Hemorrhoids high-fiber diet Surgical therapy
Transcrição
Hemorrhoids high-fiber diet Surgical therapy
Hemorrhoids Standards der proktologischen Chirurgie und Nachsorge in Bern Lukas Brügger Clinic for Visceral and Transplantation Surgery Inselspital, University of Bern Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch highhigh-fiber diet • Systematic review: - 7 RCT (n=378) Symptoms↓ by 53%, bleeding↓ by 50% • Limitations: - Publication bias - Moderate study quality Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Alonso-Coello P. Cochrane Database 2005 Rubber band ligation Metaanalysis: 18 RCTs • Response to treatment: – Hemorrhoidectomy > rubber band ligation > sclerotherapy/infrared coagulation Venotonics: Venotonics: flavonoids • Systematic review: – 14 RCT (n=1514) • Risk reduction: – – – – – Not improving symptoms 58% Bleeding 67% Pain 65% Itching 35% Recurrence 57% • Limitations: - Publication bias - Moderate study quality Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Alonso-Coello P. Br J Surg 2006 Surgical therapy ∼ 400 articles in pubmed in last 5 years ∼ 30 RCT 6 Metaanalysis • Pain: – Hemorrhoidectomy > rubber band ligation > sclerotherapy/infrared coagulation • Complication rate: – Hemorrhoidectomy > rubber band ligation = sclerotherapy Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch MacRae HM. Dis Colon Rectum. 1995 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch 1 HAL (hemorrhoidal (hemorrhoidal artery ligation) ligation) Stapled Hemorrhoidopexie(PPH) Hemorrhoidopexie(PPH) vs Conventional Hemorrhoidectomy (CH) • 12 RCT (17 potentially eligible) • After PPH – Recurrence ↑: 8.6% vs 1.5% » Odds Ratio 3.85 – Symptom of prolapse ↑ » Odds Ratio 2.68 – Trends: pain↓, pruritus ani↓, anal stenosis↓, fecal urgency↓ • No anesthetics / LA → Outpatient procedure possible • Easy (3-5 procedures) • Pain: – ↓ compared to PPH/diathermy – no difference to rubber band ligation • Other parameters in favor of CH (trends) • Skin tags? • No RCTs – Bleeding, reoperation, skin tags Jajaraman S. Cochrane Database 2006 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Faucheron JL. Dis Colon Rectum 2008 (online) Greenberg R. Dis Colon Rectum 2006 Which Therapy? Therapy? Grade I Grade II Grade III Grade IV yes Intraop Reposition no 3-22% Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Faucheron JL. Dis Colon Rectum 2008 (online) Postoperative treatment Ferguson (CH) • Paracetamol 500mg 3x1 7d (i.R 3x1), Mefenamin acid 4x500mg i.R. • Shower: 2x/die and after defaecation • High fiber • Daflon 500mg (2x1 14d) • Inability to work : 1-2 weeks • Outpatient Clinic 6 weeks Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Longo (PPH) • Paracetamol 500mg 3x1 3d (i.R. 3x1) • High fiber • Daflon 500mg (2x1 14d) • Inability to work: 3 days • Outpatient Clinic 6 weeks Conservative Rubber band (HAL) Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch •1/2 piles •skin tags ≥3piles Circular Mucosal prolapse Ferguson (HAL) Ferguson PPH (HAL) PPH Ferguson Acute perianal thrombosis • Failure / recurrence: 30-50%! • Skin tags Excision superior to Incision Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Buchmann P. Huber, Bern 2002 Cavcic J. Dig Liver Dis 2001 Cataldo P. Dis Colon Rectum 2005 Greenspon J. Dis Colon Rectum 2004 Eu KW. Br J Surg 1994 Heald RJ. Br J Surg 1986 2 Acute perianal thrombosis Perianal thrombosis • PPH vs CH • n=41, median follow up: 56/59 weeks • PPH group: – – – – – Only external Pain↓ Resumption of work earlier Time for complete wound healing↓ Recurrent symptoms↓ Patients satisfaction↑ Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Wong JCH. Dis Colon Rectum 2007 acute Excision (PPH) Incision subacute Daflon 500 mg* High fiber diet Lidocaingel/Coldpack NSAR Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Fistulotomy Fistula/Perianal abscess • Incontinence: 0-45% Hyman NH. Prim Care 1999 • Recurrence: 3-39% Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch (Cutting) Cutting) Seton Incontinence rate: up to 63% Recurrence: 0-29% Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch (Mucosa) Mucosa) Advancement Flap • Rate of incontinence: 15-21.4%* Cutting Seton: – – Van der Hagen SJ. Int J Colorectal Dis 2006 Toyonaga T. Int J Colorectal Dis 2007 *Preop: 8.9% Joy HA. Colorectal Dis 2002 Graf W. Eur J Surg 1995 Hasegawa H. Acta Chir Iugosl 2000 Isbister WH. Dis Colon Rectum 2001 Hammond TM. Colorectal Dis 2006 • Recurrence: 3-63% Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Uribe N. Int J Colorectal Dis 2007 Van der Hagen SJ. Int J Colorectal Dis 2006 Mizrahi N. Dis Colon Rectum 2002 Sonoda T. Dis Colon Rectum 2002 Ortiz H. Br J Surg 2008 3 • n=49 • Healing: Conventional* Fibrin glue Simple fistula 7/7 (100%) 3/6 (50%) Complex fistula 2/16 (13%) 9/13 (69%) • Follow up: 3 months! *draining/cutting setons, advancement flaps – 53% (10-78%); Follow up 3-28 months – Repeated glue application: 56% Lindsey I. Dis Colon Rectum 2002 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch • 14 prospective cohort studies, 1 RCT • N=378 • Healing rate: Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Swinscoe MT. Tech Coloproctol 2005 Fistula plug vs fibrin glue Prospective cohort study! - No longterm follow up! • n=30, (7 Crohn) • Healing within 3 months: 97% • Recurrence: 22% n=25 Follow up 22 (8-52 months) Johnson K. Dis Colon Rectum 2006 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Abscess Incision (Seton) MRI Endosono Seton ja EUA Seton 2 months 2 months MRI Endosono Van der Hagen SJ. Colorectal Disease 2005 Postoperative treatment Fistula Seton nein Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch No healing Diverting stoma • Paracetamol 500mg 3x1 7d (i.R 3x1), Mefenamin acid 4x500mg i.R. • Shower: 2x/die and after defaecation • High fiber • Inability to work : 1-2 weeks • Outpatient Clinic 6 weeks healing Mucosaflap Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch No healing Fistulotomy (Cutting Seton) Low fistula intersphincteric Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch 4 Topic treatment Exogenous NO donors Chronic Anal Fissure Glyceril trinitrate (GTN), isosorbide dinitrate (ISDN), Calcium channel blockers • Healing rates – 1 month: 0-40% – 2 months: -65% – 3 months: 88% Schouten WR. Gut 1996 Lund JN. Dis Colon Rectum 1997 Carapeti EA. Gut 1999 Kocher HM. Br J Surg 2002 Songun I. Dig Surg 2003 Werre AJ. Eur J Surg 2001 Evans J. Dis Colon Rectum 2002 • Headache (GTN/ISDN): 40% Nelson R. Cochrane Review 2003 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Lateral sphincterotomy Botulinum Toxin • Healing: 95% Argov S. Am J Surg 2000 • Incontinence: – Flatus: up to 45% Nyam DC. Dis Colon Rectum 1999 Ortiz H. Br J Surg 2005 Casillas S. Dis Colon Rectum 2005 Lindsey I. Br J Surg 2004 – Stool: 22% Jorge JM. Dis Colon Rectum 1993 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch T 6 % g 5% 9 n : 44 soili g alin inor e H tm en i s ran Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Systematic review • GTN marginally but significantly better than placebo – 48.6 vs 37% (p=0.004) • Recurrence 50% • No incontinence • Botox/Calcium channel blockers – Equivalent in efficacy to GTN – Fewer adverse events (headache) • No medical treatment came close to lateral sphincterotomy Jost WH. Int J Colorectal Dis 2002 Debridement • RCT: Lateral sphincterotomy ± removal anal papilla – Pain/irritation during defecation↓ – Foreign body sensation↓ – Pruritus / wetness around anal verge↓ – Patients satisfaction↑ Gupta PJ Tech Coloproctol 2003 Gupta PJ World J Gastroenterol 2004 • Debridement + Botox (cohort study) – Healing short term 90-93% – Healing long term 79% (1 year) » 5% repeated procedure Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Nelson R. Cochrane Review 2006 Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Lindsey I. Dis Colon Rectum 2004 Scholz Th. Int J Colorectal Dis 2007 5 6 weeks, 4x/d: GTN 0.2% Nifedipine 0.2% fibers No pain, fissure not healed fissure healed No improvement Fibers 3 months Diet lifelong Botox + Debridement No improvement after 3x Botox pain 6 weeks or not healed 3 months Exclusion other diseases →colonoscopy negative Lateral Sphincerotomy debridement Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch Viszerale und Transplantationschirurgie Inselspital, Universität Bern www.chirurgiebern.ch 6