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Minimally Invasive Treatments of Hemorrhoidal Disease


1 Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
*Corresponding author: Ahmad Izadpanah, Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel.: +98-7112306972, Fax: +98-7112330724, E-mail: izadpana@sums.ac.ir.
Annals of Colorectal Research. 2013 September; 1(2): 40-5. , DOI: 10.17795/acr-12966
Article Type: Review Article; Received: Jun 25, 2013; Revised: Jun 27, 2013; Accepted: Jul 1, 2013; epub: Jul 30, 2013; ppub: Sep 29, 2013

Abstract


Context: Minimally invasive procedures are used for treatment of nonresponsive hemorrhoids to conservative therapy. These OPD (Out-Patient Department) procedures are effective to eradicate the hemorrhoid symptoms with minimal postoperative pain and complications.

Evidence Acquisition: In this review, PubMed, and MEDLINE were searched with a time limitation (2002- 2012). Recent articles in English journals were reviewed to evaluate and compare these minimally invasive procedures including Rubber band ligation (RBL), Infrared coagulation (IRC), Direct current Electrotherapy (DCE), and Sclerotherapy.

Results: Upon the articles, 881 were treated with RBL, 454 with IRC, 1203 with DCE, and 2372 with sclerotherapy. Postoperative pain, which is a common complication of hemorrhoidectomy, was 3-25% in RBL, 2.13-4.3% in DCE, and 1.8-7% in sclerotherapy. Pain was mild to moderate and rarely needed analgesic. Postoperative rectal bleeding was seen in 1.26-32.4% of patients treated with RBL. Recurrence of preoperative symptoms was 1.9-39% for RBL, 6.9-21% for sclerotherapy, and 2.9-3% for DCE. Postoperative complications were minor in all procedures and for sclerotherapy it was seen in 6.9-21% of patients. Success rate was 69.4-96.4% in RBL, 80% in IRC, 89.3-99.7% in sclerotherapy, and 98.2% in DCE. Patients satisfaction was 98% for DCE versus 99% for RBL and IRC. Operation time for each tag of hemorrhoid was 4.5-10 minutes for DCE, regarding different amplitudes of currency and degrees of hemorrhoid, and 13 minutes for sclerotherapy and not reported for other methods.

Conclusions: Minimally invasive procedures are used depending on surgeons experience and preference. These modalities are comparable from different aspects. The cost of treatment and availability of equipment may affect the choice of modality. All of these techniques could be used in patients resulting in maximum success rate and minimum complications.

Keywords: Minimally Invasive, Hemorrhoids, Treatment

1. Context


Symptomatic hemorrhoids irresponsive to conservative therapy may be treated with minimally invasive procedures. Hemorrhoidectomy which was the gold standard for treatment of hemorrhoids (1) should be performed in operating room under anesthesia, and is associated with postoperative severe pain (2-4). Minimally invasive techniques including Rubber Band Ligation (RBL), Infrared Coagulation (IRC), sclerotherapy, and Direct Current Electrotherapy (DCE) used in treatment of hemorrhoids are preferred especially for internal second and third degree hemorrhoids. No need for preoperative enema and anesthesia for these OPD minimally invasive procedures are important advantages.

These modalities have less postoperative pain, complications and time off work, which causes more acceptances among patients (2, 5, 6). In these modalities, anal canal mucosa is not damaged except for RBL. Also fibrosis fixes mucosa to layers beneath and shrinks the vascular plexus. Reviewing articles, minimally invasive techniques have been compared in pairs, but no study has ever contrasted these altogether. Thus, we assessed recent articles from English Medical Journals to investigate the effectiveness and complications of different minimally invasive procedures in our review article.

2. Evidence Acquisition


In this review, PubMed, and MEDLINE were searched with a time limitation (2002- 2012). Recent articles in English journals were reviewed to evaluate and compare these minimally invasive procedures. The keywords used in the search were:"Hemorrhoids"OR"Hemorrhoid treatment"OR"External Hemorrhoids" and each of them with the following keywords with AND," Rubber band ligation (RBL)", "Infrared coagulation (IRC)", "Direct current Electrotherapy (DCE)", and "Sclerotherapy".

