Who's afraid of the dentate line? The Whitehead hemorrhoidectomy

Modified whitehead hemorrhoidectomy versus partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids: A retrospective analysis

Background

Grade IV circular hemorrhoids are difficult to treat. We aim to describe the modified whitehead hemorrhoidectomy procedure and to assess the effectiveness and safety of this procedure for grade IV circular hemorrhoid patients.

Methods

Patients with grade Ⅳ circular hemorrhoids who underwent modified Whitehead hemorrhoidectomy and partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids were retrospectively reviewed. Clinical data were extracted from the database at our institution, and long-term postoperative complications were assessed through repeated outpatient examinations and telephonic communication.

Results

A total of 205 patients were included in this study. The mean operative time was 59.2 ± 13.8 min. The average hospital stay was 4.6 ± 1.0 days. For postoperative complications, 66 (32.2%) patients had urinary retention, 10 (4.9%) patients had a sense of incomplete rectal emptying, 5 (2.4%) patients had anal incontinence, and 6 (2.9%) patients had wound infection. For long-term postoperative complications, 3 (1.5%) patients experienced mild to moderate anal stricture, 2 (1%) patients experienced mucosal ectropion, they all had smooth recoveries, and none of them needed secondary surgery. None of these patients had a hemorrhoid recurrence. A total of 205 patients who received modified Whitehead hemorrhoidectomy and 161 who received partial hemorrhoidectomy were included. There were no residual hemorrhoids in patients who received modified Whitehead hemorrhoidectomy, and none had hemorrhoid recurrence. Fifty-eight patients who received partial hemorrhoidectomy had hemorrhoidal residues, and 19 patients experienced hemorrhoid recurrence. After modified Whitehead hemorrhoidectomy, 3 patients developed anal stenosis, and 2 had mucosal ectropion. Four patients developed anal stricture after partial hemorrhoidectomy, and none had mucosal ectropion. They all had smooth recoveries, and none of them needed a secondary surgery. For the mean duration of surgery, postoperative bleeding, postoperative pain, wound infection, sense of incomplete rectal emptying, anal incontinence, and urinary retention, no statistically significant differences were found between the two groups.

Conclusions

Compared with partial hemorrhoidectomy, modified whitehead hemorrhoidectomy is an effective and safe surgical procedure and does not significantly increase the risk of anal stenosis and mucosal ectropion for grade IV circular hemorrhoid patients. Prospective randomized controlled trials are needed to verify our results.

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.

The Whitehead operation procedure: Is it a useful technique?

OBJECTIVE

Hemorrhoidal disease is a very common entity in the general population; however, the therapeutic approaches to hemorrhoids remain controversial. The choice of treatment method depends on the grade of the hemorrhoid as well as the experience of the surgeon. The Whitehead hemorrhoidectomy procedure is often applied for grade IV hemorrhoids.

MATERIAL AND METHODS

We studied 49 patients who underwent surgery between December 1982 and January 2013. The indications for the Whitehead procedure in all patients were grade IV hemorrhoidal disease. The data on these patients were evaluated retrospectively with respect to age, gender, preoperative diagnosis, and postoperative complications.

RESULTS

Of the patients included in this study, 34 were male and 15 were female. The mean age of the patients was 41.93±12.42, and the age range was 24-70 years. Complications of the Whitehead procedure included bleeding (6.12%, three cases), stricture (2.04%, one case), urinary retention (16.33%, eight cases), and temporary anal incontinence (2.04%, one case). No patients developed Whitehead deformities, entropion, or infectious complications. All patients were discharged from hospital between the fifth and eighth days post-surgery (6.45±1.00 days). The follow-up period was 1-234 months (70.02±54.89).

CONCLUSION

The Whitehead procedure is successful in patients with prevalent peripheral prolapse and/or thrombosed hemorrhoids. With the right indications, and if the surgeon has adequate experience, the morbidity rate of the Whitehead procedure is similar to that of other treatment methods.

Anal fissure and stenosis

Anal fissure is a common anorectal disorder resulting in anal pain and bleeding. Fissures can either heal spontaneously and be classified as acute, or persist for 6 or more weeks and be classified as chronic, ultimately necessitating treatment. Anal stenosis is a challenging problem most commonly resulting from trauma, such as excisional hemorrhoidectomy. This frustrating issue for the patient is equally as challenging to the surgeon. This article reviews these 2 anorectal disorders, covering their etiology, mechanism of disease, diagnosis, and algorithm of management.

