoing CD and by 7 (3.85%) undergoing SHeLF. Three patients (2.73%) undergoing CD and 1 (0.55%) undergoing SHeLF evolved with postoperative bleeding. One patient (0.55%) in the group undergoing CD required surgical review of hemostasis. Six patients (5.45%) who underwent CD and 8 (4.39%) who underwent SHeLF were reoperated due to disease recurrence. Conclusion: Comparing statistics, patients undergoing the SHeLF technique have less postoperative pain, tenesmus and postoperative bleeding when compared with CD. (AU)

Pph and biological glue in patients with high risk of bleeding in stapled hemorrhoidopexy / Pph e cola biológica em pacientes com alto risco de sangramento em hemorroidopexia por grampeamento

ABSTRACT Background: Stapled hemorrhoidopexy is a common treatment for grade 3 hemorrhoids. Patients with conditions that increase the risk of bleeding, as cardiac stents usage with clopidogrel bissulfate and liver cirrhosis, should receive an extra care in surgical procedures due to the high risk of bleeding. For this reason and for patients with third degree hemorrhoids we propose the use of stapled hemorrhoidopexy followed by the use of biological glue. Aim: Assess surgical outcomes in patients with hemorrhoids and high risk of bleeding submitted to stapled hemorrhoidopexy followed by biological glue. Methods: Between 2005 and 2015, 22 patients were analyzed, in a retrospective cohort study. Results: From 22 patients submitted to stapled hemorrhoidopexy followed by the use of biological glue, only one (4.5%) presented bleeding in the surgical postoperative. Patients do not have any other complications and pain in the postoperative period. The median (IQR) operation duration was 55 (12) min and the median (IQR) length of hospital stay after surgery was 3 (2) days. Conclusion: Patients with high risk of bleeding submitted to stapled hemorrhoidopexy followed by the use of biological glue presented very low rates of bleeding in the postoperative period.

RESUMO Racional: Procedimento para o prolapso hemorroidário é uma forma de tratamento comum para hemorróidas de grau 3. Pacientes que apresentem condições que aumentam o risco de sangramento, como o uso de stents cardíacos associado ao uso de clopidogrel e cirrose hepática, devem receber cuidado redobrado em procedimentos cirúrgicos, devido ao alto risco de sangramento. Por esta razão é aqui proposto o procedimento para prolapso hemorroidário seguido da aplicação de cola biológica em pacientes com hemorróida de grau 3. Objetivo: Avaliar os desfechos cirúrgicos em pacientes com hemorróida de grau 3 e alto risco de sangramento submetidos ao procedimento para o prolapso hemorroidário seguido da aplicação de cola biológica. Métodos: Entre 2005 e 2015, 22 pacientes foram analisados, em estudo coorte retrospectivo. Resultados: Dos 22 pacientes submetidos ao procedimento para o prolapso hemorroidário seguido pelo uso de cola biológica, apenas um (4.5%) apresentou sangramento no pós-operatório. Os pacientes não apresentaram nenhuma outra complicação ou dor no período pós-operatório. O tempo mediano da operação foi de 55 (12) min e a média do tempo de internação hospitalar foi de três (2) dias. Conclusão: Os pacientes com alto risco de sangramento submetidos ao procedimento de prolapso hemorroidário seguidos pela aplicação da cola biológica apresentaram baixa taxa de sangramento.

Long term results after stapled hemorrhoidopexy alone and complemented by excisional hemorrhoidectomy: a retrospective cohort study / Resultados tardios após hemorroidopexia mecânica isolada e complementada por operação excisional

ABSTRACT Background: Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients. Aim: To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique. Method: In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up. Results: The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97). Conclusion: Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.

