Stapler hemorrhoidectomy 3


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Stapler hemorrhoidectomy 3

  1. 1. بسم الله الرحمن الرحيم
  2. 2. مقام الإمام النووي 631 -671H 1255-1300G
  3. 3. 1 ST annul surgical symposium STAPLED HEMORRHOIDECTOMY Dr. Abdulmonem Abualsel KAMC –NGHA- ALHASA MRCS Gen. Surgery
  4. 4. DEFINITION <ul><li>Haemorrhoids :- </li></ul><ul><li>(Greek: haima=blood, rhoos=flowing) </li></ul><ul><li>Piles (latin: pila=a ball) </li></ul><ul><li>They may be external or internal </li></ul><ul><li>When the two varieties are associated they are known as interoexternal. </li></ul>
  5. 5. Anatomy <ul><li>The anal canal, 4 cm long, extends from the pubo-rectalis passes downwards and backwards, to the skin of the perineum. </li></ul><ul><li>The upper two-thirds is derived from the cloaca (endoderm), the lower one-third from the anal pit (ectoderm) . </li></ul>
  6. 7. Blood Supply <ul><li>Of the cloacal part from the superior rectal artery (Portal). </li></ul><ul><li>The sphincters, outside the mucosa, are supplied by the middle and inferior rectal arteries (systemic). </li></ul><ul><li>The mucosa of the lower third is supplied by the inferior rectal artery. </li></ul>
  7. 8. The site of Hs
  8. 9. Venous return <ul><li>Above the dentate line to the portal system through the superior rectal vein. </li></ul><ul><li>Below the dentate line , the external hemorrhoidal plexus drains via the middle and inferior rectal veins, to the internal iliac vein. </li></ul>
  9. 10. Classification <ul><li>1-By location: </li></ul><ul><li>External: from the inferior hemorrhoidal plexus, covered by modified squamous epithelium. </li></ul><ul><li>Internal: they occur above the pectinate line, may prolapse </li></ul><ul><li>Mixed: from both plexuses. </li></ul>
  10. 11. Classification <ul><li>2-By degree: </li></ul><ul><li>1 st . Degree :Simple projection. </li></ul><ul><li>2 nd .degree: Present to the outside during defecation. </li></ul><ul><li>3 rd .degree: Mixed protrude outside & require manual reduction. </li></ul><ul><li>4 th .degree: Prolapsed & irreducible. </li></ul>
  11. 12. Aetiology <ul><li>The correct treatment of Hs can only be found upon sound etiological concept. </li></ul><ul><li>Suggested by some to be due to the adoption of the erect posture by Man. </li></ul><ul><li>A consequence of the aging process. </li></ul><ul><li>However 4 major theories to be mentioned </li></ul>
  12. 13. Aetiology <ul><li>1-Abnormal dilatation of the veins of the internal hem. venous plexus. </li></ul><ul><li>2-Abnormal distension of the arterio-venous anastomoses. </li></ul><ul><li>3-Downward displacement or prolapse of the anal cushions. </li></ul><ul><li>4-Destruction of the anchoring connective tissue system. </li></ul>
  13. 14. <ul><li>Parks 1956, maintained the aetiology was compression of the low pressure superior Hs veins by efforts to expel constipated stool. ARTERIAL pressure allows blood to enter the internal Hs plexus which becomes distended and congested. Followed by partial prolapse </li></ul>parks AG the surgical treatment of hemorrhoids BrJ1956 43-51
  14. 15. Impaired v drainage
  15. 16. Aetiology <ul><li>The role of transient increase in intra-abdominal pressure, e.g. during defecation and in pregnancy. </li></ul><ul><li>The high rectal pressure in patients suffering from piles. </li></ul>
  16. 17. Theories <ul><li>Stewart 1963, divided internal Hs into 2 main groups: </li></ul><ul><li>1 -Vascular Hs with extensive dilatation of the internal Hs plexus a variety commoner in the young. </li></ul><ul><li>2 -Mucosal Hs and consists of sliding downwards of thickened mucous membrane, in the old i.e prolapse </li></ul>
  17. 18. <ul><li>1975, Thomson postulated the theory of Vascular cushions, which protect the anal canal during the act of defecation </li></ul><ul><li>The submucosa is not a continuous ring, but rather a discontinuous series of cushions, rich in blood vessels and muscle fibers, which adheres the mucosa and submucosa to the internal sphincter and supports the blood vessels. </li></ul>thompson WH .the nature of hemorrhoid 1975 surg 62- 542
