A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

Devices for the endoscopic treatment of hemorrhoids

Multiple endoscopic methods are available to treat symptomatic internal hemorrhoids. Because of its low cost, ease of use, low rate of adverse events, and relative effectiveness, RBL is currently the most widely used technique.

Optimal treatment of symptomatic hemorrhoids

Hemorrhoids are the most common anorectal complaint, and approximately 10 to 20 percent of patients with symptomatic hemorrhoids require surgery. Symptoms of hemorrhoids, such as painless rectal bleeding, tissue protrusion and mucous discharge, vary. The traditional therapeutic strategies of medicine include surgical, as well as non-surgical, treatment. To alleviate symptoms caused by hemorrhoids, oral treatments, such as fiber, suppositories and Sitz baths have been applied to patients. Other non-surgical treatments, such as infrared photocoagulation, injection sclerotherapy and rubber band ligation have been used to fixate the hemorrhoid's cushion. If non-surgical treatment has no effect, surgical treatments, such as a hemorrhoidectomy, procedure for prolapsed hemorrhoids, and transanal hemorrhoidal dearterialization are used.

Hemorrhoids

Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm. Symptomatic hemorrhoidal tissues located above the dentate line are referred to as internal hemorrhoids and produce bleeding and prolapse. Thrombosis in external hemorrhoids results in painful swelling. Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation. Internal hemorrhoids that fail to respond to these measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy, either open or closed. A stapled hemorrhoidopexy treats symptomatic internal hemorrhoids and should be employed with care and only after thorough training of the surgeon because of the risk of rare, severe complications. The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon.

Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids

OBJECTIVES

Our purpose was to compare the efficacy, complications, success rate, recurrence rate at 1 year, and crossovers of rubber band ligation (RBL) with those of bipolar electrocoagulation (BPEC) treatment for chronically bleeding internal hemorrhoids.

METHODS

A total of 45 patients of mean age 51.5 years, who had rectal bleeding from grade II or III hemorrhoids and in whom intensive medical therapy failed, were randomized in a prospective study comparing RBL with BPEC. Treatment failure was predefined as continued bleeding, occurrence of a major complication, or failure to reduce the size of all internal hemorrhoidal segments to grade I in < or =3 treatments. Patients were followed up for 1 year.

RESULTS

With similar patients, rectal bleeding and other symptoms were controlled with significantly fewer treatments of RBL than of BPEC (2.3+/-0.2 vs. 3.8+/-0.4, P<0.05), and RBL had a significantly higher success rate (92% vs. 62%, P<0.05). RBL had more cases of severe pain during treatment (8% vs. 0%, P<0.05), but significantly fewer failures and crossovers (8% vs. 38%). Symptomatic recurrence at 1 year was 10% RBL and 15% BPEC.

CONCLUSIONS

For patients with chronically bleeding grade II or III internal hemorrhoids that are unresponsive to medical therapy, safety and complication rates of banding and BPEC were similar. The success rate was significantly higher with RBL than with BPEC. Symptom recurrence rates at 1 year were similar.

Evidence based treatment of hemorrhoids

A number of different hemorrhoids' treatment modalities were introduced and discussed during last two decades. Different level of evidence supports one or another approach and new data emerge constantly. Decision to apply particular method of treatment force clinicians to make thorough judgment. The article presents the newest data about different aspects of hemorrhoids management focusing on proof of efficacy.

Hemorrhoids and fissure in ano

Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.

Prospective, randomized, controlled, observer-blinded trial of combined infrared photocoagulation and micronized purified flavonoid fraction versus each alone for the treatment of hemorrhoidal disease

BACKGROUND

Infrared photocoagulation (IRP) is commonly used in the treatment of hemorrhoids, but rectal bleeding can persist after this procedure. Adjuvant therapy may thus be considered for more definitive control of symptoms, particularly bleeding.

OBJECTIVE

The goal of this study was to compare the efficacy of a treatment combining IRP and oral micronized purified flavonoid fraction (MPFF) versus each treatment used alone on bleeding cessation in patients with grades I, II, and III acute internal hemorrhoids.

