Septic complications of hemorrhoidal banding

Rubber band ligation of symptomatic hemorrhoids: an old solution to an everyday problem

PURPOSE

The aim of this prospective study is to present the results of rubber band ligation (RBL) in 2635 consecutive patients with 2^nd, 3^rd, and 4^th degree symptomatic hemorrhoids, the pain risk factors, and the applicability of the method in patients with liver cirrhosis and portal hypertension.

METHODS

A total of 1256 patients with 2^nd, 1159 with 3^rd, and 220 with 4^th degree hemorrhoids were included in the study. Fifty-seven patients with hemorrhoids had liver cirrhosis and portal hypertension. RBL was performed using St Marks', McGinvey, and suction ligators. Single ligation was done in 178 patients, while 2457 patients had synchronous multiple ligations, in one (272), two (1289), and three (896 patients) sessions.

RESULTS

After the end of treatment, 86.8% of our patients were asymptomatic and 84.5% remained asymptomatic 2 years later. A total of 593 patients had complications. Thirty required hospitalization, while pain was the most frequent complication (16.16 %). Multiple banding, young age, male sex, and external hemorrhoids were pain risk factors. RBL proved to be safe in 57 patients with coagulation disorders due to cirrhosis. Symptomatic recurrence was detected in 327 out of 2110 patients (15.49%), with repeat RBL in 219 cases and surgery in 108 cases.

CONCLUSION

RBL is a safe, effective method for treating symptomatic 2^nd and 3^rd degree hemorrhoids. It can also be applied in selected cases of 4^th degree hemorrhoids and patients with cirrhosis and portal hypertension.

THE RUSSIAN ASSOCIATION OF COLOPROCTOLOGY CLINICAL GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF HEMORRHOIDS

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Conservative management of pelvic sepsis with severe shock and multiple organ dysfunction syndrome after rubber-band ligation of internal haemorrhoids: surgery is not the only option

Rubber-band ligation (RBL) is a safe and cost-effective approach to internal haemorrhoids. Potential side effects include pain, bleeding, urinary retention and occasionally pelvic sepsis and systemic inflammatory response syndrome (SIRS). At-risk patients are mainly those with immunocompromising conditions. Although aggressive surgical debridement or diverting colostomy appear to be obvious options when patients' life is threatened, their superiority to conservative measures has not been proven. We present the case of a 58-year-old female patient who presented 48 h after a RBL with pelvic pain, dysuria and leukocytosis. Her condition deteriorated rapidly that ventilator and inotropic support were required for a severe SIRS for almost 10 days. Laparoscopic exploration and imaging showed a rectosigmoiditis, ascites and superficial rectal necrosis with no transmural damage requiring an emergent surgery. Conservative management could possibly be a valid option in post-RBL pelvic sepsis even when severe associated multiple organ failure is present.

Rubber band ligation of hemorrhoids: A guide for complications

Rubber band ligation is one of the most important, cost-effective and commonly used treatments for internal hemorrhoids. Different technical approaches were developed mainly to improve efficacy and safety. The technique can be employed using an endoscope with forward-view or retroflexion or without an endoscope, using a suction elastic band ligator or a forceps ligator. Single or multiple ligations can be performed in a single session. Local anaesthetic after ligation can also be used to reduce the post-procedure pain. Mild bleeding, pain, vaso-vagal symptoms, slippage of bands, priapism, difficulty in urination, anal fissure, and chronic longitudinal ulcers are normally considered minor complications, more frequently encountered. Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention needing catheterization, pelvic sepsis and death are uncommon major complications. Mild pain after rubber band ligation is the most common complication with a high frequency in some studies. Secondary bleeding normally occurs 10 to 14 d after banding and patients taking anti-platelet and/or anti-coagulant medication have a higher risk, with some reports of massive life-threatening haemorrhage. Several infectious complications have also been reported including pelvic sepsis, Fournier's gangrene, liver abscesses, tetanus and bacterial endocarditis. To date, seven deaths due to these infectious complications were described. Early recognition and immediate treatment of complications are fundamental for a favourable prognosis.

New bipolar tissue ligator combines constant tissue compression and temperature guidance: histologic study and implications for treatment of hemorrhoids

Background

Several minimally invasive technologies are available to treat common soft tissue lesions including symptomatic hemorrhoids. The use of energy to deliver heat and coagulate target lesions is commonly practiced. This study compares the histologic effects produced on intestinal tissues by two energy-based systems which employ different approaches of heat delivery.

