Improved Outcomes in Colon and Rectal Surgery part 19 docx

In contrast, when there is significant disruption of the mucosal suspensory ligament in the late stages of the disease, a tech-nique resulting in fixation of the mucosa to the underlying

Dan R Metcalf and Anthony J Senagore

CHallenging Case

A 38-year-old man presents to your office after receiving an urgent

hemorrhoidectomy 1 year previously He had continued pain and

bleeding with bowel movements He feels his anus is “too tight”

and continues to be symptomatic despite attempts at dilatation,

daily fiber, and stool softeners Examination reveals three healed

incisions and anal stenosis The anus will only admit the tip of

your finger with discomfort

Case ManageMent

The patient has anal stenosis due to removal of an excessive

amount of anoderm with his surgery The management of

refrac-tory posthemorrhoidectomy stenosis usually requires some type

of flap repair The choice of flap repair selected will depend on the

degree of stenosis and the surgeon’s experience The editors have

found one or multiple house advancement flaps to be the most

common option chosen in our practice

introduCtion

Few diseases are more chronicled in human history than

sympto-matic hemorrhoidal disease.(1, 2) Citations of hemorrhoidal

dis-ease have been noted in historic texts dating back to Babylonian,

Egyptian, Greek, and Hebrew cultures.(1, 2) A multitude of

treat-ment regimens have been offered including anal dilation,

vari-ous topical liniments, and the often feared red hot poker.(3, 4)

Although few people have died of hemorrhoidal disease, some

patients wish they had particularly after therapy and this fact led

to the beatification of St Fiachre, the patron saint of gardeners

and hemorrhoidal sufferers.(5) This chapter will guide the

practi-tioner to a more humane approach to hemorrhoidal disease with

the emphasis on cost-effectiveness and obtaining superior short

and long-term outcomes

anatoMy/etiology

Hemorrhoidal cushions are located within the submucosa of the

upper anal canal and are a normal component of the anorectal

anatomy These cushions are composed of blood vessels, smooth

muscle (Treitz’s muscle), connective tissue, and elastic tissue.(6)

(Figure 17.1) Anatomically, the hemorrhoidal cushions appear

with marked predictability in the right anterior, right posterior, and

left lateral positions, although there may be intervening secondary

hemorrhoidal complexes which obscure this classic anatomy.(6)

The blood supply to the anal cushions is derived from the superior

rectal artery, a branch of the inferior mesenteric; the middle rectal

arteries arising from the internal iliac arteries; and the inferior

rec-tal arteries arising from the pudendal arteries The venous drainage

transitions from the portal venous system above the level of the

dentate line to the systemic venous system below this level.(6)

Anal cushions contribute to the maintenance of anal continence

and allow the anal canal to dilate during defecation without tearing

(6) Consequently, in some patients hemorrhoidectomy may result

in various degrees of incontinence or leakage Hemorrhoidal disease occurs as the result of abnormalities within the connective tissue

of these cushions producing bleeding with or without prolapse of the hemorrhoidal tissue.(7) This can occur as the result of exces-sive straining, chronic constipation, or low dietary fiber.(8) A clear understanding of the pathophysiology is important when consider-ing therapeutic interventions At the earlier stages of disease, when the major manifestation is transudation of blood through thin walled damaged vascular channels, ablation of the vessels should

be adequate In contrast, when there is significant disruption of the mucosal suspensory ligament in the late stages of the disease, a tech-nique resulting in fixation of the mucosa to the underlying muscu-lar wall is necessary for effective therapy.(9) Internal anal sphincter dysfunction may play a role, as a number of investigators have dem-onstrated increased internal anal sphincter tone in patients with hemorrhoidal disease.(10–12) In reality, a combination of all of the above factors are important for the ultimate development of large prolapsing hemorrhoids

Hemorrhoids are divided into two groups, external and internal External hemorrhoids are located distal to the dentate line and are covered by modified squamous epithelium (anoderm) In contrast, internal hemorrhoids are covered by columnar or transitional epi-thelium and are located proximal to the dentate line Internal hem-orrhoids are further divided into grades based on size and clinical