RESUMO Racional: A hemorroidopexia com grampeador está significativamente associada a menor dor pós-operatória e recuperação mais rápida. No entanto, há evidência de que possa ter maior taxa de recorrência sintomática. A hipótese é que empreender excisão cirúrgica limitada da doença hemorroidária após o grampeamento pode ser abordagem válida para pacientes selecionados. Objetivo: Avaliar os resultados comparativos a longo prazo após a técnica de grampeamento isolada ou associada à complementação por técnica excisional fechada. Método: Coorte retrospectiva, com 65 (29 homens) pacientes submetidos à hemorroidopexia por grampeamento e 21 (13 homens) a ela complementada por técnica excisional. Os pacientes foram submetidos à complementação do grampeamento se sintomas atribuíveis às hemorróidas externas fossem observados no pré-operatório, ou se prolapso residual ou doença externa volumosa existisse após o disparo do grampeador. A hemorroidectomia excisional fechada por eletrocauterização sem ligadura vascular foi utilizada em todos os casos de complementação. Todas as variáveis ​​clínicas foram obtidos a partir de um questionário eletrônico, entrevista por telefone, ou em consulta. Resultados: A duração média do seguimento pós-operatório foi de 48,5 (6-40) meses. Os pacientes com graus hemorroidários 3 e 4 foram operados com mais frequência usando grampeamento complementado por técnica excisional (95,2% vs. 55,4% - p=0,001). Os pacientes operados por grampeamento sem e com complementação por técnica excisional, não houve diferença entre os grupos quanto a recidiva dos sintomas (43% vs. 33%, p=0,45, respectivamente) ou quanto ao intervalo médio entre a opração e a recorrência dos sintomas (30 (8-84) vs. 38,8 (8-65) meses, p=0,80). Oito (12,3%) pacientes foram reoperados após grampeamento isolado e 2 (9,6%), após grampeamento complementado por técnica excisional (p=0,78). O grau de satisfação pós-operatória foi semelhante entre as técnicas (p=0,97). Conclusão: A hemorroidopexia por grampeamento combinada com técnica excisional foi eficaz para a doença hemorróida mais avançada. A combinação pode ter impedido a recorrência sintomática associada a hemorroidopexia isolada.

Hemorroidectomía con ligasure®: ¿mejoran el tiempo quirúrgico y la evolución postoperatoría? Comparación de los resultados con la cirugía clásica / Hemorrhoidectomy with ligasure®: do they improve surgical time and postoperative evolution? Comparison of the results with classical surgery

INTRODUCCIÓN: La hemorroidectomía es un procedimiento muy frecuentemente utilizado en la práctica diaria del coloproctólogo. Distintas técnicas fueron propuestas. Las más utilizadas son las abiertas (MilliganMorgan) o las cerradas (Ferguson). Iniciamos en 2010 nuestra experiencia utilizando el Ligasure® con una pinza especialmente diseñada a tal efecto. Los buenos resultados iniciales obtenidos nos motivaron a evaluar objetivamente esta técnica. OBJETIVO: Comparar los resultados de las hemorroidectomías utilizando el Ligasure® y los obtenidos con la clásica cirugía de Milligan-Morgan. DISEÑO: Retrospectivo sobre una base de datos de pacientes prospectiva. PACIENTES Y MÉTODO: Se evaluaron 230 pacientes operados consecutivamente entre enero de 2011 y diciembre de 2014 con el uso del Ligasure®. Estos resultados se compararon con los de otro grupo de 230 pacientes operados previamente con la técnica clásica de hemorroidectomía abierta (grupo control). El seguimiento mínimo fue de 6 meses para todos los pacientes...

BACKGROUND: Hemorrhoidectomy is daily performed in colorectal practice. Open and closed procedures has been described. In 2010 we start to perform hemorrhoidectomy with the use of the Ligasure® with a special device. The results obtained were the base to start a comparison with our standard technique. OBJECTIVE: To compare results between Ligasure® hemorrhoidectomies and classical surgical hemorrhoidectomies (control group). DESIGN: Restrospective comparison with prospective data. PATIENTS AND METHOD: Results of 230 consecutive patients operated on with the Ligasure® were compared with similar series of 230 patients operated with classical open technique. Follow-up was at least 6 months in both groups...