Methods

Two heat delivery systems were evaluated in vivo in a single porcine subject: infrared coagulator and bipolar tissue ligator utilizing constant tissue compression and temperature guidance. Eighteen treatment sites divided into three groups of six were assessed. Treatment site temperature was measured and the effects of thermal treatment in the mucosa, submucosa, submucosal vessels, and muscularis layer were scored. Lateral thermal spread beyond the energy application site was also assessed.

Results

Treatment site temperatures were much lower in the bipolar ligator group than in the infrared coagulator group. The mucosal and submucosal tissue changes observed in tissues treated with infrared energy and bipolar energy at 55°C were similar. Both the mucosal and submucosal tissue changes with bipolar energy at 50°C were significantly less.

Conclusion

Both devices achieved similar histologic results. However, the unique design of the bipolar ligator, which allows consistent capture, constant compression, and temperature monitoring of target tissue, accomplished the desired histologic changes with less muscular damage at much lower temperatures than the infrared coagulator. The use of bipolar ligation could offer clinical advantages such as reduced patient pain and a minimized chance of heat-related collateral tissue damage.

Treatment of the hemorrhoids and anal mucosal prolapse using elastic band ligature--early and long term results

THE AIM OF THE STUDY was to evaluate the results of the treatment of internal hemorrhoids and anal mucosal prolapse using elastic band ligation and to compare this method to chosen surgical procedures.

MATERIAL AND METHODS

The study included 648 patients (363 males and 285 females). 474 patients were treated using an elastic band ligature and 174 patients underwent surgical hemorrhoidectomy. The average age of the patients in both groups was similar--49 years. The treatment tolerance was evaluated in the prospective study group. The intensity and duration of pain was assessed on the first and second postoperative day using a Verbal Rating Scale.

RESULTS

86.5% of the patients were cured using Barron's procedure, success rate for second-degree hemorrhoids was 89% and for third degree--85.2%. Surgical hemorrhoidectomy was effective in 92% of patients. Early failure of elastic ligature was noted in 2.5% of patients. The recurrences of hemorrhoidal symptoms were observed in 11% of Barron's group and in 8% after hemorrhoidectomy. The intensity of pain was much higher among patients after surgical hemorrhoidectomy. The average of the pain score in the 4th hour was 0.3 for the elastic band ligation and 1.4 for the surgical treatment. In the 24th hour--0.2 and 1.7 respectively. Mean postoperative stay was 3.8 days.

CONCLUSIONS

Rubber band ligation is highly effective and well tolerated. Relatively minor pain following this procedure is found in only 9.5% of patients. The disadvantages of surgical hemorrhoidectomy are: important postoperative pain and long time of wound healing that impair the recovery to professional activity.

Long-term outcome and efficacy of endoscopic hemorrhoid ligation for symptomatic internal hemorrhoids

AIM: To assess the long-term outcome of endoscopic hemorrhoid ligation (EHL) for the treatment of symptomatic internal hemorrhoids.

METHODS: A total of 759 consecutive patients (415 males and 344 females) were enrolled. Clinical presentations were rectal bleeding (593 patients) and mucosal prolapse (166 patients). All patients received EHL at outpatient clinics. Hemorrhoid severity was classified by Goligher’s grading. The mean follow-up period was 55.4 mo (range, 45-92 mo).

RESULTS: The number of band ligations averaged 2.35 in the first session for bleeding and 2.69 for prolapsed patients. Bleeding was controlled in 587 (98.0%) patients, while prolapse was reduced in 137 (82.5%) patients. After treatment, 93 patients experienced anal pain and 48 patients had mild bleeding. Patient subjective satisfaction was 93.6%. Repeat treatment or surgery was performed if symptoms were not relieved in the first session. In the bleeding group, the recurrence rate was 3.7% (22 patients) at 1 year, and 6.6% and 13.0% at 2 and 5 years. In the prolapsed group, the recurrence rate was 3.0%, 9.6% and 16.9% at 1, 2 and 5 years, respectively.

CONCLUSION: EHL is an easy and well-tolerated procedure for the treatment of symptomatic internal hemorrhoids, with good long-term results.

Presentation and management of perirectal sepsis

Perirectal sepsis is a potentially severe complication which may follow minor anorectal intervention and be slow to be diagnosed and treated. We report the presentation and outcome of three patients with perirectal sepsis of differing aetiologies. Awareness of the possible diagnosis, urgent investigation with cross-sectional imaging and immediate treatment with broad-spectrum antibiotics is vital. However, radical surgical intervention may be necessary. This report highlights the importance of investigating patients with persistent pelvic pain after minor anorectal procedures or trauma and maintaining a high index of suspicion for this important complication.