Figure 17.1 Sagital section of anal cushion showing internal and external

hemorroids.

symptoms Grade I internal hemorrhoids bulge into the lumen and

produce bleeding; Grade II internal hemorrhoids protrude with

bowel movements and reduce spontaneously; Grade III internal

hemorrhoids protrude spontaneously or with bowel movements

and require manual reduction: Grade IV internal hemorrhoids are

permanently prolapsed and irreducible.(13) Mixed hemorrhoids are

those with components of both internal and external hemorrhoids

Although there tends to be a correlation between symptoms and the

grade of hemorrhoidal disease, therapeutic decisions should not be

based solely on these criteria As will be outlined later, it is

impor-tant to consider the relative role of internal hemorrhoidal tissue in

addition to external hemorrhoidal skin tagging when choosing a

modality for complete resolution of the patient’s symptoms.(7)

CliniCal evaluation

Among the most common symptoms associated with

hemor-rhoidal disease are bleeding, protrusion, and pain However,

Mazier reported on a series of 500 patients with anorectal

com-plaints they associated with their hemorrhoids and ultimately,

only 35% of patients were found to have any significant

hemor-rhoidal disease at all.(14) Hemorhemor-rhoidal bleeding is

characteristi-cally painless and bright red and seen on the toilet paper or in

the commode after a bowel movement However, more vigorous

bleeding can occur as the hemorrhoids enlarge, particularly in

advanced stages when a portion of the complex is fixed externally,

allowing the blood to drip or spurt into the commode Generally,

prompt reduction of the protruding mass will alleviate this

symp-tom Acute thromboses of internal or external hemorrhoids are

usually associated with a palpable mass and severe pain These

patients typically present with extreme discomfort and on clinical

examination the diagnosis is frequently obvious

Examination of the patient with hematochezia should be

tai-lored by the age of the patient and include sufficient investigations

to rule out a proximal source of bleeding such as inflammatory

bowel disease or neoplasia Hemorrhoidal bleeding as a cause of

anemia is an uncommon occurrence with an incidence of 0.5 per

100,000 per year.(15) Consequently, hemorrhoids should not be

dismissed as the cause of iron deficiency anemia

The authors examine patients in the left lateral position with

the knees drawn up toward the chest as high as possible This

approach allows relative patient comfort and the ability to clearly

inspect the perianal skin, perform anoscopy, and

proctosig-moidoscopy A careful digital examination of the anal canal and

distal rectum should be performed with the addition of prostate

examination in male patients Examination with an anoscope is

essential to adequately inspect the hemorrhoidal tissue and anal

canal Inspection of the three common locations for hemorrhoids

should be performed with documentation of the size, friability,

and ease of prolapse Documentation of anal pathology should

be described by anatomic position (anterior, posterior, etc.,) to

avoid confusion regarding the position in which the patient was

examined Upon completion of this portion of the exam, a

deci-sion should be made regarding the need for more proximal

evalu-ation of the colon and rectum However, rigid proctoscopy should

be the minimum in all patients After appropriately grading the

hemorrhoidal disease, discussion can ensue with the patient

regarding the various treatment options

nonexCisional options

The majority of patients with hematochezia attributable to hem-orrhoids can be managed conservatively without surgical inter-vention Dietary and lifestyle modification, reduction of straining with defacation, sclerotherapy, infrared coagulation, and rubber band ligation are described in chapter 18 These options are considered before considering excisional options

exCisional HeMorrHoideCtoMy

Approximately 5–10% of patients will require surgical manage-ment of their hemorrhoids.(16) Excisional hemorrhoidectomy should be considered in those patients with extensive sympto-matic disease who have failed or are not candidates for medical and nonexcisional options In addition to this, the customary indications for hemorrhoidectomy include frequent or per-sistent prolapse requiring manual reduction resulting in dis-comfort and anal seepage, and hemorrhoids associated with conditions such as fissure, fistula, ulceration, or extensive anal skin tags The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids It is apparent however that similar full excisional hemorrhoidectomy can be per-formed using standard closed hemorrhoidectomy techniques without undue complications Specifically, the risk of steno-sis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites In the case of limited external hemor-rhoidal thromboses, surgical excision may also be warranted for more rapid pain relief and avoidance of a residual skin tag (17–20) Limited external thromboses can be easily managed in the office setting with local anesthesia and complete excision with or without skin closure.(Figure 17.2)