  18. 19. <ul><li>Straining causes these cushions to slide downwards and internal Hs </li></ul><ul><li>Develop Prolapse of the anal mucous and hemorrhoidal cushions is a very common condition over the age of 50. </li></ul>thompson WH .the nature of hemorrhoid 1975 surg 62- 542
  19. 20. Aetiology <ul><li>Thomson demonstrated that the fragmentation of the supporting tissue is the cause for the Prolapse, affecting the hemorrhoidal tissue and the anal mucosa. </li></ul><ul><li>The collapse of Park’s ligament causes a permanent downward sliding of the anal mucosa that loses its normal topographic relationship with the sphincters. </li></ul>thompson WH .the nature of hemorrhoid 1975 surg 62- 542
  20. 21. Aetiology <ul><li>Under this circumstance the mucosa of the rectal ampulla occupies the muscular anal canal permanently, while the anal mucous membrane and the piles are distally displaced. </li></ul><ul><li>The anal prolapse cause an alteration of the vascular arrangement and of the anatomical relationship between the …… </li></ul>
  21. 22. <ul><li>Internal and external hemorrhoidal plexuses. </li></ul><ul><li>Based on the previous theories a stapler hemorrhiodectomy was one of the modalities of treatment of piles. </li></ul>
  22. 23. <ul><li>It is assumed that the technique of stapled hemorrhoidectomy aims to preserve the anal mucosa and the hemorrhoidal tissue, however, maintaining the suture carried out above the anorectal ring. </li></ul><ul><li>Under some circumstances the transection of some anal mucosa is necessary. </li></ul>
  23. 24. Longo A (1998) Treatment of haemorrhoidal disease <ul><li>Introduction of stapled hemorrhoidopexy by Longo in 1998 [1] represented a radical change in the treatment of hemorrhoids. </li></ul><ul><li>By avoiding multiple excisions and suture lines in the perianal region, SH is intended to offer less postoperative pain than with conventional techniques </li></ul>longoA1998 treatment of hemorhoidal disease
  25. 26. Definition and Principles <ul><li>The operation is based on the principle of a mucosectomy at least 3-4 cm above the dentate line where: </li></ul><ul><li>A purse string suture placed at that level and tied around the stapler shaft then resection and stapling of the mucosa are carried out, simultaneously. </li></ul>
  26. 27. Cont … <ul><li>This procedure effectively reduces mucosa </li></ul><ul><li>Blocks the end of branches of the upper rectal artery thus stopping venous and arterial blood flow of hemorrhoidal plexus. </li></ul>
  27. 40. Medical treatment <ul><li>Fibres </li></ul><ul><li>Over the counter </li></ul><ul><li>daflon </li></ul>
  28. 41. Nonoperative treatment <ul><li>Sclerotherapy </li></ul><ul><li>Cryotherapy </li></ul><ul><li>Rubber band ligation </li></ul><ul><li>Bipolar diathermy and infrared photocoagulation </li></ul>
  29. 42. Surgical treatment <ul><li>Excision </li></ul><ul><li>Anal dilatation </li></ul><ul><li>stapler </li></ul>
  30. 43. المسجد الأموي في دمشق
  31. 44. Study from April 2003 till January 2009
  32. 45. Abstract <ul><li>Objectives: present our retrospective results of circular stapler hemorrhoidcetomy (SH) for the treatment of haemorrhoids. </li></ul><ul><li>Data collection:160 patient operated in national guard from 2003 up to January 2009. </li></ul>
  33. 46. <ul><li>The goals of the study were to evaluate the efficacy and reproducibility of stapled hemorrhoidectomy . </li></ul>
  34. 47. <ul><li>The indication for surgery </li></ul><ul><li>bleeding and / or prolapsed of 2nd ,3rd and 4 th degree piles </li></ul>
  35. 48. Results: <ul><li>96 male(60%) </li></ul><ul><li>64 female(40%) </li></ul><ul><li>The age between 20- 80 year with average (35,5) year </li></ul>
  36. 49. DR: Ahmad Salman
  37. 50. METHODS <ul><li>160 pt </li></ul><ul><li>Complication </li></ul><ul><li>Hospital length </li></ul><ul><li>Operation time. </li></ul><ul><li>Follow up 2 week ,0ne month,3month,6month one year and 2 year. </li></ul>
  38. 51. Total Number of Patient - 160 <ul><li>Youngest – 20 years old </li></ul><ul><li>Oldest – 80 years old </li></ul><ul><li>Average – 35.5 years old </li></ul>
  39. 52. <ul><li>(71%)of pts with 3ed degree </li></ul><ul><li>(28%) ==== 4 th degree </li></ul><ul><li>(1%) ==== 2ed degree </li></ul>
