*Małgorzata Kołodziejczak1, 2, Przemysław Ciesielski1, 2
Recent trends in the treatment of benign proctological diseases in relation to historical methods. What has changed? What has survived?
Najnowsze trendy w leczeniu łagodnych chorób proktologicznych w odniesieniu do metod historycznych. Co się zmieniło? Co przetrwało?
1Warsaw Proctology Centre St. Elizabeth’s Hospital in Warsaw
2Department of General Surgery SPZ ZOZ in Ostrow Mazowiecki
W artykule przedstawiono najnowsze trendy w leczeniu łagodnych chorób proktologicznych: choroby hemoroidalnej, szczeliny odbytu, przetoki odbytu, cysty włosowej i inkontynencji, w oparciu o piśmiennictwo i własne doświadczenie, odnosząc się do metod historycznych. W ostatnich kilkudziesięciu latach nastąpił skokowy rozwój diagnostycznych metod obrazowych. Udoskonalenie sprzętu operacyjnego wpłynęło na pojawienie się nowych technik operacyjnych.
W artykule omówiono techniki małoinwazyjne ze szczególnym uwzględnieniem technik endoskopowych w leczeniu choroby hemoroidalnej i wskazania do ich zastosowania, trendy w leczeniu przetok odbytu, szczelin i inkontynencji. Porównując współczesne metody leczenia chorób proktologicznych i metody historyczne, stwierdzono, że pomimo postępu w zakresie diagnostyki, metod operacyjnych, sprzętu operacyjnego i stosowanych leków, większość zasad leczenia pacjentów proktologicznych przetrwała. Podstawowe principia w postaci dążenia do zachowania kontynencji u pacjenta oraz ograniczenie infekcji pozostały niezmienione.
This paper presents the latest trends in the treatment of benign proctological diseases such as haemorrhoidal disease, anal fissure, anal fistula, hair cyst and incontinence, based on the literature and our own experience, as well as referring to historical methods. The last few decades have seen a leap in the development of diagnostic imaging methods. Furthermore, improvements in surgical equipment have contributed to new surgical techniques.
This article discusses minimally invasive techniques, with particular emphasis on endoscopic methods, in the treatment of haemorrhoidal disease and indications for their use, as well as trends in the treatment of anal fistulas, anal fissures and incontinence. Comparison of modern and historical therapeutic approaches used in proctological diseases showed that despite advances in diagnosis, surgical methods and equipment, as well as pharmacotherapy used, most principles for treating proctological patients have persisted. The basic principles of aiming to preserve continence and limit infection remained unchanged.
Having practised as a surgeon for more than 40 years, during my career I have witnessed the development of proctology in Poland. New diagnostic modalities, surgical techniques, equipment and methods of anaesthesia have emerged. At the beginning of my medical career, I was fortunate to learn from such masters as the associate professor Mieczysław Tylicki and Maciej Grochowicz, MD, PhD and to witness successive innovations introduced in the treatment of proctology patients. I observed that many of the principles of surgical management that I have learnt from my masters are timeless. These thoughts prompted me to write an article in which we will attempt to present the latest surgical trends in the context of historical methods. For clarity, the topic will be discussed in relation to specific clinical entities.
The principle that patients with first grades (I-II) of haemorrhoidal disease are treated conservatively by recommending a fibre-rich diet combined with topical and systemic medications has not changed. If conservative treatment is ineffective, the next step is to use alternative methods, which include treatment up to grade III haemorrhoidal disease. A number of minimally invasive methods for haemorrhoidal disease have been used for many years, including rubber band ligation (Barron’s method), sclerotherapy, laser obliteration, Doppler Guided Haemorrhoidal Artery Ligation (DGHAL), radiofrequency and others. In most cases, these procedures are performed on an outpatient basis, using a conventional, rigid, anoscope. In recent years, many reports have been published showing the great benefits of using a flexible endoscope (colonoscope or gastroscope) for the above procedures (1). Some authors are of the opinion that endoscopic treatment of haemorrhoids causes only negligible complications, causes little pain and should be first-line treatment for haemorrhoidal disease, although it is less effective than classical surgery (1).
Endoscopic procedures for haemorrhoidal disease
The historical method of rubber band ligation (RBL) is the most commonly performed endoscopic procedure for haemorrhoids. The technique was originally described by Blaisdell in 1958 (2), modified by Barron in 1963 (3), and is still the most commonly used alternative option for the treatment of low-grade haemorrhoidal disease. Its next modification may show promise.
In the literature, endoscopic ligation of haemorrhoids is referred to as ERBL (endoscopic rubber band ligation). The first ERBL procedure was described by Trowers et al. (4) as early as in 1998, but it is only in recent years that this technique has become more widely used.
The endoscopic procedure is performed with colonoscope or gastroscope positioned in inversion. An important advantage of the procedure is that bands can be placed on all three haemorrhoids during the same session. When performed correctly (as with the classic Barron’s procedure), the procedure should be pain-free, as the haemorrhoids are located above the pectinate line, i.e. above the zone sensitive to pain, and the bands are placed approximately 5 mm above the pectinate line, directly on the uninnervated pedicles.
Sclerotherapy is a palliative treatment for low-grade haemorrhoidal disease. The first obliteration was performed by Morgan (Dublin) in 1869. He injected iron persulphate into haemorrhoids. Mitchell (Clinton), who in 1871 began using obliteration in the form of injections of a solution consisting of one part carbolic acid, or phenol, and two parts olive oil, is considered the pioneer of sclerotherapy in the United States. Officially, the obliteration method was described by Blanchard in 1928. Blanchard used 5% phenol in almond oil for obliteration. Today, the most commonly used preparation is 3% polidocanol.
