2. Anestesia locale o nessuna anestesia
Dimissione in giornata
Procedure ambulatoriali:
• no sdo
• pagamento ticket
Procedure in day surgery:
• si sdo o bic
• no ticket tranne bic
Definizioni
4. Nostra realtà
UCP Cantu’
2018: 98% patologia proctologica trattata in anestesia locale (ed
eventuale benzodiazepina ev) e dimissione in giornata comprese
prolassectomie con stapler, emorroidectomie sec MM
7. Blaisdell PC Office ligation of internal hemorrhoids Am J Surg 1958;96:401-404
Barron J. Office ligation treatment of haemorrhoids. Dis Colon Rectum 1963;19:283-6
Tecnica ambulatoriale piu’ utilizzata
Fissa la mucosa e sottomucosa alla tonaca muscolare prevenendo il prolasso
Legatura elastica
8. Fissa il tessuto mucoso e sottomucoso riducendo il prolasso
Tecnica mediante aspirazione o trazione
Vantaggi dell’aspirazione: operatore unico, monouso, meno dolore e sanguinamento
* Ramzisham ARM: Prospective randomized trial on 100..; 2006
Legatura elastica tecnica
9. Legatura elastica anestesia locale ?
Metaanalisi 4 trial randomizzati 387 pazienti 2005 meno
dolore immediato
1999 randomizzato anestetico vs placebo vs nulla meno
dolore immediato
Diversi anestetici, sedi di iniezione
Sajid et al Local anestetic infiltration for the rubber band ligation of early symptomatic hemorroids a sistematic
review and metanalysis.Updates surg 2015 3-9
11. Legatura elastica anestesia locale?
Nostra esperienza
Mai
Se dolore al rilascio del laccio,
rimozione immediata
12. Legatura elastica tecnica: singola o multiple ?
nessuna differenza statistica tra efficacia, discomfort ed insorgenza di complicazioni
in pazienti sottoposti a legatura singola o multipla.
Kubchandani ‘A randomized comparision of single and multiple rubber band ligations’
Dis Col Rect 1983;26;705-8
13. Legatura singola vs multipla
177 pazienti multiple singola
Discomfort e dolore 29% 4.5%
Disturbi vaso vagali 5.2% 0%
Sanguinamenti ed edema 14,2% 0%
Disturbi urinari 12,3% 0%
Lee, Dis Col Rect 1994;37:37-41
17. Legatura elastica risultati immediati
Guariti o migliorati 69-97%
Successiva emorroidectomia 7.5-10%
Risultati a distanza
Follow up medio 4.8 anni 125 pz 89% curati e soddisfatti
44% completamente asintomatici
12% ulteriori trattamenti ambulatoriali
2% emorroidectomia
Follow up medio 5 anni 260 pz 69% asintomatici
80% migliorati
7.5% emorroidectomia
Steinberg et al, Br j Surg 1975;62:144-6
Wroblesky,Dis Col Rect 1980
18. Legatura elastica risultati a distanza
701 paz
Follow up medio 3,3 anni
70% soddisfatti dopo una seduta
30,2% ulteriore seduta
80,2% soddisfatti dopo seconda seduta
7% intervento chirurgico
Iyer, Dis Col Rect 2004
19.
20. Legatura elastica risultati
HubBLe trial
Legature vs Hal doppler
370 pazienti
II e III grado (anche recidive dopo legatura)
Recidive a 1 anno 30% HAL 49% legatura singola
37.5% multiple
Risoluzione sintomi, complicanze, qualita’ di vita e continenza no differenze
HAL piu’ dolore, maggiori costi
Brown et al Haemorroidal artery ligation versus rubber band ligation for symptomatic second and third degree hemorroids:a
multicentre randomised controlled trial and health economic evaluation. Health Technol Assessm 2016 Nov.20(88)1.150
23. Descritta da Mitchell nel 1869
Trombosi vasale, fibrosi e sclerosi mucosa e sottomucosa
Iniezione diretta o via endoscopio
Scleroterapia
24. Scleroterapia risultati a distanza
Kouri 1985 successo 89%
Santos 1993 recidiva a 4 anni 30%
Senapati a 6 mesi nessuna differenza
tra scleroterapia e lassativo
25. Scleroterapia complicanze
Dolore 12-70% vicino linea pettinata
Emorragia 2-3% superficiale
Ascessi fistole 8% profondo
Impotenza, ritenzione urinaria, necrosi della mucosa,stenosi, shock anafilattico
Cellulite pelvica 3 casi con mortalita’ 35%
Sim 1983
Bullock Br Med Surg 1987
Mc Cloud Review 2006
27. Cina
30 pazienti, nessun sanguinamento
(4 settimane)
100% soddisfatti
Lauromacrogol
I II III grado
Scleroterapia
Cap assisted endoscopic sclerotherapy
World J gastrointest Endoscopy 2015
29. Giappone
II e III grado
604 pazienti (300.000 pz trattati in Giappone)
Successo 95% 93 % 89% II grado a 1 3 5 anni
83% 89% 72% III grado a 1 3 5 anni
47 pz complicanze ( febbre,dolore,ritenzione urinaria, ulcera rettale)
Scleroterapia
World J Hepatol. 2016 Jul 18; 8(20): 844–849.
