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© Borgis - Postępy Nauk Medycznych 8/2013, s. 548-551
*Przemysław Ciesielski1, Małgorzata Kołodziejczak2
Co nowego w leczeniu choroby hemoroidalnej?
What’s new in the treatment of hemorrhoidal disease?
1Department of General Surgery, District Hospital, Wołomin
Head of Department: Krzysztof Górnicki, MD, PhD
2Department of General Surgery, Proctology Unit, Solec Hospital, Warsaw
Head of Department: Jacek Bierca, MD, PhD
Head of Unit: Małgorzata Kołodziejczak, MD, PhD
Od wielu lat zakres wykonywanych zabiegów i operacji w chorobie hemoroidalnej ulega jedynie niewielkim zmianom. Różnorodność metod leczniczych, oraz kolejne pojawiające się modyfikacje zabiegów i operacji mają służyć poprawieniu komfortu pacjenta, zmniejszeniu ilości powikłań i kosztów leczenia. Przedstawiona w pracy analiza obejmuje literaturę publikowaną w ostatnich latach w Polsce i zagranicą. Ujawnia trendy w prowadzonych badaniach nad nowymi metodami oraz podejmuje próbę oceny skuteczności poszczególnych operacji w oparciu o publikowane badania randomizowane. W pracy przedstawiono również wyniki prac oceniających stosowanie nowych preparatów w leczeniu zachowawczym choroby hemoroidalnej, oraz spostrzeżenia dotyczące pojawiających się powikłań wczesnych i późnych niektórych metod operacyjnych. Autorzy przedstawili wyniki badań nad zwalczaniem bólu pooperacyjnego u pacjentów po operacji choroby hemoroidalnej w IV stopniu, oraz preparatami stosowanymi w gojeniu ran pooperacyjnych. Omówiono również spostrzeżenia dotyczące leczenia chorych ze współistniejącymi z chorobą hemoroidalną chorobami zapalnymi jelita grubego i odbytnicy.
For many years, the number of treatments and operations for hemorrhoids is only slightly changed. The variety of treatment methods, and subsequent modifications emerging treatments and operations are designed to improve patient comfort, reduce the number of complications and costs. Analysis presented in the paper covers the literature published in recent years in Poland and abroad. It reveals trends in current research on new methods and attempts to assess the effectiveness of these operations on the basis of published randomized trials. The paper presents the results of evaluating a new formulation for the treatment of hemorrhoidal disease, and insights on emerging early and late complications of certain surgical procedures. The authors present the results of research on postoperative pain management in patients after surgery hemorrhoidal disease stage IV, and preparations used in the healing of surgical wounds. It also discusses insights into the treatment of patients with co-existing with the hemorrhoids inflammatory diseases of the colon and rectum.
Epidemiology of hemorrhoidal disease, particularly in the context of increasingly earlier diagnoses in young people creates the need to search for new methods of treatment or modifications of the proven techniques of surgical and operational treatment. Despite numerous attempts of many years, the number of treatments and operations for hemorrhoids is only slightly changed. Modifications of the various methods are designed to improve the patient’s comfort, reduce the number of complications and cost of treatment. Similar goals are set to explore new methods of conservative treatment. Especially a lot of work is devoted to the treatment of postoperative pain.
The methods so far working in patients with the second and third degree hemorrhoidal disease are used in some modifications in the fourth degree of the disease, researchers are trying to prove their superior efficacy using the asset of less tissue trauma. Long-term results of treatment also verify the correctness of the set thesis.
The established position of conservative treatment of hemorrhoidal disease in the early stages of its progress is evident. Researchers are still looking for new, more effective methods of conservative treatment of symptoms associated with a history of surgery.
According to the Chinese researchers large doses of micronized oral diosmin proved to be one such method of treatment. Treatment with the described preparations reduces pain, bleeding and itching accelerating wound healing, as shown in a randomized study of statistically significant levels during the period from the operation to 8 weeks after treatment (1).
Reduction of pain in the early postoperative period may be obtained by the application of Bupivacaine injections of 300 mg in the form of liposomal particles of long release to the surgical wounds. This relationship has been proven as part of its multi-center randomized study in a large population of people undergoing Milligan-Morgan procedures. The resulting pain relief also allowed to reduce the supply of opioids and NSAIDs for up to 72 hours after surgery (2).
The authors describe good results of analgesia with the oral use of metronidazole or in the form of suppositories (3). In our own surgical practice we often use metronidazole suppositories and topically acting 2% diltiazem ointment decreasing the tension of sphincters. Calcium channel blockers as a factor reducing postoperative pain proposed by other authors as well (4).