A modified Ferguson hemorrhoidectomy for circumferential prolapsed hemorrhoids with skin tags

PURPOSE

We describe a modification of the Ferguson hemorrhoidectomy for circumferential prolapsed hemorrhoids. This details the operative procedure and compares the results of other radical methods in patients with circumferential hemorrhoidal disease.

METHODS

A total of 738 patients (mean age, 43 (range, 19-83) years) were treated with our modified Ferguson method under sedative analgesia between 1989 and 2004: 576 patients had Grade III and 162 patients had Grade IV hemorrhoids, and 131 patients also had a partial lateral internal sphincterotomy to correct anal hypertonia.

RESULTS

Postoperative bleeding occurred in 16 patients, 3 of whom required surgical hemostasis. Fecal impaction occurred in 11 patients and wound complications in 6 patients. Thirty-two patients needed bladder catheterization because of acute urinary retention. The median follow-up was 13.2 months in our outpatient department. One patient developed mild gas incontinence, five developed anal stenosis, and three had an anal fissure. Only three patients had recurrent skin tags, which did not affect their quality of life.

CONCLUSIONS

Our modified Ferguson method represents a good choice for radical treatment of circumferential prolapsed hemorrhoids because it is easy to perform, has few complications, and provides satisfying results.

Analysis of surgical treatments for circumferentially protruding haemorrhoids: complete excision with repair using flaps versus primary excision with secondary suture-ligation

BACKGROUND

Circumferentially protruding haemorrhoids (CPH) are troublesome lesions for both patients and surgeons, and in most cases demand surgical intervention. However, such surgery carries the risks of complications and recurrence. This study compared two surgical procedures in order to identify the optimal approach for CPH.

METHODS

All patients underwent an open haemorrhoidectomy for primary haemorrhoids, after which patients underwent either of the two procedures for secondary haemorrhoids. Group 1 (n = 104) comprised patients who underwent submucosal excision with repair using remnant anodermal flaps; this procedure was performed between 1991 and 1996. Group 2 (n = 113) comprised patients who underwent suture-ligation; this procedure was performed between 1997 and 2002. Surgical outcomes including surgical variables, wound healing, complications and patient satisfaction were compared between the two groups.

RESULTS

For group 2, surgical time and duration of analgesic use (mean +/- SEM, 22 +/- 0 minutes and 3 +/- 0 days, respectively) were significantly shorter than for group 1 (28 +/- 1 minutes and 4 +/- 0 days, respectively; p < 0.001 for both comparisons). In terms of complication rates, there was no significant difference between group 2 (15 patients, 14%) and group 1 (25 patients, 22%), and most complications were satisfactorily treated using conservative management. Skin tags and perianal abscesses were more frequent in group 1 than in group 2. The final follow-up was undertaken at 6 months postoperatively, at which time there were no recurrences in patients of either group. For both groups, over 90% of patients reported that they were satisfied with the outcome of surgery.

CONCLUSION

Although both surgical approaches were successful for treating CPH, open haemorrhoidectomy for primary haemorrhoids combined with suture-ligation for secondary haemorrhoids appears to be the optimal approach considering its rapidity, simplicity and lower associated costs.

Early and late (ten years) experience with circular stapler hemorrhoidectomy

PURPOSE

We present a retrospective clinical study concerning the preliminary experience with the circular stapler in the treatment of hemorrhoids. Early results, complications, and long-term follow-up are revisited.

METHODS

Fifty-six consecutive patients with second-, third-, and fourth-degree hemorrhoids were included in the study. Data about operation, early postoperative results, and follow-up at one, two, and four weeks were collected. Patients were also contacted by phone after a long-term follow-up (mean, 33 (range, 5-120) months).