Aluminum potassium sulfate and tannic acid sclerotherapy for Goligher Grades II and III hemorrhoids: Results from a multicenter study
Hidenori Miyamoto, Takenori Hada, Gentaro Ishiyama, Yoshito Ono, and Hideo Watanabe
30. Fotocoagulazione ad infrarossi
• Ideata da Neiger nel 1979
• I e II grado
• Distruzione del tessuto con calore fino a 3 mm profondità
fissando la mucosa
• Sessioni multiple
• Costi elevati
31. Fotocoagulazione ad infrarossi risultati
• Dennison 1990 successo 67-96%
• Leicester 1981 minor dolore rispetto a legature elastiche (8.5% vs 70%)
• Johanson 1992 peggior risultati a lungo termine verso legature elastiche,
minori complicanze e minor dolore
36. Descritta da Lewis nel 1969
Distruzione terminazioni nervose e necrosi tessuto emorroidario
La crioterapia delle emorroidi non è tra i metodi previsti dalle linee guida internazionali sul
trattamento delle emorroidi, raccolte dalla National Guidelines Cleringhouse del Dipartimento della
salute del governo degli Stati Uniti – le linee guida più accreditate a livello mondiale, stilate, nel caso
delle emorroidi, dalla American Society of Colon and Rectal Surgeons
Crioterapia
37. [Necessary and unnecessary treatment options for hemorrhoids].
Zindel J1, Inglin R1, Brügger L1.
AmericaTher Umsch. 2014 Dec;71(12):737-51
“Anal dilation, sphincterotomy, cryosurgery, bipolar
diathermy, galvanic electrotherapy, and heat therapy
should be regarded as obsolete given the poor or
missing data reported for these methods.”
Crioterapia
38. several clinical trials revealed that it was associated with prolonged pain, foul-smelling discharge and
a high rate of persistent hemorrhoidal mass. It is therefore rarely used.
Smith LE, Goodreau JJ, Fouty WJ. Operative hemorrhoidectomy versus cryodestruction. Dis Colon
Rectum. 1979;22:10–16
Crioterapia
39. Twenty-six patients were treated for hemorrhoids by a combination of
cryodestruction and closed operative hemorrhoidectomy.
Patients were able to draw their own conclusions about the efficacies of these treatments.
They had no difficulty in distinguishing exactly which area was causing pain.
The operative site was a source of greater pain until the second day after the procedure,
when the pain resulting from cryodestruction equalled surgical pain; then cryodestruction associated pain
continued longer. Cryodestruction was associated with production of a foul discharge.
Residual hemorrhoids were present in 50 per cent of patients' cryodestruction sites.
