Hemorredectomy: Evaluation of Techniques and Satisfaction
Keywords:
milligan-morrhoidectomy, ligation of the hemorrhoidal artery, and rectoanal repair.Abstract
A number of surgical procedures have been suggested as potential treatments for hemorrhoidal disease (HD). Still up for discussion, however, is which method is best suited to deal with certain situations. The researchers in this study set out to see how the Milligan-Morgan (MM) hemorrhoidectomy stacked up against the HAL-RAR method. We performed a retrospective study on the database of patients who had HD surgery in our department, which had been prospectively gathered. The MM group and the HAL-RAR group were the two sets of patients that were studied. Both the recurrence rate and the patient satisfaction rate were considered primary end goals. For numerical variables, we used the unpaired t test, and for categorical variables, we utilized the x2 test.
The outcomes are: A total of sixty-two individuals were selected for hemorrhoidectomy, with the option to undergo HAL-RAR or MM. Four (4) patients were not included in the analysis due to not being followed up. Of the remaining 58 patients, 35 (27 men and 8 females) with a median age of 47 (range 18-69) were part of the HAL-RAR group, and 22 (nineteen males and three females) with a median age of 52 (range 32-71) were a part of the MM group. Out of a total of 72 months of followup, 12 occurred in the HAL-RAR group and 4 in the MM group at a median follow-up of 41 months (p 0.229). In the HAL-RAR group, the average period between the surgery and recurrence was 14.1 ± 9.74 months, whereas in the MM group, it was 21 ± 13.34 months. Subjected to MM, patients whose primary symptoms of HD were itching, pain, or discomfort had considerably fewer recurrences (p 0.0354) and reported much higher satisfaction ratings (6.72 ± 2.15 vs. 8.11 ± 1.99—p 0.0111). Patients in the HAL-RAR group reported substantially higher levels of satisfaction (8.59 ± 1.88 vs. 6.45 ± 2.70— p 0.0013) when bleeding was the presenting symptom in the subgroup of patients. Final thoughts: Compared to HAL-RAR, MM resulted in lower recurrence rates and higher patient satisfaction ratings in HD patients whose first symptoms were pain, itching, or discomfort. Compared to MM, HAL-RAR resulted in higher patient satisfaction and equal recurrence rates in individuals whose bleeding was the primary presenting symptom of HD.
References
Gallo G, Sacco R, Sammarco G. Epidemiology of Hemorrhoidal Disease. In: Ratto C, Parello A, Litta F, editors. Hemorrhoids Coloproctology, vol. 2. Cham: Springer; 2018.
Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical manage- ment. World J Gastroenterol. 2012;18(17):2009–17. https://doi.org/10.3748/ wjg.v18.i17.2009.
Goenka MK, Kochhar R, Nagi B, Mehta SK. Rectosigmoid varices and other mucosal changes in patients with portal hypertension. Am J Gastroenterol. 1991;86:1185–9.
Thomson WH. The nature of haemorrhoids. Br J Surg. 1975;62:542–52.
Sun WM, Peck RJ, Shorthouse AJ, Read NW. Haemorrhoids are associated not with hypertrophy of the internal anal sphincter, but with hypertension of the anal cushions. Br J Surg. 1992;79:592–4.
Ho YH, Seow-Choen F, Goh HS. Haemorrhoidectomy and disordered rectal and anal physiology in patients with prolapsed haemorrhoids. Br J Surg. 1995;82:596–8.
Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B, Engelhardt V, Lametschwandtner A, Wienert V, Böhler U, Margreiter R, Fritsch H. Revised morphology and hemodynamics of the anorectal vascular plexus: impact on the course of hemorrhoidal disease. Int J Colorectal Dis. 2009;24:105–13.
American Gastroenterological Association medical position state- ment. Diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126:1461–2.
Goligher JC. Haemorrhoids or piles. In: Goligher JC, Duthie HL, Nixon HH, editors. Surgery of the anus, rectum and colon. 4th ed. London: Baillière Tindall; 1980. p. 96.
