الرحمن الله بسمالرحيم

اإلمام مقامالنووي 631 -671H1255-1300G

1ST annul surgical symposium STAPLED HEMORRHOIDECTOMY

1ST annul surgical symposium STAPLED HEMORRHOIDECTOMY

Dr. Abdulmonem Abualsel

KAMC –NGHA- ALHASA

MRCS Gen. Surgery

DEFINITIONDEFINITION

Haemorrhoids :- (Greek: haima=blood, rhoos=flowing) Piles (latin: pila=a ball) They may be external or internal When the two varieties are associated

they are known as interoexternal.

AnatomyAnatomy

The anal canal, 4 cm long, extends from the pubo-rectalis passes downwards and backwards, to the skin of the perineum.

The upper two-thirds is derived from the cloaca (endoderm), the lower one-third from the anal pit (ectoderm) .

Blood SupplyBlood Supply

Of the cloacal part from the superior rectal artery (Portal).

The sphincters, outside the mucosa, are supplied by the middle and inferior rectal arteries (systemic).

The mucosa of the lower third is supplied by the inferior rectal artery.

The site of HsThe site of Hs

Venous returnVenous return

Above the dentate line to the portal system through the superior rectal vein.

Below the dentate line , the external hemorrhoidal plexus drains via the middle and inferior rectal veins, to the internal iliac vein.

ClassificationClassification

1-By location: External: from the inferior hemorrhoidal

plexus, covered by modified squamous epithelium.

Internal: they occur above the pectinate line, may prolapse

Mixed: from both plexuses.

ClassificationClassification

2-By degree:

1st. Degree :Simple projection.

2nd.degree: Present to the outside during defecation.

3rd.degree: Mixed protrude outside & require manual reduction.

4th.degree: Prolapsed & irreducible.

AetiologyAetiology

The correct treatment of Hs can only be found upon sound etiological concept.

Suggested by some to be due to the adoption of the erect posture by Man.

A consequence of the aging process. However 4 major theories to be

mentioned

AetiologyAetiology

1-Abnormal dilatation of the veins of the internal hem. venous plexus.

2-Abnormal distension of the arterio-venous anastomoses.

3-Downward displacement or prolapse of the anal cushions.

4-Destruction of the anchoring connective tissue system.

parks AG the surgical treatment of hemorrhoids BrJ1956 43-51

Parks 1956, maintained the aetiology was compression of the low pressure superior Hs veins by efforts to expel constipated stool. ARTERIAL pressure allows blood to enter the internal Hs plexus which becomes distended and congested. Followed by partial prolapse

Impaired v drainageImpaired v drainage

AetiologyAetiology

The role of transient increase in intra-abdominal pressure, e.g. during defecation and in pregnancy.

The high rectal pressure in patients suffering from piles.

TheoriesTheories

Stewart 1963, divided internal Hs into 2 main groups:

1-Vascular Hs with extensive dilatation of the internal Hs plexus a variety commoner in the young.

2-Mucosal Hs and consists of sliding downwards of thickened mucous membrane, in the old i.e prolapse

thompson WH .the nature of hemorrhoid 1975 surg 62- 542

1975, Thomson postulated the theory of Vascular cushions, which protect the anal canal during the act of defecation

The submucosa is not a continuous ring, but rather a discontinuous series of cushions, rich in blood vessels and muscle fibers, which adheres the mucosa and submucosa to the internal sphincter and supports the blood vessels.

thompson WH .the nature of hemorrhoid 1975 surg 62- 542

Straining causes these cushions to slide downwards and internal Hs

Develop Prolapse of the anal mucous and hemorrhoidal cushions is a very common condition over the age of 50.

thompson WH .the nature of hemorrhoid 1975 surg 62- 542

AetiologyAetiology

Thomson demonstrated that the fragmentation of the supporting tissue is the cause for the Prolapse, affecting the hemorrhoidal tissue and the anal mucosa.

The collapse of Park’s ligament causes a permanent downward sliding of the anal mucosa that loses its normal topographic relationship with the sphincters.

AetiologyAetiology

Under this circumstance the mucosa of the rectal ampulla occupies the muscular anal canal permanently, while the anal mucous membrane and the piles are distally displaced.

The anal prolapse cause an alteration of the vascular arrangement and of the anatomical relationship between the ……

Internal and external hemorrhoidal plexuses.

Based on the previous theories a stapler hemorrhiodectomy was one of the modalities of treatment of piles.

It is assumed that the technique of stapled hemorrhoidectomy aims to preserve the anal mucosa and the hemorrhoidal tissue, however, maintaining the suture carried out above the anorectal ring.