Given the choice at the one year follow-up examination, 65 per cent preferred surgical treatment
and 35 per cent preferred cryodestruction
40. Crioterapia risultati
Southam 1983 successo 83%
Keighley 1979 dolore, astensione lavoro, 50% insoddisfatti
Complicanze
Dolore 15%
Emorragia 2-3%
Stenosi 0.5-1%
Rit urinaria, febbre
Perdite sierose 60-70%per 24 settimane
Ascessi epatici 5 casi (20% decesso)
Cellulite pelvica 5 casi (20% decesso)
Mc Cloud review 2006
43. Tecniche combinate
7850 pazienti in 9 anni
Risultato soddisfacente 90.5% emorroidectomia 9,5%
Complicanze dolore lieve moderato 22.6%, severo 2.2%, emorragia moderata
2.5%,severa 0.1%
Scleroterapia prima
Legature elastiche e Coagulazione infrarossi 15 gg dopo insieme
Ogni 15 gg, massimo 7 sedute
16% primo grado
56% secondo
25% terzo
3% quarto
Accarpio et al Tech Coloproctol 2002
44. Tecnica di Elbetti
3 grado
Anestesia locale
pessie multiple
Complicanze 5.1%
0.9% recidive follow up medio 19 mesi
48. Comparative clinical study of Apamarga Kshara application, infrared coagulation and Arshohara Vati in the management of Arsha (1st and 2nddegree hemorrhoids)
Komang Sudarmi and Tukaram Sambhaji Dudhamal1
Apamarga Kshara exerts many actions such as incision, excision debridement, scrapping and dissolution
and Kshara cauterizes the tissue indirectly by virtue of its Ksharana property (corrosiveness), in the form of local
application. It is due to its properties such as Pachana, Tikshana, Vilayaka, Shodhana, Shoshana, Amahara, Dahana,
Stambhana and Lekhana that reduced all the symptoms in case of internal hemorrhoid.
The study concluded that Apamarga Kshara application is the most effective treatment for the
management of internal hemorrhoid of 1st and 2nd degree in comparison to IRC procedure and
administration of Arshohara Vati
49. Quale tecnica scegliere
Linee guida a confronto
I grado Terapia medica Terapia medica
National UK audit
Procedure for PPH is a safe and
effective procedure for
symptomatic haemorrhoids with
good short-term outcomes. Long-
term follow up is required
perhaps through a compulsory
national register
II grado Terapia medica
Terapia ambulatoriale
(legatura elastica)
III grado
Terapia ambulatoriale
(legatura elastica)
oppure
Terapia chirurgica
(emorroidectomia)
“Stapled hemorrhoidectopexy is a new
alternative available for individuals with
significant hemorrhoidal prolapse”
Terapia chirurgica
(emorroidopessi/emorroidectomia)
IV grado Terapia chirurgica
(emorroidectomia)
Terapia chirurgica
(emorroidectomia)
Dis Colon Rectum 2005;48:189-194
Tech Coloproctol 2006;10:181-186
Colorectal Disease 2008;10:440–445
51. 18 studi 1952 pazienti
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
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
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.
Quale tecnica scegliere?
Dis Colon Rectum. 1995 Jul;38(7):687-94.
Comparison of hemorrhoidal treatment modalities. A meta-analysis.
MacRae HM1, McLeod RS.
52.
53. G Chir. 2017 Jan-Feb; 38(1): 5–14.
The non-surgical management for hemorrhoidal disease. A systematic review
G. COCORULLO,1 R. TUTINO,1 N. FALCO,1 L. LICARI,1 G. ORLANDO,1 T.
FONTANA,1 C. RASPANTI,1G. SALAMONE,1 G. SCERRINO,1 G. GALLO,2 M.
TROMPETTO,2 and G. GULOTTA1
21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS
In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%–83.8%.
IV degree prolapse should have a more invasive treatment
IS brings to the resolution of prolapse in 90%–100% of II degree and allows good results for
III degree
even if reported only by case series
54.
55. Terapia conservativa 45.2% 35.6%
Legature elastiche 44.8% 13.1%
Sclero + infrarossi 0.7% 12.5%
Chirurgia 9.3% 38.8%
SITUAZIONE DIVERSA IN PAESI DIVERSI
Diseases of the Colon & Rectum
May 1992, Volume 35, Issue 5, pp 477–481
Symptomatic hemorrhoids: Current incidence and complications of
operative therapy
Ronald Bleday
Tech Coloproctology
1995
Bottini et al
USA ITALIA
60. Conclusioni
Trattamenti efficaci con indicazione intermedia tra terapia medica e chirurgia maggiore
Vantaggio significativi per paziente e ssn (costi,tempi ripresa, complicanze)
INFORMARE sempre i pazienti per recidive non infrequenti ed eventuale necessita’ di trattamenti
ripetuti o terapie maggiori