Bacterial endocarditis following rubber band ligation in a patient with a ventricular septal defect: report of a case and guideline analysis

Rubber band ligation is a common option used to treat symptomatic internal hemorrhoids. Severe complications such as pelvic sepsis are a rare occurrence. We report a case of endocarditis leading to septic pulmonary and renal emboli following single-quadrant rubber band ligation. The patient had a known ventricular septal defect and developed low back pain and fever after ligation of a right anterior internal hemorrhoid. He was found to have septic pulmonary emboli, a renal wedge septic infarct, and a large vegetation on his membranous ventricular septal defect requiring operative intervention. Before this report, rubber band ligation has not been associated with endocarditis. According to several guidelines, this patient did not require antibiotic prophylaxis. It is unclear whether prophylaxis could have prevented this complication. Surgeons utilizing rubber band ligation need to be familiar with all potential complications.

Life-threatening sepsis following treatment for haemorrhoids: a systematic review

INTRODUCTION

Haemorrhoids are a common complaint with estimates suggesting a prevalence of 4% of the adult population. Treatments such as rubber band ligation (RBL), sclerotherapy and excisional surgery have been in use for many years, and recently stapled haemorrhoidopexy, or procedure for prolapsing haemorrhoids (PPH) has gained acceptance. However, there have been consistent reports of severe sepsis, including a number of deaths. The purpose of this review was to assess the scale of the problem, and identify any predisposing factors, common presenting features, and treatment options in those who suffer these complications.

RESULTS

Twenty-nine papers were identified, reporting 38 patients. Of these, 17 had undergone RBL, three had sclerotherapy, one had cryotherapy, 10 had excisional surgery and seven had PPH. Ten died as a result of their sepsis. The cases included 16 with perineal sepsis, seven with retroperitoneal gas and oedema, and six with liver abscesses. Common presenting features were urinary difficulties, fever, severe pain, septic shock and leucocytosis. Most were managed by means of surgery, although a minority survived having received conservative therapy. With the exception of two patients (one of whom was human immunodeficiency virus positive and the other had a drug-induced agranulocytosis) all were well prior to surgery.

CONCLUSIONS

Although extremely uncommon, severe sepsis does occur post-treatment for haemorrhoids and all surgeons who treat such patients should be aware of the potential complications and alert to their presenting features. Early presentation without evidence of tissue necrosis may be managed conservatively, although most cases are managed by means of surgery.

Stapled hemorrhoidopexy: the argument for usage

Stapled hemorrhoidopexy is a new procedure for the treatment of symptomatic internal hemorrhoids. Experience and prospective trials are helping to define this procedure's role. Published data confirm that stapled hemorrhoidopexy offers similar control of symptoms with the benefits of reduced postoperative pain when compared with excisional techniques. Reduction in pain is the most significant benefit of this operation. Clearly, the cost of the stapling device exceeds the cost of the sutures required to perform an excisional hemorrhoidectomy. Patients should undergo medical therapy and rubber band ligation first; however, patients being considered for excisional hemorrhoidectomy should be offered stapled hemorrhoidectomy as a less painful alternative.

Infrared coagulation: a preferred option in treating early hemorrhoids

BACKGROUND: The ideal therapy for hemorrhoids is always debated. For early grades of the disease, many different modalities of treatment have been proposed. Some are effective but are more painful, others are less painful but their efficacy is not assured on long term. Infrared photocoagulation has emerged as a new addition to the list. In this procedure, the tissue is coagulated by infrared radiation. During treatment, mechanical pressure and radiation energy are applied simultaneously to ablate the blood supply to the hemorrhoidal mass. METHODS: In the present retrospective study, the effect of infrared coagulation on patients with early grades of hemorrhoids is described. In a separate study, a comparison is made between Infrared coagulation and rubber band ligation in terms of their effectiveness and discomfort. RESULTS: 212 patients were treated by infrared coagulation and were followed up for a period of 18 months. Only 28 patients had persistence or recurrence of bleeding. Overall ratio of comfort and patient satisfaction from pain and bleeding was quite satisfactory. The comparative study showed that though rubber band ligation is more effective, it is a more painful procedure. CONCLUSION: These studies shows that Infrared coagulation for hemorrhoids in early stages could prove to be a easy and effective alternative to conventional methods as it is quick, less painful and safe. The procedure can be repeated in case of recurrence and should be considered as the first choice in early hemorrhoids.

Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids

BACKGROUND

This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of patients with symptoms caused by internal hemorrhoids.

METHODS

A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients). The severity of the hemorrhoids was classified by using the grading system of Goligher.