2.1. Rubber Band Ligation (RBL)

In this technique, a part of hemorrhoid is squeezed by a Rubber band hard enough to cause relative ischemia to the tissue contained within (Figure 1), which would then slough ( 2 , 6 - 8 ). Each rubber band grasps a small segment of hemorrhoid tissue; therefore, it is needed for several bands to treat each hemorrhoidal tag. Rubber bands have to be placed proximal to the dentate line; hence, severe pain is inevitable. Grasping the sphincter muscle results in severe spasm and subsequent pain. Tissue slough may lead to severe bleeding which requires suturing.

Figure 1.
Instruments and Method for Doing RBL. A Rubber Band Is Fixed Around a Piece of Hemorrhoid Tissue (27).
2.2. Sclerotherapy

In this procedure, a sclerosing agent like aluminium potassium sulfate and tannic acid (ALTA) ( 5 , 9 ), is injected into the hemorrhoid tissue which creates fibrosis and fixation of the hemorrhoid mucosa to the underlining sphincter muscle ( 5 , 8 - 10 ). Sclerosant is usually injected into each hemorrhoid (Figure 2).

Figure 2.
Injection of Sclerosant Agent Into Hemorrhoid (27)
2.3. Direct Current Electro therapy (DCE)

In this technique, the negative electrode is directed into the base of hemorrhoid (Figure 3), and the positive electrode is placed under patient's buttocks to create the shortest electrical pathway ( 11 - 13 ). A direct current is delivered at increasing amperage up to 16 mAmp in patients without general anesthesia, and 30 mAmp with general anesthesia ( 11 , 12 ). In patients with no anesthesia, amperage more and faster than abovementioned causes pain and microshock, respectively ( 11 , 12 ). The time course to treat hemorrhoid depends on the applied amperage. To illustrate, grade I hemorrhoids need 16 mAmp for 10 minutes, while may be treated in 2.5 minutes with 30 mAmp. The negative electrode should be placed proximal to the dentate line. It seems that direct current causes electrolisation and then fibrosis of the hemorrhoid plexus.

Figure 3.
Apparatus and How to Apply in DCE Method, 16 to 30 m Amp Direct Current Is applied to Hemorrhoid Plexus; Plate Which Is the Positive Electrode Is Fixed to the Patient's Buttock (12).
2.4. Infrared coagulation (IRC)

In this procedure infrared radiation coagulates proteins and creates fibrosis to eliminate the hemorrhoid in two weeks ( 14 , 15 ). The applicator tip is placed at the apex of hemorrhoid to yield a 4 mm 2 focus of coagulation with a 2.5 mm depth (Figure 4). Radiation close to the dentate line or more excess than indicated causes pain or bleeding, respectively.

Figure 4.
Apparatus and the Method Used for IRC (27)

We searched PubMed for English articles on treatment of hemorrhoid by minimally invasive techniques published in the recent 20 years. We extracted data from articles presented (Table 1) to compare these procedures regarding their effectiveness and complication.

3. Results


As shown in Table 1, the number of adult patients of either sex treated was 881 for RBL ( 16 - 21 ), 454 for IRC( 18 , 22 - 24 ), 1203 for DCE ( 11 - 13 , 25 ), and 2372 for sclerotherapy ( 5 , 9 , 10 , 26 ). Posttreatment pain, also a common complication of hemorrhoidectomy, was 3-25% in RBL, 2.13-4.3% in DCE, and 1.8-7% in sclerotherapy. This was mild to moderate and rarely needed oral analgesic. Posttreatment rectal bleeding was seen in 1.26-32.4% of patients treated with RBL. Recurrence of preoperative symptoms during follow-up was 1.9-39% for RBL, 2.9-3% for DCE, and 6.9-21% for sclerotherapy. Posttreatment complications were minor in all procedures, and for sclerotherapy it was seen in 6.9-21% of patients ( 5 ). Success rate was 69.4-96.4% in RBL, 89.3-99.7% in sclerotherapy, 80% in IRC, and 98.2% in DCE ( 4 , 5 , 9 - 11 , 13 - 24 , 26 ). Patients satisfaction was 99% for RBL and IRC versus 98% for DCE. Operation time per tag of hemorrhoid regarding different amplitudes of currency and degrees of hemorrhoid was 4.5-10 minutes for DCE ( 11 , 12 , 14 ), and 13 minutes for sclerotherapy ( 10 ), and not reported for other methods.