Under some circumstances the transection of some anal mucosa is necessary.

longoA1998 treatment of hemorhoidal disease

Longo A (1998) Treatment of haemorrhoidaldisease

Longo A (1998) Treatment of haemorrhoidaldisease

Introduction of stapled hemorrhoidopexy by Longo in 1998 [1] represented a radical change in the treatment of hemorrhoids.

By avoiding multiple excisions and suture lines in the perianal region, SH is intended to offer less postoperative pain than with conventional techniques

DR :ANTONIO LONGODR :ANTONIO LONGO

Definition and PrinciplesDefinition and Principles

The operation is based on the principle of a mucosectomy at least 3-4 cm above the dentate line where:

A purse string suture placed at that level and tied around the stapler shaft then resection and stapling of the mucosa are carried out, simultaneously.

Cont…Cont…

This procedure effectively reduces mucosa

Blocks the end of branches of the upper rectal artery thus stopping venous and arterial blood flow of hemorrhoidal plexus.

Medical treatmentMedical treatment

Fibres Over the counter daflon

Nonoperative treatmentNonoperative treatment

Sclerotherapy Cryotherapy Rubber band ligation Bipolar diathermy and infrared

photocoagulation

Surgical treatmentSurgical treatment

Excision Anal dilatation stapler

في األموي المسجددمشق

Study from April 2003 till January

2009

AbstractAbstract

Objectives: present our retrospective results of circular stapler hemorrhoidcetomy (SH) for the treatment of haemorrhoids.

Data collection:160 patient operated in national guard from 2003 up to January 2009.

The goals of the study were to evaluate the efficacy and reproducibility of stapled hemorrhoidectomy .

The indication for surgery bleeding and / or prolapsed of

2nd ,3rd and 4th degree piles

Results:Results:

96 male(60%) 64 female(40%) The age between 20- 80 year with

average (35,5) year

DR: Ahmad SalmanDR: Ahmad Salman

METHODSMETHODS

160 pt Complication Hospital length Operation time. Follow up 2 week ,0ne

month,3month,6month one year and 2 year.

Total Number of Patient - 160Total Number of Patient - 160

Youngest – 20 years old

Oldest – 80 years old

Average – 35.5 years old

(71%)of pts with 3ed degree (28%) ==== 4th degree (1%) ==== 2ed degree

Operative TimeOperative Time

Quickest – 8 minutes Longest – 70 minutes Average Time – 32 minutes

4 case stapler + peri anal fistula

0

10

20

30

40

50

60

malefemale

Those patients were operated by 6 surgeons

4 consultant . 2 senior registrar. Dr salman is the first one who start this

and the one teach us .

Visual analogue scaleVisual analogue scale

Post operative was managed according to guideline of VAS (0-no pain)to (10-mexionir pain)

The aim was to keep down to VAS score <3 Analgesic, was given according WHO system. During operation immediately of the recovery.((IM)

NSAID. Or mepridine ) During hospital stay: VAS<3 class1 analgesic paracetamol tab. VAS<3-5 class 11 paracetamol + NSAID

(tab) VAS<5 class 111 mepridine IM injection

Analgesia Analgesia

60 % received a single does. Pethidine

inj only. 15 % received. only 1 dose Voltaren inj. 10 % received.acetaminophen and

voltaren tab. 15% received. acetaminophen tab only.

complicationscomplications

Complications during the first 24 hours were

fecal urgency (25%), urinary retention (10%), rectal bleeding (2%). Pruritus ani (5%)??

ComplicationComplication

Post anal fissure –6 case 3,7% Anal stricture – 5 cases 3.1 perianal fistula &Thrombosed pile

– 2 case 1.6% Reintervension

*2 case for bleeding

*5 cases for anal dilation

Anal pain – 6 cases 3,75%

4 cases low stapler line . Recurrance : 4 cases after 2 year Satisfaction – 94%

• - 60%. by asking the patient during clinic visit

• -40%. by telephone

Hospital Length of StayHospital Length of Stay

75% 1 days 15% 2 days 10% > 2 days

– Causes: a. bleeding

b. Anal pain

c. Social.

Return to work:

10 days post op in more than 95%

They were no cases of permanent incontinence, chronic pain or deaths in this series

literatures

Department of Surgery, Università Tor Vergata, Rome, Italy,

Department of Surgery, Università Tor Vergata, Rome, Italy,

: 171 patients (95 cases in SH group and 76 cases in MMH group) entered the study:

83 cases were III degree hemorrhoids, 88 IV degree.