RESULTS

All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8 to 24 months). The mean number of band ligations per session was 2.86. The mean number of treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients (95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered uneventfully.

CONCLUSIONS

Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for patients with symptoms caused by internal hemorrhoids.

Infrared coagulation versus rubber band ligation in early stage hemorrhoids

The ideal therapy for early stages of hemorrhoids is always debated. Some are more effective but are more painful, others are less painful but their efficacy is also lower. Thus, comfort or efficacy is a major concern. In the present randomized study, a comparison is made between infrared coagulation and rubber band ligation in terms of effectiveness and discomfort. One hundred patients with second degree bleeding piles were randomized prospectively to either rubber band ligation (N = 54) or infrared coagulation (N = 46). Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate. The mean age was 38 years (range 19-68 years). The mean duration of disease was 17.5 months (range 12 to 34 months). The number of male patients was double that of females. Postoperative pain during the first week was more intense in the band ligation group (2-5 vs 0-3 on a visual analogue scale). Post-defecation pain was more intense with band ligation and so was rectal tenesmus (P = 0.0059). The patients in the infrared coagulation group resumed their duties earlier (2 vs 4 days, P = 0.03), but also had a higher recurrence or failure rate (P = 0.03). Thus, we conclude that band ligation, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort to the patient. As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered to be a suitable alternative office procedure for the treatment of early stage hemorrhoids.

Prospective randomized study of bacteraemia in diathermy and stapled haemorrhoidectomy

BACKGROUND

The incidence and consequences of bacteraemia associated with diathermy and stapled haemorrhoidectomy have not been studied previously.

METHODS

Two hundred and five healthy patients randomized to stapled haemorrhoidectomy or diathermy haemorrhoidectomy had perioperative blood cultures taken. The clinical sequelae of bacteraemia and complications of surgery were assessed prospectively.

RESULTS

Six patients were excluded for protocol violations. Eleven (11 per cent) of 101 patients with stapled and five (5 per cent) of 98 who had diathermy haemorrhoidectomy had positive blood cultures for organisms after haemorrhoidectomy, predominantly anaerobes commonly found within the bacterial flora of the anorectum (P = 0.19). Transient postoperative pyrexia in several patients did not correlate with detected bacteraemia and settled spontaneously without treatment. There were no serious complications from either operative technique, and no clinical consequences from proven bacteraemia.

CONCLUSION

Transient bacteraemia may complicate surgical haemorrhoidectomy but has no serious clinical consequences for healthy adults.

Septic complications after treatment of haemorrhoids

BACKGROUND

Recent reports of serious sepsis following stapled haemorrhoidectomy have raised concerns about the appropriate treatment of haemorrhoidal disease.

METHODS

A Medline search was undertaken for reports of sepsis following the commonly practised conservative and surgical treatments of haemorrhoids.

RESULTS

Published accounts of significant septic complications after injection sclerotherapy, rubber-band ligation, cryotherapy, open and closed haemorrhoidectomy, and stapled haemorrhoidectomy are discussed. This is supplemented by the authors' own experiences of stapled haemorrhoidectomy.

CONCLUSION

Septic complications following both conservative and surgical treatment of haemorrhoids are rare but may be catastrophic. Immunological compromise poses an additional risk for many treatment modalities. The technique of stapled haemorrhoidectomy should be learned diligently to avoid septic complications.

Retroflexed endoscopic band ligation of bleeding internal hemorrhoids

BACKGROUND

Elastic band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids, stages II-III. Usually, one or two bands are placed at a single session by using rigid instruments. The aim of this study was to assess the feasibility, tolerability, safety, and efficacy of multiple band ligation of internal hemorrhoids performed in one session by using a flexible endoscope with an attached band ligation device in the retroflexed position.

METHODS

Eighty-three patients with chronically bleeding and/or prolapsing internal hemorrhoids were treated by retroflexed endoscopic band ligation. From 1 to 6 bands were placed in a single session. Bands were targeted at the apex and proximal body of the internal hemorrhoid so that final band placement was entirely proximal to the dentate line. Malpositioned bands were removed by using a novel method. Patients were followed prospectively to assess tolerance, complications, and efficacy. Retreatment was offered if the desired result was not achieved.

RESULTS

A mean of 3.0 (SD 1.2) bands (range 1-6) were placed in a single session. Five percent of bands were malpositioned and removed. Patients were followed for 26 (17) months (range 1-52 months). An excellent result was achieved in 80% of patients with stage II hemorrhoids. Patients with stage II hemorrhoids were more likely to have an excellent result compared with patients with stage III hemorrhoids (80% vs. 54%, p < 0.01). Retroflexed endoscopic band ligation was well tolerated overall. The rate of major, nonfatal complications was 4%.