The multitude of obliterating substances used reflects imperfection and constant search for improving treatment outcomes (mainly efficacy) with this method. It does not solve the problem of mucosal prolapse and is effective for minor bleeding in low-grade haemorrhoidal disease. Although sclerotherapy is considered the oldest treatment modality for haemorrhoidal disease, it is also offered alongside recent endoscopic techniques. As a method, sclerotherapy has survived for many years (with short learning curve and negligible complications) and has also been rejuvenated in the form of endoscopic administration of obliterating agents. The first endoscopic administration of hypertonic saline to the base of a haemorrhoid was described in 1991 by Ponsky et al (5). In order to minimise the risk of complications, some authors recommend performing the so-called cap-assisted endoscopic sclerotherapy (CAES), which allows better visualisation and thus precise administration of the obliterating agent during the procedure (6, 7).
Other endoscopic procedures for haemorrhoids include haemorrhoid energy therapy (HET). To date, there are no large randomised trials on HET, although some reports on this procedure are promising (8).
Good visualisation of the surgical field during the procedure and the simultaneous possibility of diagnosing other anorectal pathologies (inflammatory bowel diseases, tumours) are undoubtedly advantages of endoscopic procedures. Furthermore, endoscopic procedures are minimally invasive and also have a negligible rate of complications, such as postoperative bleeding and pain. Although less invasive compared with classical haemorrhoidectomy, they are also less effective as they fail to solve the problem of perianal lesions, hypertrophied anodermal folds or perianal thrombosis and it seems that they should be used up to grade III haemorrhoidal disease at the furthest.
Laser obliteration of haemorrhoids
Diode laser obliteration has been used since 2006 for grade II and III haemorrhoidal disease. In some cases, the procedure is combined with classical removal of marginal anodermal folds. The laser can be used in two options: HeLP (haemorrhoid laser procedure) and LHP (laser haemorrhoidoplasty), and the two methods differ in where the laser fibre is inserted (above the pectinate line in HeLP, at the base of the haemorrhoid in LHP). In order to perform the procedure more precisely, some surgeons predetermine the location of the haemorrhoidal arteries using Doppler (9-11). The laser method is well-established in the treatment algorithm for haemorrhoidal disease; nevertheless, it can also be associated with serious complications, such as abscess or iatrogenic fistula, and sometimes, surprisingly for patients, with postoperative pain and swelling.
Modifications of the Milligan-Morgan method
Classical haemorrhoidectomy was described in 1937 by Milligan and Morgan in Lancet and is still the most widely used classical method of haemorrhoid removal worldwide (12). The principle of the method in the form of puncturing individual vascular pedicles and resecting the haemorrhoids, leaving the wounds to heal open is used by most surgeons, although many modifications have been introduced (13). The search for new solutions is dictated by the need to reduce postoperative pain after classical surgery, accelerate the healing process and reduce possible complications, such as anal canal stenosis. For these reasons, some surgeons supplement the method with an internal sphincterotomy, which undoubtedly reduces post-operative pain associated with increased internal sphincter tone. Personally, I rarely combine sphincterotomy with haemorrhoidectomy; I do so in carefully selected cases, usually when haemorrhoidal disease is accompanied by anal fissure and sphincter tone is pathologically increased. Any modification of a proven, conventional method should be preceded by a careful analysis of the anatomical consequences associated with the procedure (including distant sequelae), as confirmed by some experts (14). Contemporary use of historical therapeutic methods for haemorrhoidal disease is summarized in table 1.
Tab. 1. Contemporary use of historical therapeutic methods for haemorrhoidal disease
|Historical method||In what form has it survived|
– endoscopic obliteration
|Baron’s rubber band ligation||– classical rubber band ligation (RBL)|
– endoscopic rubber band ligation (ERBL)
|surgical treatment||– classical Milligan-Morgan surgery|
– modification of surgery with sphincterotomy
Further development of fistula imaging methods (transrectal ultrasound and MRI) is being observed in fistula diagnosis. More and more is also expected of radiologists – not only a description of the relation of the fistulous tract to the sphincter and the location of the internal opening, but also an assessment of the width of the tract in individual sections (the transsphincteric in particular), which determines the possibility of using many minimally invasive methods (e.g. laser, where the obliteration radius specified by the manufacturer is 6 mm, while a fistulous tract up to 4 mm in diameter is obliterated in practice). Also, before applying some of the latest surgical techniques, e.g. before the transanal opening of intersphincteric space (TROPIS), the author of the method recommends MRI to visualise the location of intersphincteric reservoirs, especially if the internal opening is not visible on clinical examination. The author of the TROPIS method, doctor Garg from India, presented a paper describing a group of 757 patients with horseshoe anal fistulas. The internal opening could not be located in 22% patients as opposed to 78%. All of them had a preoperative MRI scan performed, which made it possible in patients with incomplete fistulas to locate the site where the internal opening was closest to the internal sphincter, and to assume that the internal opening was most likely to be in this location. In posterior horseshoe fistulas without an internal opening, it was assumed that the opening was in the posterior crypt. A fistulotomy was performed in low fistulas and a sphincter-sparing approach was used in high fistulas, achieving a similar 90% cure rate in both groups. The new procedure was successful as a high cure rate could be achieved for fistulas with an unidentified internal opening. The outcome was comparable to the second group of patients with complete fistulas (15). Garg demonstrated the high diagnostic value of MRI for incomplete fistulas, which was reflected in practice when treating these patients.
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