  40. 53. Operative Time <ul><li>Quickest – 8 minutes </li></ul><ul><li>Longest – 70 minutes </li></ul><ul><li>Average Time – 32 minutes </li></ul><ul><li>4 case stapler + peri anal fistula </li></ul>
  41. 55. <ul><li>Those patients were operated by 6 surgeons </li></ul><ul><li>4 consultant . </li></ul><ul><li>2 senior registrar. </li></ul><ul><li>Dr salman is the first one who start this and the one teach us . </li></ul>
  42. 58. Visual analogue scale <ul><li>Post operative was managed according to guideline of VAS (0-no pain)to (10-mexionir pain) </li></ul><ul><li>The aim was to keep down to VAS score <3 </li></ul><ul><li>Analgesic, was given according WHO system. </li></ul><ul><li>During operation immediately of the recovery.((IM) NSAID. Or mepridine ) </li></ul><ul><li>During hospital stay: </li></ul><ul><li>VAS<3 class1 analgesic  paracetamol tab. </li></ul><ul><li>VAS<3-5 class 11  paracetamol + NSAID (tab) </li></ul><ul><li>VAS<5 class 111  mepridine IM injection </li></ul>
  43. 59. Analgesia <ul><li>60 % received a single does. Pethidine inj only. </li></ul><ul><li>15 % received. only 1 dose Voltaren inj. </li></ul><ul><li>10 % received.acetaminophen and voltaren tab. </li></ul><ul><li>15% received. acetaminophen tab only. </li></ul>
  44. 60. complications <ul><li>Complications during the first 24 hours were </li></ul><ul><li>fecal urgency (25%), </li></ul><ul><li>urinary retention (10%), </li></ul><ul><li>rectal bleeding (2%). </li></ul><ul><li>Pruritus ani (5%)?? </li></ul>
  45. 61. Complication <ul><li>Post anal fissure –6 case 3,7% </li></ul><ul><li>Anal stricture – 5 cases 3.1 </li></ul><ul><li>perianal fistula &Thrombosed pile – 2 case 1.6% </li></ul><ul><li>Reintervension </li></ul><ul><li>*2 case for bleeding </li></ul><ul><li>*5 cases for anal dilation </li></ul>
  46. 62. <ul><li>Anal pain – 6 cases 3,75% </li></ul><ul><li>4 cases low stapler line . </li></ul><ul><li>Recurrance : 4 cases after 2 year </li></ul><ul><li>Satisfaction – 94% </li></ul><ul><ul><ul><li>- 60%. by asking the patient during clinic visit </li></ul></ul></ul><ul><ul><ul><li>-40%. by telephone </li></ul></ul></ul>
  47. 63. Hospital Length of Stay <ul><li>75% 1 days </li></ul><ul><li>15% 2 days </li></ul><ul><li>10% > 2 days </li></ul><ul><ul><li>Causes: a. bleeding </li></ul></ul><ul><ul><li>b. Anal pain </li></ul></ul><ul><ul><li>c. Social. </li></ul></ul>
  48. 64. <ul><li>Return to work: </li></ul><ul><li>10 days post op in more than 95% </li></ul>
  49. 65. <ul><li>They were no cases of </li></ul><ul><li>permanent incontinence, </li></ul><ul><li>chronic pain </li></ul><ul><li>or deaths in this series </li></ul>
  50. 66. literatures
  51. 67. Department of Surgery, Universit à Tor Vergata, Rome, Italy, <ul><li>: 171 patients (95 cases in SH group and 76 cases in MMH group) entered the study: </li></ul><ul><li>83 cases were III degree hemorrhoids, 88 IV degree. </li></ul><ul><li>Surgical time was 28.41 +/- 10.78 for MMH and 28.30 +/- 13.28 min in SH </li></ul>
  52. 68. <ul><li>during the following 6 days, patients treated with SH had less pain (4.63 +/- 2.04 in MMH vs 3.60 +/- 2.35 in SH; </li></ul>
  53. 69. Colorectal Surgery Division, Hospital Santa Helena, Sao Paulo (SP), Brazil. <ul><li>A series of 108 patients </li></ul><ul><li>76 Patients who underwent stapled hemorrhoidectomy were compared to 32 patients submitted to closed diathermy-excision hemorrhoidectomy due to </li></ul><ul><li>, median and maximum daily pain scores were lower in the stapled group (P < 0.001). </li></ul>
  54. 70. <ul><li>days Resumption of activities occurred after 9 days (mean; range 2 to 17 days) after stapling and 14 days (7 to 24) after diathermy surgery - P < 0.001. After one </li></ul><ul><li>year, 45 (80.4%) patients in the stapled group and 18 (78.3%) in the diathermy group were asymptomatic </li></ul>
  55. 71. Many center in France <ul><li>*CHU Rangueil, Toulouse, France; CHU Nantes, Nantes, France; CHU Trousseau, Tours, France; Clinique Charcot, Lyon, France; Polyclinique de Franche Comt é , Besancon, France; CHU Limoges, Limoges, France, Angers, France </li></ul>