Table 1.
Reviewed Articles on Minimally Invasive Methods for Hemorrhoid Diseases in the Last 20 Years
Table 2.
Results of Comparing Items in Reviewed Articles About Minimally Invasive Modalities

4. Conclusion


Hemorrhoidectomy, as the gold standard in treatment of hemorrhoid, is associated with severe postoperative pain and sometimes with profuse bleeding as such the patient has to be returned back to the operating room. It is associated with more operating time, too. Patients for hemorrhoidectomy should undergo general anesthesia at hospital, and bear prolonged delay in returning to normal activities for up to a month. Thus, minimally invasive procedures have been widely adopted since years ago, holding both advantages and disadvantages. None of these techniques has been proven to be favored over others. In RBL, used for first- and second- rarely third- degree internal hemorrhoids, a small segment of hemorrhoid is placed in a rubber band, so for one hemorrhoid tag several rubber bands are used in different parts (16, 17). This means several visits for full treatment. Postoperation pain, resulting from placement of band less than two cm proximal from the dentate line or grasping the sphincter muscle, had surgeons to remove the rubber band. Sloughing of mucosa contained within the band may cause bleeding which needs surgical intervention. Serious site infection is also reported (18). In IRC, limitation of employing infrared radiation for an area of maximum 3-4 mm necessitates treatment for different parts of one hemorrhoid (22). This together with the relatively high recurrence has made this procedure unfavorable to surgeons. Injection sclerotherapy may change the anal sphincter function, induce postoperative infection and make mucosa slough creating long- term ulcer (5, 10). These have eliminated the use of this technique in most centers.

In direct- current electrotherapy (DCE), the low amperage (16 mAmp) and easy technique without the need to inject sclerosant introduce it as a safe procedure (3, 11). One drawback of this technique is the time course required to treat each hemorrhoidal tag (11) which is usually up to 30 minutes (2.5 times; each time 10 minutes). However, the advantage of not sloughing of mucosa and not adverting effect on the anal sphincter muscle, encourage surgeons to welcome it.

In further studies using DCE, increasing the amperage up to 30m Amp ( 12 , 14 ), has decreased time course of procedure to less than five minutes for each hemorrhoid. However, applying more than 16m Amp necessitates regional, spinal or general anesthesia ( 12 , 14 ). As shown in Table 2 minimally invasive techniques have few comparable complications.

Postoperative pain is reported by a small percentage of patients undergoing any technique except for RBL for up to 25% of patients. Of course, degree of pain is mild to moderate for all of these procedures not making one preferable to the other ones. Postoperative bleeding has also been reported in a small number of patients treated by any procedure, while was observed up to 32% for RBL(18), and 10% for sclerotherapy in some studies. Recurrence rate during follow up time was up to 39% for RBL, 20% for IRC, and 10.7 % for sclerotherapy (26), and was 2.5% - 3% for DCE using 30 mAmperage (12, 14). The time course required to treat was comparable for all techniques almost the same for DCE using 30m Amperage, RBL and IRC but the longest for sclerotherapy with about 13 minutes (10). Almost all patients were treated in OPD setting and as a consequence returned back to normal activities within a day. Postoperative complication was, minimal while the success rate was significant in all. Although, some studies have reported success rates of 69.4 % (22) and 79.5 % (24) for RBL and IRC correspondingly, but overall success rate for all procedures was acceptable and up to 99% (5, 9-14, 16-24, 26). Patients' satisfaction in RBL, IRC, and DCE was 98% - 99% (12, 14, 18). Postoperative complication following sclerotherapy was more than other methods resulting in less preference among physicians.

Considering limitations of this review article, minimally invasive procedures which are used depending on surgeons experience and preference are comparable from different aspects, while availability of equipment and cost of treatment may affect choice of modality. One cannot prefer one modality over the other types. It seems that all of these techniques have the opportunity to be used in patients resulting in maximum success and minimum complications.

Acknowledgments

The author would like to thank Colorectal research center of Shiraz University of Medical Sciences for their cooperation.