Options for excisional hemorrhoidectomy include the follow-ing techniques: Milligan-Morgan hemorrhoidectomy; Ferguson Closed hemorrhoidectomy; Whitehead hemorrhoidectomy; sta-pled hemorrhoidectomy; and variations of the Milligan-Morgan and Ferguson techniques using alternative energy devices The use

of lasers for excisional hemorrhoidectomy offers no advantage and in fact causes delayed healing, increased pain, and increased cost.(21) The procedures are usually performed in the operating room after minimal preoperative bowel preparation The choice

of anesthetic is typically left to the anesthesiologist and patient, however local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective and short act-ing The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention do to a higher intraop-erative administration of intravenous fluids

The Milligan-Morgan hemorrhoidectomy (Figure 17.3), which

is widely practiced in Europe, was originally described in 1937 and its efficacy has subsequently been documented in many series.(22–24) This technique involves resection of the internal and external hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.(22) The distal ano-derm and external skin are left open to heal by secondary inten-tion to minimize the risk of infecinten-tion This technique has been proven to be a safe and effective means for managing advanced hemorrhoidal disease.(22) However, the open wounds typically

take 4–8 weeks to heal and can be a cause of considerable

discom-fort and prolonged morbidity after this procedure

The closed Ferguson hemorrhoidectomy (Figure 17.4) was

proposed as an alternative to the Milligan-Morgan technique

and enjoys a similar large body of evidence regarding its safety

and efficacy.(17–20) This technique utilizes an hourglass-shaped

excision of the entire internal and external hemorrhoidal

com-plex (centered at the midportion of the anoderm), preservation

of the internal and external anal sphincters, and primary closure

of the entire wound Occasionally, it is necessary to undermine

flaps of anoderm and perianal skin to allow excision of

inter-mediate hemorrhoidal tissue, while preserving the bridges of

anoderm between pedicles This technical adjustment will avoid

postoperative strictures

The Whitehead hemorrhoidectomy (Figure 17.5), described in

1882, involves a circular incision at the level of the dentate line

with subsequent circumferential excision of the hemorrhoidal

tissue and relocation of the dentate line which is often a

com-ponent of prolapsing hemorrhoids.(25) Although this technique

had a long period of widespread use in the United Kingdom, it

was subsequently largely abandoned because of the high rates of

mucosal ectropion and anal stricture.(26–29) However, using a

modification of the original technique it has enjoyed renewed

support by some surgeons in the United States with minimal

stricture rates and no occurrences of mucosal ectropion.(30–31)

Despite these promising reports, the Whitehead procedure is

technically demanding because of the need to accurately identify

the dentate line and relocate it to its proper location

Stapled hemorrhoidopexy is a relatively novel technique

with growing acceptance as an alternative to excisional

rhoidectomy for the treatment of grade III and grade IV

hemor-rhoids The technique, as described in 1998 by Antonio Longo (32),

involves circumferential excision of the mucosa and submucosa

above the hemorrhoids using a circular stapler resulting in

reloca-tion and fixareloca-tion of the internal hemorrhoids Briefly, a circular

anoscope is inserted into the anal canal to reduce the prolapsing tissue and allow placement of a circumferential purse-string suture