CONCLUSIONS

Retroflexed endoscopic band ligation is a feasible, well-tolerated, effective, and safe for treatment of bleeding stage II internal hemorrhoids. A novel method of endoscopic band removal is described.

Hepatic abscesses complicating injection sclerotherapy of haemorrhoids

We report the case of a 50-year-old man who developed a febrile illness four days after injection sclerotherapy of his haemorrhoids. The patient increasingly became unwell and was eventually found to have multiple hepatic abscesses. He made a complete recovery with antibiotic therapy. The importance of educating both patients and doctors about this complication is emphasized.

Life threatening pelvic sepsis after stapled haemorrhoidectomy

We describe a case of severe retroperitoneal sepsis after stapled haemorrhoidectomy. The operation seemed to be technically satisfactory, and we suggest that routine antibiotic prophylaxis may be indicated with this procedure.

Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case

We present a case of life-threatening retroperitoneal sepsis after injection sclerotherapy for first-degree hemorrhoids.

Anorectal disorders

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Primary care office management of perianal and anal disease

Benign anorectal processes, hemorrhoids, fissures, abscesses, fistulas, and infections, as well as some functional disorders, are common. They generate significant patient discomfort and disability. Appropriate recognition of these processes allows for outpatient, office-based intervention. With the techniques and management described in this article, many patients' symptoms can be ameliorated expeditiously.

Randomized, prospective trial of direct current versus bipolar electrocoagulation for bleeding internal hemorrhoids

Fifty patients with bleeding internal hemorrhoids unresponsive to 6 weeks of standard medical therapy were randomly assigned to receive treatment with direct current or bipolar electrocoagulation. Treatment groups were similar in bleeding severity and internal hemorrhoid grade. Treatment sessions were significantly longer for direct current electrocoagulation (8.8 +/- 0.2 minutes) than for bipolar electrocoagulation (0.1 +/- 0.03 minutes) (p < 0.001). When compared to the bipolar electrocoagulation group, direct current electrocoagulation patients had more procedural pain that terminated therapy (5 of 25 patients [20%] versus 0 of 25 [0%], for a difference of 20% [95% confidence interval, 4% to 36%]; p = 0.05) and prolonged pain after the procedure (4 of 25 patients [16%] versus 1 of 25 [4%], for a difference of 12% [95% confidence interval, -4% to 28%]; p = 0.35). However, more post-treatment rectal ulcerations were seen in the bipolar electrocoagulation-treated group (6 of 25 patients [24%] versus 1 of 25 [4%], for a difference of 20% [95% confidence interval, 2% to 38%]; p = 0.10). Treatment groups did not differ in number of treatment sessions or months of follow-up. The rates of success, defined as obliteration of the hemorrhoids or cessation of bleeding with reduction of the hemorrhoids to grade 1 or less, for the direct current electrocoagulation and the bipolar electrocoagulation groups were 88% and 92%, respectively. Failures in the direct current electrocoagulation group were uncontrollable bleeding (n = 1) and refusal to continue therapy because of pain (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)

Office management of common anorectal problems

Common anorectal problems can often be treated in the office setting. Hemorrhoids are usually relieved with use of bulk laxatives or stool softeners; if this fails, coagulation or rubber band ligation may be effective. Surgical therapy is still preferred for third- and fourth-degree hemorrhoids. Perirectal and perianal abscesses are treated by drainage, but in up to 30% of cases a fistula occurs following treatment. Surgical evaluation is appropriate when a fistula is suspected. Acute anal fissures often heal with conservative management; sphincterotomy may be needed for chronic fissures. Anal warts tend to recur and require several treatment sessions with use of ablative techniques.

Hemorrhoidectomy with lasers and other contemporary modalities

Hemorrhoids should be classified so that the treatment can be individualized. Minor or asymptomatic hemorrhoids usually do not require any treatment. Diet modification is a useful adjunct in all degrees of hemorrhoids. Fixation procedures may be employed in the office for first-, second-, and minor third-degree hemorrhoids. These techniques are valuable in elderly and poor-risk patients. Excisions may be performed by standard instruments or lasers with good results. These techniques may be employed with local anesthesia and in an outpatient setting. Lasers may be effective as either a fixation device or an excisional tool. The problem is cost and maintenance of the equipment and the cost of the disposable apparatus. If the equipment is already available or can be shared for multidisciplinary use, hemorrhoidectomy can be accomplished in a cost-effective manner with excellent results.