A similar effect of analgesia after open surgery was also confirmed in studies with 2% diltiazem (5). There is no evidence, however, that another calcium channel blocker, nifedipine which is given in the form of a 0.3% ointment enhanced the analgesic effect of standard measures after hemorrhoid surgeries (6).
An interesting proposal for the conservative treatment of acute hemorrhoids is the oral administration of calcium channel blockers. These drugs are designed to reduce the tension of the internal sphincter and secondary reduction of pain symptoms (7). It is known that calcium channel blockers have their use in the treatment of anal fissure, where the increase of the tension of internal sphincter is one of the main factors involved in the pathogenesis of this disease. The authors, in patients treated with this method, observed in anoscopy reducing inflammatory states.
In the publications of the last two years there have been reports describing the use of a combination of aluminum, potassium sulfate and tannic acid (ALTA) in the treatment of hemorrhoidal disease. It is given as a submucosal injection. The procedure is performed under local anesthesia and the early effects of treatment are judged to be very good and involving a small number of complications (8, 9).
Another novelty is the combination of DGHAL method (Doppler Guided Hemorrhoidal Artery Ligation) with a laser. In this case, the laser takes the place of a surgical thread closing the vessel located using the Doppler head. In the opinion of the authors, published in Disease Colon and Rectum last year the new method of operation gives less postoperative pain and improves the quality of life in patients with the second and third degree hemorrhoidal disease. The cost of this treatment is still greater than in the case of DGHAL (10, 11).
A notable use of DGHAL method is the treatment of hemorrhoidal disease in patients with Crohn’s disease (12). As is known, healing of the anal canal in patients with inflammatory bowel is, particularly during acute inflammatory disease, significantly impaired. The authors of that article describe good results of the use of DGHL in patients with Crohn’s disease in the 3rd period of hemorrhoidal disease.
Another new method of operation is marginal fold resection with submucosal electrocoagulation of hemorrhoids (SEC – submucosal electrocoagulation). Electrocautery electrode is inserted under the mucosa through the wound after the cut without cutting the marginal folds of the mucous membrane of the anal canal. According to the authors, this approach reduces pain, accelerates wound healing, prevents bleeding and stenosis after surgery (13).
Satisfactory results obtained in the treatment of the hemorrhoidal disease in stage II and III using the DGHAL method prompted researchers to attempt to search for the application of this method in the higher stages of the disease (III and IV). The innovative solution of DG-RAR method involves enrichment of the method resulting in duplications of mucosa allowance in a line parallel to the long axis of the anal canal. The result is “pulling in” external hemorrhoids. DG-RAR (Doppler-guided Recto-Anal Repair) at the same time reduces pain and perioperative bleeding (14). Other researchers shall describe similar observations and good results (15).
A large number of papers published on stapler hemoroidectomia shows the popularity of this method. Opinions as to its effectiveness, complications and costs, however, are divided. The works positively assessing long-term positive effect of the treatment often stress the importance of surgical technique and the learning curve in this method. A study based on a group of more than 7300 patients operated at a single center over subsequent seven years showed a small percentage of bleeding (4%), urinary retention (4%), postoperative pain (1.7%) and stenosis (1.2%). Relapse concerned only 14 patients in such a large study group. This demonstrates the clear impact of surgical technique on outcomes (16). In multicenter studies the described recurrence and complications after hemoroidectomia surgery using a circular stapler are much higher and estimated at about 10% (17).

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2. Gorfine SR, Onel E, Patou G, Krivokapic ZV: Bupivacaine extended-releaseliposom injection for prolonged postsurgical analgesia in patients undergoing haemorrhoidectomy: A multicenter, randomised, duble-blind, placebo-controled trial. Dis Colon Rectum 2011; 54(12): 1552-1559.
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otrzymano: 2013-05-15
zaakceptowano do druku: 2013-06-26

Adres do korespondencji:
*Przemysław Ciesielski
Department of General Surgery, District Hospital
ul. Gdyńska 1/3, 05-200 Wołomin
tel.: +48 (22) 763-31-16
e-mail: przemyslaw.ciesielski@szpitalwolomin.home.pl

Postępy Nauk Medycznych 8/2013
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