Severe cases of hemorrhoidal prolapse – 3rd and 4th Degree – will normally require surgery. Traditional hemorrhoidectomy is notorious for the level of post operative pain the patient must endure, coupled with a long recuperation period.
Newer surgical procedures include stapled transanal rectal resection (STARR) and procedure for prolapse and hemorrhoids (PPH). Both STARR and PPH are contraindicated in persons with either enterocele or anismus.[1]
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Hemorrhoids are amongst the most common anal disorders. Patients may complain of bleeding, prolapse, personal discomfort and minor anal leakage.
Where traditional palliative measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments.
Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without anaesthetic, the lasting effect of these conservative therapies has been questioned. Many patients treated with rubber band ligation or injection sclerotherapy require multiple treatments and there is high recurrence rate following these procedures.
Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period. This can put a stress on a general practitioner’s resources, may alienate the patient and delays the patient’s return to a full, normal lifestyle and the workplace.
Because of this, surgeons will generally reserve formal excision for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments.
PPH uses a circular stapler to reduce the degree of prolapse. The procedure avoids the need for wounds in the sensitive perianal area thus reducing post-operative pain considerably, and facilitates a speedier return to normal activities.[2][3][4]
This procedure was first described by an Italian surgeon – Dr. Antonio Longo, Department of Surgery, University of Palermo – in 1993 and since then has been widely adopted through Europe.
This procedure avoids the need for wounds in the sensitive perianal area and, as a result, has the advantage of significantly reducing the patient’s post operative pain.[2][3][4] Follow-up on relief of symptoms indicate a similar success rate to that achieved by conventional haemorrhoidectomy.[2][5]
Since PPH was first introduced it has been the subject of numerous clinical trials and in 2003 the National Institute of Clinical Evidence (NICE) in the UK issued full guidance on the procedure stating it was safe and efficacious.
PPH employs a unique circular stapler which reduces the degree of prolapse by excising a circumferential strip of mucosa from the proximal anal canal. This has the effect of pulling the hemorrhoidal cushions back up into their normal anatomical position.
In addition to correcting the symptoms associated with the prolapse, problems with bleeding from the piles are also resolved by this excision. Although the cushions may be totally or partially preserved, the blood supply is interrupted or venous drainage is improved by the repositioning. Any external component which remains will usually regress over a period of 3–6 months. Prominent skin tags may, on occasion, be removed during the operation, but this has not been associated with any significant increase in pain.
PPH is generally indicated for the more severe cases of hemorrhoidal prolapse (3rd and 4th degree) where surgery would normally be indicated. It may also be indicated for patients with minor degree haemorrhoids who have failed to respond to conservative treatments. The procedure may be contra-indicated when only one cushion is prolapsed or in severe cases of fibrotic piles which cannot be physically repositioned.
Usually the patient will be under general anesthetic, but only for 20–30 minutes. Many cases have been successfully performed under local or regional anesthesia and the procedure is suited to day case treatment.
Due to the low level of post-operative pain and reduced analgesic use, patients will usually be discharged either the same day or on the day following surgery.
Most patients can resume normal activities after a few days when they should be fit for work. The first bowel motion is usually on day two and should not cause any great discomfort. Staples may be passed from time to time during defecation. This is normal and should not be a cause for concern.
Urinary retention in the immediate post-operative period appears to be the most common complication.
Should there be some post-operative bleeding, this can be dealt with either by the district nurse or in the GP surgery. If it is still a concern, refer the patient back to the hospital.
Cheetham et al. conclude that a disturbingly high proportion of patients developed persistent, severe pain and faecal urgency following stapled hemorrhoidectomy, and the long-term complications following this procedure outweigh the benefits of decreased postoperative pain.[6]
A condition called post PPH syndrome is also possible. This occurs when the staples are placed slightly low and it can cause the internal sphincter muscle to become inflamed. Treatment includes anti-inflammatory oral medications and suppositories.
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