Das Corpus cavernosum recti-die Grundlage der inneren H�morrhoiden

[Operations for hemorrhoids: indications and techniques]

Haemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000-50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Haemorrhoids - a collagen disease?

OBJECTIVE

The cause of haemorrhoidal disease is unknown, epidemiological data and histopathological findings support the hypothesis that reduced connective tissue stability is associated with the incidence of haemorrhoids. Therefore the aim of this study was to analyse the quantity and quality of collagen formation in the corpus cavernosum recti in patients with III°/IV° haemorrhoids in comparison with persons without haemorrhoids.

METHOD

Haemorrhoidectomy specimens of 31 patients with III°/IV° haemorrhoids were examined. The specimens of 20 persons who died a natural death and who had no haemorrhoidal disease served as the controls. The amount of collagen was estimated photometrically by calculating the collagen/protein ratio. The collagen I/III ratio served as parameter for the quality of collagen formation and was calculated using cross polarization spectroscopy.

RESULTS

Patients with haemorrhoids had a significantly reduced collagen/protein ratio (42.2 ± 16.2μg/mg vs 72.5±31.0μg/mg; P= 0.02) and a significantly reduced collagen I/III ratio (2.0±0.1 vs 4.6±0.3; P<0.001) compared with persons without haemorrhoidal disease. There was no correlation with patients' age or gender.

CONCLUSIONS

 There is a fundamental disorder of collagen metabolism in patients with haemorrhoidal disease. It remains unclear whether this is due to exogenous or endogenous influences.

Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy

OBJECTIVE

The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures.

METHOD

The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%).

RESULTS

More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied.

CONCLUSIONS

DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.

Anatomical branches of the superior rectal artery in the distal rectum

OBJECTIVE

The aim of this experimental study was to study the arterial supply of the corpus cavernosum recti in the inner wall of the distal rectum in relation to haemorrhoidal ligation therapy.

METHOD

In 10 nonfixed human cadavers, the arterial vasculature of the rectum was studied using the Araldite casting method. Subsequently, the specimens were treated with methylbenzoate in order to obtain semitransparent specimens in which the corpus cavernosum recti could be studied.

RESULTS

Specimens were obtained permitting study of the arterial vasculature of the rectum and corpus cavernosum recti at all levels. The superior rectal artery was found to supply the corpus cavernosum recti which consisted of a variable number of equally spaced twisting arteries.

CONCLUSION

The distal rectum is supplied by the superior rectal artery. The supplying arteries of the corpus cavernosum recti are not confined to the strict locations described in the literature. This finding is of importance in surgical treatment of haemorrhoidal disease.

Transanal hemorrhoidal dearterialization: a systematic review

PURPOSE

Transanal hemorrhoidal dearterialization consists of a Doppler-guided ligation of the distal branches of the rectal arteries. The aim of this review is to assess the current evidence on dearterialization, establish the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations.

METHODS

All published studies on dearterialization without language restrictions were reviewed systematically. Primary outcome measures were postoperative pain and hemorrhoidal recurrences.

RESULTS

Seventeen articles including a total of 1,996 patients were analyzed. In general, the quality of the studies was low. Operating time ranged between 5 and 50 minutes. Hospital stay was one day for most patients, whereas the return to normal activities was between two and three days in most cases. Postoperative pain was present in 18.5% of patients. Three patients experienced significant postoperative hemorrhages. There were no other major complications. The overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding, and 4.7% for pain at defecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding, and 8.7% for pain at defecation. When reported as a function of the hemorrhoidal grade, the recurrence rate was higher for fourth-degree hemorrhoids (range, 11.1-59.3%).

CONCLUSION

Transanal hemorrhoidal dearterialization appears to be a potential treatment option for second-degree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

[Stage-adjusted treatment for haemorrhoidal disease]

Haemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is eradication of symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of the disease: First-degree haemorrhoids are treated conservatively. In addition to high fibre diet, sclerotherapy is used. Haemorrhoids of the 2nd degree prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Third-degree haemorrhoids that prolapse during defecation have to be digitally reduced. The majority of these patients need surgery. For segmental disorders haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease Stapler haemorrhoidopexy is now the procedure of choice. Using a classification orientated therapeutical regime orientated to the classification of haemorrhoidal disease offers high healing rates with a low rate of complications and recurrences.

Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease

BACKGROUND

Transanal haemorrhoidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorrhoidal plexus. The aim of this study was to assess the long-term efficacy of this treatment.

METHODS

The procedure was carried out using a proctoscope with a Doppler probe. The terminal branches were located with Doppler and then sutured.

RESULTS

From January 2000 to May 2006, we performed THD in 330 patients (180 men; mean age, 52.4 years), including 138 second-degree, 162 third-degree and 30 fourth-degree haemorrhoids. There were 23 postoperative complications (7 cases of bleeding, 5 thrombosed piles, 4 rectal haematomas, 2 anal fissures, 2 cases of dysuria, 1 of haematuria and 2 needle ruptures). The mean postoperative pain score was 1.32 on a visual analog scale. 219 patients were followed for a mean of 46 months (range, 22-79), including 100 patients with second-degree, 104 with third-degree and 15 with fourth-degree haemorrhoids. The operation completely resolved the symptoms in 132 patients (92.5%) with preoperative bleeding and in 110 patients (92%) with preoperative prolapse.