4 cm proximal to the dentate line into the mucosa and submucosa

A 33 mm hemorrhoidal circular stapler (EthiconEndo-Surgery; PPH03) with the anvil fully extended is then advanced proximal to the purse-string which is then gently tightened around the shaft of the stapler The free ends of the suture are then threaded through the lateral channels of the stapler housing to provide traction on the purse-string as the stapler is closed and advanced into the anal canal Once in position the stapler is closed and fired The staple line should be inspected for hemostasis and bleeding controlled with an absorbable suture.(Figure 17.6) Numerous randomized controlled trials comparing stapled hemorrhoidopexy to conven-tional hemorrhoidectomy have substantiated the benefits of sta-pled hemorrhoidectomy, namely reduced operating room time, less pain and analgesic use, and earlier return to work with similar symptom control.(33–36) In a prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and closed hemorrhoidectomy Senagore et al reported less pain, less pain at first bowel movement, less analgesic use and similar symptom con-trol using stapled hemorrhoidopexy in which 88% of patients were treated as outpatients.(36) As demonstrated in a recent systematic review of 25 randomized, controlled trials comparing stapled orrhoidopexy to conventional hemorrhoidectomy, stapled hem-orrhoidopexy is a safe and effective procedure for the treatment symptomatic hemorrhoids with superior short-term outcomes (37) This review indicates that the incidence of recurrent hem-orrhoids is significantly higher at one or more years after stapled hemorrhoidopexy (5.7% vs 1%), however, the overall recurrence

or persistence of hemorrhoidal symptoms was similar between the

groups (SH vs conventional: 25.3% vs 18.7%, p = 0.07).(37) In a

retrospective review of 291 patients submitted to stapled hemor-rhoidopexy with grade III and grade IV hemorrhoids, the overall recurrence rate after a minimum follow-up of 5 years was 18.2% (38) They showed a tendency for higher recurrence in grade IV

Figure 17.2 Excision of thrombosed external

hemorrhoid.

Figure 17.3 Open (Milligan-Morgan) hemorrhoidectomy (A) External hemorrhoids grasped with forceps and retracted outward (B) Internal hemorrhoids grasped

with forceps and retracted outward with external hemorrhoids (C) External skin and hemorrhoid excised with scissors (D) Suture placed through proximal internal hemorrhoid and vascular bundle (E) Ligature tied (F) Tissue distal to ligature is excised Insert depicts completed three bundle hemorrhoidectomy.

Figure 17.4 Modified Ferguson excisional hemorrhoidectomy (A) Double ellipitical incision made in mucosa and anoderm around hemorrhoidal bundle with a

scalpel (B) The hemorrhoid dissection is carefully continued cephalad by dissecting the sphincter away from the hemorrhoid (C) After dissection of the hemorrhoid

to its pedicle, it is either clamped, secured, or excised The pedicle is suture ligated (D) The wound is closed with a running stitch Excessive traction on the suture is avoided to prevent forming dog ears or displacing the anoderm caudally.

Figure 17.5 Whitehead hemorrhoidectomy (A) Suture placed through proximal internal hemorrhoid for orientation Excision started at dentate line and continued to

proximal bundle (B) Internal hemorrhoidal tissue excised above ligated bundle (C) Vascular tissue excised from underside of elevated anoderm (D) End of anoderm reaproximated with sutures to original location of dentate line (E) Completed procedure.

hemorrhoids with a significantly higher reoperation rate.(38) In

some instances this was thought to be related to inappropriate

patient selection In a large series reported by Jongen et al stapled

hemorrhoidopexy with good patient selection was associated with

a low rate (3.4%) of reoperation for persistent or recurrent

hemor-rhoidal prolapse.(39)