METHODS

This was a prospective, randomized, controlled, single-blind study. Consecutive outpatients were randomly assigned to a treatment combining MPFF and IRP or to each treatment separately. For each patient, bleeding status was reported at day 0 (day of inclusion) and compared with that at day 5 after treatment by observers blinded to treatment assignment. Follow-up visits were planned at days 7, 30, 60, and 90 of therapy, including monitoring of treatment-related side effects and self-reporting by patients of any problem related to hemorrhoidal disease.

RESULTS

A total of 351 patients (180 women, 171 men) were enrolled in the study. Their mean age was 49.2 years (range, 29-71 years). Hemorrhoids were grade I in 33.6% (118 patients), grade II in 48.7% (171 patients), and grade III in 17.7% (62 patients) of the study population. Patients were randomly assigned to each of the 3 treatment groups (117 patients in each), with no significant difference between groups in the age, sex, or distribution of grade of hemorrhoids. The percentage of patients with no bleeding after 5 days of treatment was higher in the combined treatment group (74.8%) compared with MPFF alone (59.6%; P = 0.023) or with IRP alone (55.6%; P = 0.004). MPFF alone was as effective as IRP alone at stopping bleeding. Patients with grades I and II hemorrhoids responded significantly better (82.5% and 61.7%, respectively) to either treatment than those with grade III hemorrhoids (22.9%; P < 0.001). Of the 216 patients who were followed up for 90 days, 3 had a gastrointestinal adverse event, and 19 had a relapse of bleeding.

CONCLUSION

Five days of treatment combining MPFF with IRP significantly reduced bleeding status in these study patients with grades I and II acute internal hemorrhoids compared with each treatment used alone.

Novel technology and innovations in colorectal surgery: the circular stapler for treatment of hemorrhoids and fibrin glue for treatment of perianal fistulae

The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called "stapled hemorrhoidectomy" has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.

Prospective randomized comparative study of bipolar electrocoagulation versus heater probe for treatment of chronically bleeding internal hemorrhoids

BACKGROUND

Our purpose was to compare the efficacy, complications, failure rates, and crossovers of heater and bipolar probe treatments of chronically bleeding internal hemorrhoids.

METHODS

Eighty-one patients (31 female, 50 male) with mean age of 53 years had large (grade 2 to 3) internal hemorrhoids with bleeding for a mean of 12 years, had failed medical management, and were randomized in a prospective study of anoscopic treatments to heater versus bipolar probes. Failure was defined as a major complication or failure to reduce the size of all internal hemorrhoids with three or more treatments.

RESULTS

With similar background variables and no difference in treatment times, rectal bleeding and other symptoms were controlled in a shorter time with the heater probe than with the bipolar probe (77 versus 121 days). Five complications (fissures, bleeding, or rectal spasm) occurred with the bipolar probe, and two occurred with the heater probe. The heater probe caused more pain during treatments but had significantly fewer failures and crossovers.

CONCLUSIONS

For patients who had failed medical management of chronically bleeding internal hemorrhoids, the techniques and complications of heater and bipolar probes were similar, but pain was more common, failures and crossovers were less frequent, and the time to symptom relief was shorter with the heater probe than with the bipolar probe.

Comparison of hemorrhoidal treatment modalities. A meta-analysis

PURPOSE

The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials.

METHOD

A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain.

RESULTS

A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (P = 0.0017), with less need for further therapy (P = 0.034), no significant difference in complications (P = 0.60), but significantly more pain (P < 0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation (P = 0.001), although complications were greater (P = 0.02) as was pain (P < 0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (P = 0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2; P = 0.007; Grade 3 hemorrhoids, P = 0.042), with no difference in the complication rate (P = 0.35). Patients treated with sclerotherapy (P = 0.031) or infrared coagulation (P = 0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P = 0.03 for sclerotherapy; P < 0.0001 for infrared coagulation).

CONCLUSION

Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.

