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
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