The data clearly indicate that stapled hemorrhoidopexy is a

safe and effective option to treat symptomatic hemorrhoids with

superior short-term outcomes Although a higher rate of late

recurrence is reported with this technique in the current literature,

an appropriately designed randomized trial with adequate power

and longer follow-up is needed to ultimately define the durability

of stapled hemorrhoidopexy Patient selection for stapled

hemor-rhoidopexy may also play an important role in short and long term

outcome analysis

Improper technique with PPH has led to significant

complica-tions Placement of the purse-string suture too high (cranial) or

too deep has led to a full thickness excision and occasional

anas-tomotic leaks with subsequent sepsis and some deaths Placement

of the purse-string suture too low may lead to impaired

conti-nence (inclusion of sphincter muscle in staples) or pain Chronic

pain following PPH may respond to anti-inflammatory agents or

time Some success in refractory patients has been obtained with

removal of residual staples (usually done under anesthesia) or

injection of long duration steroids

In the quest to provide patients with the benefit of less

post-operative pain, alternative devices such as the Harmonic Scalpel®

and LigaSure™ have recently been used to perform excisional

hemorrhoidectomy There have been four randomized, controlled

trials published in an attempt to assess the efficacy of Harmonic

Scalpel® hemorrhoidectomy.(40–43) Although all studies indicate

that the harmonic scalpel is an effective alternative with a

simi-lar complication profile to more conventional methods, there is

inconsistency regarding the short term benefits such as

postop-erative pain across these studies Multiple randomized, controlled

trials evaluating LigaSure™ hemorrhoidectomy to conventional

techniques have been performed; (44–50) Most of these

stud-ies demonstrate a reduction in postoperative pain and operating

time when using the LigaSure™ A multicenter, prospective,

ran-domized study by Altomare et al showed significantly less pain

12 hours after defacation, lower analgesic requirements, and faster return to work and normal activity with no difference in early or late complications.(48) Both instruments have been shown to be a safe and effective alternative to conventional hemorrhoidectomy However, the added cost, conflicting short term outcomes, and lack of long term follow-up prelude recommendations for their routine use At the present time, conventional methods of exci-sional hemorrhoidectomy remain the “gold standard”

postoperative CoMpliCations

Regardless of the excisional technique used for treatment of advanced hemorrhoidal disease, the key to effective patient management is avoidance of postoperative complications

Pain

The anoderm has a rich supply of sensory nerves and pain arises from involvement of the anoderm below the dentate line Posthemorrhoidectomy pain is associated with reflex spasm of the urethral and anal sphincter muscles Spasm of these muscles leads

to difficulty voiding and urinary retention and difficulty with evac-uation and constipation Both of which are covered later From the patient’s perspective, pain is the most feared element of the pro-cedure A variety of analgesic regimens have been recommended, usually consisting of a combination of oral and parenteral nar-cotics.(51–55) Local anesthetic agents such as 0.5% bupivacaine solution may provide analgesia for up to 6–8 hours after surgery The use of ketorolac has demonstrated considerable efficacy in managing posthemorrhoidectomy pain.(51) Alternative adminis-tration routes for narcotics either by patch or subcutaneous pump have been successful in controlling pain, however due to the risk

of narcotic respiratory depression, administration by these routes can be risky in the outpatient setting.(53–55) The most appropri-ate regimen following outpatient hemorrhoidectomy appears to

be intraoperative use of ketorolac, sufficient doses of oral narcotic analgesics for home administration, and supplementation of the narcotics by an oral nonsteroidal medication

Urinary Retention

Urinary retention is a frequent postoperative complication follow-ing hemorrhoidectomy with an incidence from 1–52%.(16, 56–58)

A variety of strategies have been used to treat this problem

includ-ing parasympathomimetics, alpha-adrenergic blockinclud-ing agents, and

sitz baths.(59, 60) However, prevention seems to be the best strategy

by limiting perioperative fluid administration to 250 ml, avoiding

the use of spinal anesthesia and anal packing, and prescribing an

aggressive oral analgesic regimen.(56) Elderly men with obstructive

uropathy are at increased risk for urinary retention If

catheteriza-tion becomes necessary, intermittent catherizacatheteriza-tion under sterile

conditions is the option of choice Urologic consultation may be

sought for patients with persistent symptoms of bladder outflow obstruction

Hemorrhage

Early postoperative bleeding (<24 hours) occurs in approxi-mately 1% of cases and represents a technical error requir-ing return to the operatrequir-ing room for repair of the offendrequir-ing wound.(61) Occasionally bleeding may continue undetected, with blood accumulating in the capacious rectum The first

Figure 17.6 Stapled anoplasty (procedure for prolapse and hemorrhoids [PPH]) (A) Retracting anoscope and dilator inserted (B) Monofilament pursestring suture

(eight bites) placed using operating anoscope approximately 3–4 cm above anal verge (C) Stapler inserted through pursestring Pursestring suture tied and ends of suture manipulated through stapler (D) Retracting on suture pulls anorectal mucosa into stapler (E) Stapler closed and fired (F) Completed procedure.