Footnotes

Implication for health policy/practice/research/medical education: This article is a review of Minimally Invasive Treatments of Hemorrhoidal Disease. It is helpful for gastroenterologist colorectal and general surgeons.
Authors' Contribution: The author has conducted the whole manuscript.
Financial Disclosure: No financial interest to report.
Funding/Support: The work was supported by colorectal research center of Shiraz University of Medical Sciences.

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Table 1.

Reviewed Articles on Minimally Invasive Methods for Hemorrhoid Diseases in the Last 20 Years

Publishing Date Retrospective vs. prospective Modality of treatment No. of patients (Success rate, %) Post–op pain, % Post–op bleeding (continuous bleeding), % Recurrence, % Return time to work Satisfaction of patient,% (or score) Modality Facility Operation Time, minutes/tag of hemorrhoid Complications
Norman DA, 1989, 16m Amp Prospective DCE 120 Safe, pain less, effective 10
Wright RA, 1991 CE 16
Izadpanah A, 2004, 30m Amp Prospective CE 931 (97.1) 8,One day 2.5 2.9% 2days 98 Safe, effective, No complication 4.5-7
Izadpanah A, 2005, 30m Amp Prospective CE 136 (91) 15, 2-7 days 3 3% 1-2 98 Safe effective short operative duration, less pain 6.1
Filingeri, 2012 Prospective RBL 360 (69.4) 2.08 ± 1.1 (2.69 ± 1.12) ? 30.6% 6.61± 2.35 comfort
Yano T, 2012 Prospective Sclerotherapy (ALTA) 37 2.13 ± 1.26 (2.38 ± 1.18) 20.5% 6.72 ± 2.28
Jahanshahi A, 2012 prospective Diode laser, IRC 341 3.51%
Miyamotor H. Yano To, 2012 Sclerotherapy 28(89.3%) 57 (53%) 10.7% 21% 10.7% 42% Useful, less invasive 21% (7% real)
Hachiro Y, 2011 Sclerotherapy 121 48 706 5 (96.4-99.7%) 3.6% 6.3% Simple safe 6.9%
Tokunaga Yakihiko, 2010 Sclerotherapy 784(96) 1.8 4% Out patient 13 minutes
Sekowskam, 2011 RBL 474(68.5) Score of pain: 0.3 (95%) 11% 3.8 days Tolerable
Marques CF, 2006 IRC 47 29.6% 4.3% 99% Effective Minor
RBL 47 19.2% 32.4% 99%
Wehrmann T, 2004 Prospective RBL 100 25%, Severe 7% 3.5% 20% Minor
Fukuda A, 2004 Prospective RBL 82 (89) 1.0.3 1.26 1.94 Safe effective
Vrzgula A, 2001 Prospective RBL 77 (91) 8% 39% 1day
Gupta PJ, 2007 Prospective IRC 300 Easy Safe Painless Quick Pruritus defecation discomfort anal discharge
Poen AC, 2000 Prospective RBL IRC 65 (97%) 68 (92%) More severe than IRC 18%, In time of F.U. 20% Effective

Table 2.

Results of Comparing Items in Reviewed Articles About Minimally Invasive Modalities

VariablesRBLIRCDCESclerotherapy
Patients, No.8845412042374
Pain mild/moderate, %0.3 - 252.13 - 4.38 - 151.8 - 7
Bleeding, %1.26 - 32.44.32.5 - 310.7
Recurrence, %1.9 - 39202.9 - 33.6 - 10.7
Operation time-4.5 - 10 m/tag a13 m b
Return to work, day111 - 2 1
Post op complicationMinorMinor6.9 (21)
Success rate, %69.4 - 9979.5 - 9997 - 97.196 - 96.4
Patients satisfaction, %999998
Abbreviations: a m/tag; minutes/tag oh hemorrhoid, b m; minutes

Figure 1.

Instruments and Method for Doing RBL. A Rubber Band Is Fixed Around a Piece of Hemorrhoid Tissue (27).

Figure 2.

Injection of Sclerosant Agent Into Hemorrhoid (27)

Figure 3.

Apparatus and How to Apply in DCE Method, 16 to 30 m Amp Direct Current Is applied to Hemorrhoid Plexus; Plate Which Is the Positive Electrode Is Fixed to the Patient's Buttock (12).

Figure 4.

Apparatus and the Method Used for IRC (27)