CONCLUSIONS

The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

Therapie des Hämorrhoidalleidens

Hemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is freedom from symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of disease: haemorrhoids 1 are treated conservatively. In addition to high-fibre diet, sclerotherapy is used. Haemorrhoids 2 prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Haemorrhoids 3 that prolapse during defecation have to be digitally reduced, and the majority need surgery. For segmental disorders, haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease, Stapler hemorrhoidopexy is now the procedure of choice. Using a therapeutic regime according to the hemorrhoidal disease classification offers high healing rates and low rates of complications and recurrence.

The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids

BACKGROUND

The hemorrhoidal artery ligation has been used for submucosal ligation of hemorrhoidal arteries by means of an ultrasonographic transducer since 1995. The success of this technique depends on the submucosal course of these arteries. Our investigation deals with branches of the superior rectal artery which pierce the rectal wall where they cannot be reached by this method.

METHODS

The branching patterns were investigated by means of 5 macroscopic preparations of adult pelves, histological section series of 35 fetal and 3 adult pelves impregnated in epoxy-resin, and transperineal color Doppler ultrasound of 7 proctologic patients and 28 volunteers.

RESULTS

Additional branches of the superior rectal artery coursing in outer layers of the rectal wall were shown entering the rectal wall just above the levator ani muscle to supply the internal hemorrhoidal plexus (corpus cavernosum recti).

CONCLUSIONS

The terminal course of the branches of the superior rectal artery is not only applied to the rectal submucosa. We have shown that additional branches may be detected by ultrasonography and should be taken into account by the operating surgeon.

[Vascular anatomy of the anorectal transition]

Based on selective dye injection studies, the regions of supply of the 3 rectal arteries have been defined. The cranial portion of the rectum receives its blood supply from the superior rectal artery, the inferior rectal artery supplies the entire rectal wall in a fan-shaped configuration up to the dentate line. A wedge-shaped portion of the muscularis in the proximal distribution of the inferior rectal artery receives a relatively reduced supply. The middle rectal artery can supply a variable portion of the muscularis which is usually supplied by the distal superior rectal artery. Intramural anastomoses between these regions exist only between the superior and inferior rectal arteries at the level of the dentate line in the submucosa.

[Results of treatment following corrective surgery of Whitehead anus]

For the corrective surgery of a Whitehead anus an uncomplicated operative treatment was developed, which up to now has been performed on 34 patients. The operative technique and the late results obtained are presented.

[The hypoganglionic and aganglionic high pressure zone of the anterior esophagus (the esophageal opening) and its special blood supply (angiomuscular sphincter closure]

At the mouth of the oesophagus there is an aganglionic zone similar to that in the anorectal organ of continence. This is part of the system of permanent closure. Since the musculature at the oesophageal entrance is arranged in a screw-like fashion the aganglionic zone lies obliquely to the longitudinal axis of the oesophagus. Closure at the oesophageal entrance is further supported by a kind of corpus cavernosum similar to that in the rectum. In this pharyngeal corpus cavernosum blood is drained between the muscular fibres and their contraction prevents its drainage, thus facilitating the closure of the musculature. The constrictor pharyngeus muscle takes a similar course as does the puborectalis which leads to a bend in the anal canal. Thus also at the entrance to the gastrointestinal tract an arterial angiomuscular system of closure exists in the center of which an aganglionic segment is conspicuous.

[Functional anatomy of the anorectal sphincter]

Sensory component, reflexes and motor components are responsible for anorectal continence. The most important factors are the extraperitoneal part of the rectum, the M.m. sphincter ani internus and externus, the levator ani muscles and the corpus cavernosum recti. The diagnostic of anal incontinence is usually evident from history and physical examination. Additionally intraluminal pressure recordings and electrical measurements are helpful.

What are hemorrhoids and what is their relationship to the portal venous system?

New concepts of the pathophysiology of hemorrhoids have been defined during the past eight or more years, yet medical education at the undergraduate and graduate levels has not kept pace with the newer concepts. The traditional concepts are being perpetuated in all medical dictionaries and in most textbooks of surgery, medicine, anatomy, and pathology. Hemorrhoids are not varicosities, but rather are vascular cushions composed of arterioles, venules, and arteriolar-venular communications which slide down, become congested and enlarged, and bleed. The pathogenesis begins in the fibromuscular supporting layer in the submucosa, above the vascular cushions. The bright red bleeding, which accompanies hemorrhoidal disease, is arteriolar in origin. Portal hypertension has been shown not to be the cause of hemorrhoids. The use of rubber bands, sclerosing solutions, cryosurgery, or the infra-red beam in the early stages of hemorrhoidal disease can take care of prolapse and bleeding and can prevent the development of third and fourth degree hemorrhoids.