Surgical time was 28.41 +/- 10.78 for MMH and 28.30 +/- 13.28 min in SH

during the following 6 days, patients treated with SH had less pain (4.63 +/- 2.04 in MMH vs 3.60 +/- 2.35 in SH;

Colorectal Surgery Division, Hospital Santa Helena, Sao Paulo (SP), Brazil.

Colorectal Surgery Division, Hospital Santa Helena, Sao Paulo (SP), Brazil.

A series of 108 patients 76 Patients who underwent stapled

hemorrhoidectomy were compared to 32 patients submitted to closed diathermy-excision hemorrhoidectomy due to

, median and maximum daily pain scores were lower in the stapled group (P < 0.001).

days Resumption of activities occurred after 9 days (mean; range 2 to 17 days) after stapling and 14 days (7 to 24) after diathermy surgery - P < 0.001. After one

year, 45 (80.4%) patients in the stapled group and 18 (78.3%) in the diathermy group were asymptomatic

Many center in FranceMany center in France

*CHU Rangueil, Toulouse, France; CHU Nantes, Nantes, France; CHU Trousseau, Tours, France; Clinique Charcot, Lyon, France; Polyclinique de Franche Comté, Besancon, France; CHU Limoges, Limoges, France, Angers, France

A series of 134 patients were included at 7 hospital centers. They were randomized according to a single-masked design

The mean follow-up period was 2.21 years

Hospital stay was significantly shorter in the SH group (SH 2.2 ± 1.2 [0; 5.0] versus MM 3.1 ± 1.7 [1; 8.0] P < 0.001

No patient needed a second procedure for recurrence within 2 years

A clear difference in morphine requirement became evident after 24 hours

the overall incidence of complications was the same,

Rev Gastroenterology Mex. 2006 Oct-Dec;71(4):422-7 Mexico

Rev Gastroenterology Mex. 2006 Oct-Dec;71(4):422-7 Mexico

In a 27 months period, 160 patients were treated (105 men and 55 women),

mean age was 44.1 years (range: 24 to 72 years), 110 patients had grade III hemorrhoid disease. Non procedure complications were noted, early complications were detected in 5% of patients late complications were detected in 10% of patients. mean follow-up of 18.8 months, 82.5% of the patients remained asymptomatic and 94.4 of the

patients reported a good satisfaction score. A second surgery was required in three patients because of

recurrence.

ConclusionConclusion

This study confirms the feasibility of circular stapler hemorrhoidectomy complication and post-operative pain were minimal and goes with most of the international studies.

SH is safe and simple procedure, SH can eliminate hemorrhoidal bleeding, SH successfully eliminates pain in hemorrhoidal disease, SH successfully eliminates hemorrhoidal prolapse SH is a minimally invasive surgical procedure.

1. Longo A (1998) Treatment of haemorrhoidaldisease by reduction of mucosaand haemorrhoidal prolapse Rome, Italy, pp 3–63

2. Lacerda-Filho A, Da Silva RG. Stapledhemorrhoidectomy: present status. Arq Gastroenterol2005;42:191–4.

References

3. Thompson WH. The nature of haemorrhoids. Br JSurg 1975;62:542–52.4. Brisinda G. How to treat haemorrhoids.Prevention is best; haemorrhoidectomy needsskilled operators. BMJ 2000;321:582–3.5. Lacerda-Filho A, Da Silva RG. Stapledhemorrhoidectomy: present status. Arq Gastroenterol2005;42:191–4.6. Nisar PJ, Scholefield JH. Managing haemorrhoids.BMJ 2003;327:847–51.7. Johanson JF. Evidence-based approach to thetreatment of hemorrhoidal disease. Evid BasedGastroenterol 2002;3:26–31

ReferencesReferences

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14. Haas PA, Haas GP, Schmaltz S, Fox TA Jr. Theprevalence of hemorrhoids. Dis Colon Rectum1983;26:435–9.15. Lunniss PJ, Mann CV. Classification of internalhaemorrhoids: a discussion paper. Colorectal Dis2004;6:226–32.16. Madoff RD, Fleshman JW. AmericanGastroenterological Association technical review onthe diagnosis and treatment of hemorrhoids.Gastroenterology 2004;126:1463–73.

17. Polglase AL. Haemorrhoids: a clinical update. MedJ Aust 1997;167:85–8.22. Senagore AJ. Surgical management ofhemorrhoids. J Gastrointest Surg 2002;6:295–8.18. Cataldo PA. Hemorrhoids. Clin Colon Rectal Surg2001;14:203–14..

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