(a)

(d)

(b)

(e)

(c)

(f)

sign of this complication may be pallor, tachycardia, and

hypo-tension This patient requires fluid resuscitation and a return

to the operating room for suture ligation or diathermy control

of the bleeding site

Bleeding from the staple line when using a PPH can be

con-trolled by oversewing the bleeding point of the staple line This is

less common with the second generation 33 mm hemorrhoidal

circular stapler (Ethicon endosurgery; PPH03) which has a shorter

stapler height

Delayed hemorrhage occurs in 0.5–4% of cases of excisional

hemorrhoidectomy and often occurs at 5–10 days postoperatively

(62–64) The etiology has been held to be early separation of the

ligated pedicle before adequate thrombosis in the feeding artery can

occur.(65) Hemorrhage in this situation is frequently significant and

requires some method for control of ongoing hemorrhage Options

include return to the operating room for suture ligation, or

tampon-ade at the beside by Foley catheter or anal packing.(66–68) The

out-come after control of secondary hemorrhage is generally good with

virtually no risk of recurrent bleeding It may be helpful to irrigate

out the distal colon and rectum at the time of intraoperative control

of hemorrhage to avoid confusion in the postoperative period

Constipation and Fecal Impaction

Fecal impaction is a distressing complication of excisional

hemo-rrhoidectomies Postoperative pain, the patient’s fear of pain

associated with defecation, and the constipating effects of

nar-cotics are contributing factors Hence, providing adequate

anal-gesia and patient reassurance are important Patients should be

instructed on the importance of adequate hydration Many

sur-geons also recommend bulking agents and/or laxatives (e.g.,

pol-yethylene glycol solution), and topical anesthetics before a bowel

movement to facilitate evacuation.(69) When fecal impaction

is identified, early, simple irrigating enemas may help clear the

anorectum of impacted feces If the impactions are soft, an oral

cleansing regime (17 gm of polyethelyene glycol solution in 4 oz

of water every 15–20 minutes until the impaction is cleared) may

be utilized.(70) In more severe cases, manual disimpaction under

conscious sedation or general anesthesia may be necessary

Infection

Infection of the urinary tract may result from either stasis of urine

or instrumentation of the urinary tract A 3% incidence has been

reported from one institution following hemorrhoidal surgery

(16) A urine culture should be obtained before administration of

appropriate antibiotics

The anoderm harbors an abundance of potentially pathologic

bacterial microorganisms Despite this, infective complications

after hemorrhoidectomy are infrequent Bacteremia and sepsis

have been documented after hemorrhoidectomy, but abscess

formation is rare unless a hematoma becomes infected Isolated

liver abscesses have been reported, and this very rare

complica-tion should be considered in patients with postoperative fever It

is usually currently identified by abdominal CT scan

Another potential infectious complication is postoperative

pel-vic sepsis This can occur after any anorectal procedure

includ-ing rubber band ligation and excisional hemorrhoidectomy

Classic findings include anorectal pain, fever, and difficulty

with urination A high index of suspicion is required as delay in diagnosis can have fatal consequences As described in chapter

18, patients with suspected pelvic sepsis require resuscitation, diagnostic evaluations (pelvic CT scans and/or anoscopic evalu-ation), and treatment (broad spectrum antibiotics and debride-ment of necrotic tissue)