  56. 72. <ul><li>A series of 134 patients were included at 7 hospital centers. They were randomized according to a single-masked design </li></ul><ul><li>The mean follow-up period was 2.21 years </li></ul><ul><li>Hospital stay was significantly shorter in the SH group (SH 2.2 ± 1.2 [0; 5.0] versus MM 3.1 ± 1.7 [1; 8.0] P < 0.001 </li></ul>
  57. 73. <ul><li>No patient needed a second procedure for recurrence within 2 years </li></ul><ul><li>A clear difference in morphine requirement became evident after 24 hours </li></ul><ul><li>the overall incidence of complications was the same, </li></ul>
  58. 74. Rev Gastroenterology Mex. 2006 Oct-Dec;71(4):422-7 Mexico <ul><li>In a 27 months period, 160 patients were treated (105 men and 55 women), </li></ul><ul><li>mean age was 44.1 years (range: 24 to 72 years), </li></ul><ul><li>110 patients had grade III hemorrhoid disease. </li></ul><ul><li>Non procedure complications were noted, </li></ul><ul><li>early complications were detected in 5% of patients </li></ul><ul><li>late complications were detected in 10% of patients. </li></ul><ul><li>mean follow-up of 18.8 months, </li></ul><ul><li>82.5% of the patients remained asymptomatic and 94.4 of the patients reported a good satisfaction score. </li></ul><ul><li>A second surgery was required in three patients because of recurrence. </li></ul>
  59. 75. Conclusion <ul><li>This study confirms the feasibility of circular stapler hemorrhoidectomy complication and post-operative pain were minimal and goes with most of the international studies. </li></ul>
  60. 76. <ul><li>SH is safe and simple procedure, </li></ul><ul><li>SH can eliminate hemorrhoidal bleeding , </li></ul><ul><li>SH successfully eliminates pain in </li></ul><ul><li>hemorrhoidal disease, </li></ul><ul><li>SH successfully eliminates hemorrhoidal </li></ul><ul><li>prolapse </li></ul><ul><li>SH is a minimally invasive surgical </li></ul><ul><li>procedure. </li></ul>
  61. 77. 1. Longo A (1998) Treatment of haemorrhoidal disease by reduction of mucosa and haemorrhoidal prolapse Rome, Italy, pp 3–6 3 2. Lacerda-Filho A, Da Silva RG. Stapled hemorrhoidectomy: present status. Arq Gastroenterol 2005; 42:191–4. References
  62. 78. References 3. Thompson WH. The nature of haemorrhoids. Br J Surg 1975; 62:542–52. 4. Brisinda G. How to treat haemorrhoids. Prevention is best; haemorrhoidectomy needs skilled operators. BMJ 2000; 321:582–3. 5. Lacerda-Filho A, Da Silva RG. Stapled hemorrhoidectomy: present status. Arq Gastroenterol 2005; 42:191–4. 6. Nisar PJ, Scholefield JH. Managing haemorrhoids. BMJ 2003; 327:847–51. 7. Johanson JF. Evidence-based approach to the treatment of hemorrhoidal disease. Evid Based Gastroenterol 2002; 3:26–31
  63. 79. . 8. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 1990; 98:380–6. 9. Nelson RL, Abcarian H, Davis FG, Persky V. Prevalence of benign anorectal disease in a randomly selected population. Dis Colon Rectum 1995; 38:341–4. References
  64. 80. 10. Johansson HO. Haemorrhoids: aspects of symptoms and results after surgery. Acta Univ Ups 2005; 86:90. 11. Haas PA, Fox TA, Haas GP. The pathogenesis of haemorrhoids. Dis Colon Rectum 1984; 27:442–50. 12. Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H, Margreiter R, et al. The vascular nature of hemorrhoids. J Gastrointest Surg 2006; 10: 1044–50. 13. Balasubramaniam S, Kaiser AM. Management options for symptomatic hemorrhoids. Curr Gastroenterol Rep 2003; 5:431–7.
  65. 81. 14. Haas PA, Haas GP, Schmaltz S, Fox TA Jr. The prevalence of hemorrhoids. Dis Colon Rectum 1983; 26:435–9. 15. Lunniss PJ, Mann CV. Classification of internal haemorrhoids: a discussion paper. Colorectal Dis 2004; 6:226–32. 16. Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126:1463–73.
  66. 82. 17. Polglase AL. Haemorrhoids: a clinical update. Med J Aust 1997; 167:85–8. 22. Senagore AJ. Surgical management of hemorrhoids. J Gastrointest Surg 2002; 6:295–8. 18. Cataldo PA. Hemorrhoids. Clin Colon Rectal Surg 2001; 14:203–14. . 26 26
  67. 83. 19. Parks AG. The surgical treatment of haemorrhoids. Br J Surg 1956; 43:337–51. 20. Cheetham MJ, Phillips RK. Evidence-based practice in haemorrhoidectomy. Colorectal Dis 2001; 3:126–34.
  68. 84. Thank You!!! Thank you