Gallo G, Martellucci J, Sturiale A, Clerico G, Milito G, Marino F, Cocorullo G, Giordano P, Mistrangelo M, Trompetto M. Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease. Tech Coloproctol. 2020;24(2):145–64. https://doi.org/ 10.1007/s10151-020-02149-1.
van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, Higuero T, Muris JWM, Breukink SO. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020;22(6):650–62. https://doi. org/10.1111/codi.14975.
Gallo G, Pietroletti R, Novelli E, Sturiale A, Tutino R, Lobascio P, Laforgia R, Moggia E, Pozzo M, Roveroni M, Bianco V, Luc AR, Giuliani A, Diaco E, Naldini G, Trompetto M, Perinotti R, Sammarco G. A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLERO- FOAM). Tech Coloproctol. 2022;26(8):627–36.
https://doi.org/10.1007/ s10151-022-02609-w.
Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284–92.
https://doi.org/10.1097/DCR.0000000000001030.
Similis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effec- tiveness of surfigal treatment for haemorrhoids. Br J Surg. 2015;102:1603–18.
De Nardi P, Tamburini AM, Gazzetta PG, Lemma M, Pascariello A, Asteria CR. Hemorrhoid laser procedure for second- and third-degree hemor- rhoids: results from a multicenter prospective study. Tech Coloproctol. 2016;20(7):455–9.
https://doi.org/10.1007/s10151-016-1479-6.
Ram E, Bachan GR, Goldes Y, Joubran S, Rath-Wolfson L. Modified Doppler- guided laser procedure for the treatment of sec-ond- and third-degree hemorrhoids. Laser Ther. 2018;27:137–42.
Giamundo P, De Angelis M, Mereu A. Hemorrhoid laser procedure with suture-pexy (HeLPexx): a novel effective procedure to treat hemorrhoidal disease. Tech Coloproctol. 2020;24(2):199–205. https://doi.org/10.1007/ s10151-020-02152-6.
Fitz-Henry J. The ASA classification and peri-operative risk. Ann R Coll Surg Engl. 2011;93:185–7. https://doi.org/10.1308/147870811X565070.
Hoyuela C, Carvajal F, Juvany M, Troyano D, Trias M, Martrat A, Ardid J, Obiols J. HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a pro- spective study after two-years follow-up. Int J Surg. 2016;28:39–44. https:// doi.org/10.1016/j.ijsu.2016.02.030.
Milligan ETC, Morgan CN. Surgical anatomy of the anal canal andoperative treatment of haemorrhoids. Lancet. 1937;2:1119–24.
Altomare DF, Roveran A, Pecorella G, Gaj F, Stortini E. The treatment of hemorrhoids: guidelines of the Italian Society of Colorectal Surgery. Tech Coloproctol. 2006;10(3):181–6.
Sobrado Júnior CW, de Almeida Obregon C, da Silva e Sousa Júnior AH, Sobrado LF, Nahas SC, Cecconello I. A new classification for hemorrhoidal disease: the creation of the “BPRST” staging and its application in clinical practice. Ann Coloproctol. 2020;36(4):249–55.
Rubbini M, Ascanelli S. Classification and guidelines of hemorrhoidal dis- ease: present and future. World J Gastrointest Surg. 2019;11(3):117–21.
Karkalemis K, Chalkias PL, Kasouli A, Chatzaki E, Papanikolaou S, Dedemadi G. Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease. Langenbecks Arch Surg. 2021;406(7):2489–95. https://doi.org/10.1007/s00423-02102190-0.
Scheyer M, Antonietti E, Rollinger G, Lancee S, Pokorny H. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol. 2015;19(1):5–9. https://doi.org/ 10.1007/s10151-014-1246-5.
Carvajal López F, Hoyuela Alonso C, Juvany Gómez M, Troyano Escribano D, Trias Bisbal MA, Martrat Macià A, Ardid BJ. Prospective randomized trial comparing HAL-RAR versus excisional hemorrhoidectomy: postoperative pain, clinical outcomes, and quality of life.
Surg Innov. 2019;26(3):328–36. https://doi.org/10.1177/1553350618822644.
Brown SR, Tiernan JP, Watson AJM, Biggs K, Shephard N, Wailoo AJ, Bradburn M, Alshreef A, Hind D, HubBLe Study team. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second- degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet. 2016;388(10042):356–64. https://doi. org/10.1016/S0140-6736(16)305
