MANEJO ACTUAL DE LAS HEMORROIDES
Dr. Stanley Goldberg
INTRODUCTION
Hemorrhoid disease afflicts over one million Americans per year. Problems with
hemorrhoids manifest in several ways, including isolated external disease with
thrombosis, mixed internal and external hemorrhoid disease, and primary
internal hemorrhoidal disease are common and present with either prolapse,
bleeding, or thrombosis.
GRADE AND TREATMENTS
The severity of the rectal mucosal prolapse in internal hemorrhoidal disease
varies from Grade I, with minimal redundant mucosa and no prolapse, to
Grades II and III, with increasing degrees of either spontaneously or manually
reducible hemorrhoidal mucosa, up to Grade IV, where there is complete
prolapse of the hemorrhoidal mucosa that cannot be reduced back into the anal
canal. For most patients with symptomatic Grade I disease, we recommend
conservative therapy with a combination of supplementary dietary fiber and
counseling on bathroom habits. For patients with symptomatic Grade II disease
or minimal Grade III disease, we recommend an office procedure such as
rubber band ligation to fix the redundant prolapsing mucosa to the underlying
muscle. For advanced symptomatic Grade IV disease, we recommend surgery.
Approximately 25% of patients who undergo surgery present with acute
symptoms and have to be brought to the operating room on an emergency
basis. This group includes postpartum patients. We recommend urgent surgery
for acute symptoms in postpartum patients if they have had a previous history of
symptomatic hemorrhoids.
In a recent five-year review of the University of Minnesota experience, with over
20,000 patients who presented with symptomatic hemorrhoids, we found that
only 9% of patients required surgery. Conservative therapy was given to 45%
of patients, while 46% had an office-based fixation procedure such as rubber
band ligation.
SURGICAL TECHNIQUE
For surgery, we used a variety of anesthetics from general endorectal
anesthesia to local anesthesia with intravenous sedation. We prep the patient
with two Fleet enemas about 1-2 hours before surgery. We place the patient in
the prone position. The incision is started caudal to the dentate line in order to
remove present or potential skin tags, then carried cephalad removing only a
small wedge of anoderm. The mucosa is undermined and all hemorrhoid tissue
is removed down to the internal sphincter muscle. Hemostasis is insured with
the cautery. We have found that about 20% of patients will have an associated
fissure, especially those with Grade II disease. We perform a partial lateral
internal sphincterotomy in these patients and in other patients who have
evidence of fibrosis and scarring of the distal internal sphincter muscle. We
approximate the mucosal edges with a chromic stitch and often reinforce the
proximal dissection with a figure-eight “crown” stitch of 2-0 vicryl. We do not
use any packing. We continue to use this standard closed hemorrhoidectomy
technique and have not been impressed enough with new techniques, such as
laser hemorrhoidectomy, to change our practice.
COMPLICATIONS AND LENGTH OF STAY
Our complications include a 10-20% urinary retention rate, and a 2% incidence
of delayed hemorrhage. Abscessses or cellulitis infections are extremely rare.
Our overall length of stay in hospital averages 2.5 days, and has decreased
over the past decade from an average of 4 days.
EXTERNAL HEMORRHOIDS
For isolated external hemorrhoid thrombosis, we recommend early excision of
the thrombosed hemorrhoid, not incision. We have had excellent results with
this procedure because it immediately relieves the pain of thrombosis and
prevents recurrence.
CONCLUSION
Most cases of symptomatic hemorrhoids can be managed without surgery. For
internal or mixed hemorrhoid disease, we recommend a closed technique if
surgery is needed. Even though we are limiting surgery to only those patients
with the most severe disease, the length of stay for operative therapy is
decreasing. We predict that in the future, the incidence of office-based
procedures such as rubber band ligation or infrared coagulation will increase,
with a decrease In the incidence of operative therapy for symptomatic
hemorrhoids.