RESULTS

Every operation attempted was successfully terminated. The length of the operation was less than 15 minutes. No major bleeding or anastomotic disruption occurred. Six patients (13 percent) who underwent spinal or epidural anesthesia had urinary retention. One patient (1.7 percent) had minor bleeding, and four patients (7.1 percent) experienced transient edema of the anastomotic ring after the operation. None needed further treatments. The mean analgesic requirement was 1.4 (range, zero to eight) ketorolac 30-mg injections; 23 patients (41 percent) received no analgesics, and seven patients (12 percent) required a single extra dose of opiates (10 mg morphine cloridrate). Length of hospital stay was between 0 and 11 (mean, 2.7) days, but 20 patients (35 percent) received an additional operation for coexisting surgical disease. At one week, almost all patients experienced little pain at digital inspection and little bleeding after defecations. No anastomotic leakage, wound infection, or healing delay was found. Three patients (5.3 percent) experienced wound edema and pain during defecation. Two weeks later, one patient (1.7 percent) suffered from painful defecation and ten patients (17 percent) reported minor bleeding, but all returned to normal activities. No pain during defecation, bleeding, stenosis, soiling, incontinence, or other anal symptoms were found at one month after the operation, and all patients were well. All patients were contacted by phone 5 to 120 (mean, 33) months later, and all were pleased with the results of this procedure. There were no symptomatic recurrences.

DISCUSSION

Our study confirms the feasibility of circular stapler hemorrhoidectomy in the treatment of hemorrhoids. Complications and postoperative pain were minimal. There were no recurrences during long-term follow-up.

CONCLUSION

Mechanical hemorrhoidectomy is a promising new option in the treatment of all patients eligible for a surgical approach.

How I do it. Anal stenosis

BACKGROUND

Anal stenosis represents a technical challenge in terms of surgical management. It is a rare but serious complication of anorectal surgery, most commonly seen after surgical hemorrhoidectomy. However, stenosis can also occur in the absence of an anorectal surgical history.

DATA SOURCES

A review of the current surgical literature was performed. The etiology, classification, and diagnostic modalities for anal stenosis were reviewed. A detailed overview of surgical and nonsurgical therapeutic options was developed.

CONCLUSIONS

Anal stenosis may be anatomic (stricture) or functional (muscular). Anal stricture is most often a preventable complication. It is most commonly seen after overzealous surgical hemorrhoidectomy. A well-performed hemorrhoidectomy is the best way to avoid anal stricture. Symptomatic mild functional stenosis and stricture may be managed conservatively with diet, fiber supplements, and stool softeners. A program of gradual manual or mechanical dilatation may be required. Sphincterotomy and various techniques of anoplasty have been used successfully in the treatment of symptomatic moderate to severe functional anal stenosis and stricture, respectively.

Surgical treatment of piles: prospective, randomized study of Parks vs. Milligan-Morgan hemorrhoidectomy

PURPOSE

The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan-Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience.

METHODS

Thirty-four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow-up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation.

RESULTS

No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomy vs. 4.6 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively; P = 0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomy vs. 20.2 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively; P < 0.001) differed significantly between the Milligan-Morgan and Parks patients. Until two weeks after the operation, Milligan-Morgan hemorrhoidectomy patients experienced significantly more pain.

CONCLUSIONS

Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.

Prospective randomized study of radical versus four piles haemorrhoidectomy for symptomatic large circumferential prolapsed piles

Twenty-eight patients (14 men, 14 women) with circumferential prolapsed piles were prospectively randomized to undergo either modified radical haemorrhoidectomy (group 1; 14 patients) or four piles haemorrhoidectomy (group 2; 14). The median duration of surgery was 30 and 10 min respectively in groups 1 and 2. After operation all patients in group 1 were continent compared with 12 of 14 in group 2. Two patients in group 2 developed an anal stricture requiring manual dilatation. Five patients in group 1 had wound dehiscence requiring secondary suture; three of these developed an anal stricture: two needed anal dilatation and one required anoplasty. Two patients in group 1 had residual anal skin tags, compared with nine in group 2. Two patients in group 2 had symptomatic residual piles, whereas none in group 1 had this problem. At 6 months, six patients in group 2 considered the results to be excellent, seven acceptable and one was disappointed. In group 1 two considered the operation to be excellent, ten acceptable and two were disappointed.

Inpatient management of piles: a surgical audit

A retrospective study was performed on 160 patients admitted to the University Surgical Unit between July 1975 and November 1989 with haemorrhoidal disease. Patients' records were analysed with respect to predisposing factors, inpatient management, postoperative analgesia, hospital stay and post-management complications. One hundred and nineteen patients had haemorrhoidectomy (low ligation combined with an anal stretch). Of these, 1.6% developed urinary retention and 4.2% bled postoperatively but did not require surgical intervention. Ten patients were found to have tight anal canals post surgery and required outpatient anal dilatation. In no case was dilatation necessary for more than 3 months. Three patients required a therapeutic course of antibiotics. Of the 119 patients, 60 required narcotic analgesia for less than 24 hours. Hospital stay was 1-4 nights.