Prospective randomized comparative study of bipolar versus direct current electrocoagulation for treatment of bleeding internal hemorrhoids

Internal hemorrhoids are the most common cause of lower gastrointestinal bleeding. Although new anoscopic therapies are available, few comparative randomized studies have evaluated them in regard to long-term efficacy, recurrence rates, and safety. Our purpose was to compare the treatment of internal hemorrhoids with direct current (Ultroid, Cabot Medical, Langhorn, Pa.) and bipolar (BICAP, Circon ACMI, Stamford, Conn.) hemorrhoid probes. One hundred patients with symptomatic internal hemorrhoids were randomized: 50 to direct current electrocoagulation and 50 to bipolar electrocoagulation. Follow-up and treatment were at 3- to 4-weekly intervals; two to three hemorrhoid segments were treated at each session until relief of symptoms (bleeding, prolapse, and discharge) and a reduction in hemorrhoid size to grade 1 or 0 were noted. The hemorrhoids of 98% of all patients studied were grade 2 or 3; 2% of patients had grade 1 hemorrhoids and none had grade 4 hemorrhoids. At 1 year after treatment, most patients had no (69%) or only mild (23%) recurrence, and a few had severe, symptomatic (8%) hemorrhoid recurrence. A greater recurrence rate was noted after direct current treatment (34%) than bipolar treatment (29%). In contrast, rebleeding at 1 year occurred less frequently after direct current treatment (5%) than after bipolar treatment (20%). Our conclusions were as follows: (1) Both direct current and bipolar probes were effective for control of chronic bleeding from grade 1 to 3 internal hemorrhoids. (2) Bipolar probe was significantly faster than direct current probe. (3) Direct current treatment produced fewer complications than bipolar treatment (12% versus 14%). (4) Recurrence rates were low after 1 year with either device (8%).(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial comparing diathermy hemorrhoidectomy with the scissor dissection Milligan-Morgan operation

Twenty consecutive patients (12 male and 8 female) with second-degree, third-degree, or thrombosed hemorrhoids were randomly allocated to undergo either diathermy hemorrhoidectomy (n = 10) or a scissor dissection Milligan-Morgan hemorrhoidectomy (n = 10). No significant difference was found in the postoperative pain score between the groups. On a scale of 0 to 10, the mean daily pain score in the diathermy group was 4.0, and it was 4.1 in the scissor dissection group. Nor was there any significant difference in the length of inpatient stay (diathermy group, 3.5 days; scissor dissection group, 4.0 days) or in the time between the operation and the first bowel action (diathermy group, 2.0 days; scissor dissection group, 3.0 days). Diathermy hemorrhoidectomy has no significant advantage over the scissor dissection classical Milligan-Morgan hemorrhoidectomy.

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.

A prospective crossover trial of direct current electrotherapy in symptomatic hemorrhoidal disease

Many new modalities have been developed to treat symptomatic hemorrhoidal disease. In order to determine whether direct current electrotherapy therapy is effective, a prospective, crossover study was done. Sixteen patients referred for treatment of symptomatic hemorrhoids underwent a 16-week treatment protocol. Patients were randomized to receive either medical therapy with a sham therapy, or medical therapy with active direct current electrotherapy at 4-week intervals. All patients were instructed in medical therapy including sitz baths, hydrocortisone suppositories, topical preparations, and a high fiber diet with an educational booklet. Patients who did not respond to initial therapy were crossed over at 8 weeks, receiving alternate therapy twice. Improvement in symptoms, or lack thereof, was not statistically different between the two treatment groups. Comparisons of the internal sphincter pressure, external sphincter pressure, maximum squeeze pressure, and rectal sensitivity to balloon insufflation (volume) were not statistically different before, during, or after any treatment modality (p = 0.46, 0.60, 0.33). The size and grade of hemorrhoids on entry into the study had no bearing on the outcome. In a prospective crossover trial, no difference could be found between standard medical therapy and direct current electrotherapy in the treatment of symptomatic-hemorrhoidal disease.