Anal Stenosis

Anal stenosis results from excessive stripping of anal mucosa, which may leave inadequate bridges of anoderm for healing to occur without stenosis.(71) Secondary hemorrhoids should be managed with either submucosal hemorrhoidectomy or conserv-ative methods such as sclerotherapy or rubber band ligation at a subsequent visit In mild cases, stenosis may simply be a web that disappears with graduated anal dilatation in the office In more severe cases, surgical intervention may be required to relive ste-nosis Surgical correction may be accomplished by one of several reconstructive operations including skin and subcutaneous tissue flaps These flap techniques are discussed in chapter 20

Mucosal Ectropion (Whitehead Deformity)

Mucosal ectropion with the classic “Whitehead deformity”

is commonly seen after an incorrectly performed procedure described by Whitehead.(22) As described previously, the oper-ation entails making a circumferential incision at the level of the dentate line, elevating a flap of anal mucosa, and performing a submucosal hemorrhoidal excision Redundant mucosa is then excised, and the anal canal is reconstructed with sutures If the reconstruction does not relocate the dentate line in the correct location in the anal canal, anal mucosal will be located in the distal anal canal or perineum Persistent mucous discharge and perianal irritation may result Correction requires resection of the mislocated anal mucosa and reconstruction, which usually requires flaps

Fecal Incontinence

Incontinence of feces results chiefly from damage to the internal anal sphincter during hemorrhoidectomy.(72) The internal anal sphincter is a thin, whitish, smooth muscle composed of circular fibers located just beneath the anal mucosa It is almost always absent at the anal verge because its inferior limit is a few milli-meters proximal to it During surgery, the hemorrhoidal column should be lifted off the internal anal sphincter, which must be identified before excision of hemorrhoidal tissue It is important

to document the state of continence in patients before surgery Soiling and fecal leakage are the chief impairments of continence resulting from internal anal sphincter damage Treatment for soil-ing and leakage includes bulksoil-ing agents and slowsoil-ing agents (e.g., loperamide) and consideration of biofeedback therapy Attempts

to surgically repair damaged internal sphincter muscle have been disappointing

Anal Fistula

Fistula in ano is an uncommon complication of hemorrhoidec-tomy and is thought to occur more commonly after a closed pro-cedure.(73) The fistula is usually a simple submucosal tract that may be treated by simple unroofing

Anal Tags

Anal skin tags after hemorrhoidal excision are not uncommon

Usually these tags are edematous areas of anoderm that generally

resolve spontaneously some weeks after surgery Reassurance will

help allay patient’s concerns It the tags remain bothersome or are

associated with symptomatic pruritis, they can be excised in the

office using local anesthesia

speCial situations

Postpartum Hemorrhoids

Postpartum hemorrhoids that are refractory to conservative

measures may require surgical management Hemorrhoidectomy

in this setting is safe, has a low prevalence of complications, and

in many cases will minimize recovery time Proper patient

posi-tion (usually left lateral Sims) and good anesthetic techniques are

important As in other urgent hemorrhoidectomies, preservation

of as much anoderm as possible is also critical

Anorectal Varices

Unlike hemorrhoids, varices result from portal venous

hyperten-sion Differentiation from hemorrhoids is essential because

exci-sion of varices may result in venous bleeding that may be difficult

to control A history of anal bleeding in a cirrhotic patient should

arouse suspicion Varices may be present in the rectum, anal canal,

or anal verge.(74) Duplex Doppler ultrasonography of the

anorec-tum may confirm the diagnosis Active bleeding from varices will

usually require oversewing with a continuous suture technique

ConClusion

The management of symptomatic hemorrhoidal disease should

be directed at the symptom complex of the patient The

major-ity of these patients can be effectively treated by reducing strain

at defacation, correcting constipation, the use of any of a variety

of anal ointments For those patients with persistent symptoms,

either injection or banding of the internal hemorrhoids offers

predictably successful results Only a minority of patients should

require excisional hemorrhoidectomy by any of the described

techniques Stapled hemorrhoidopexy, Harmonic Scalpel®, and

LigaSure™ all offer safe and effective alternatives to the

tradi-tional open or closed excisional hemorrhoidectomy, however

more long-term data is needed to provide recommendations for

their routine use

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