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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Surgical Treatment of Haemorrhoids


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Haemorrhoids are common in men and women. About half of the population has haemorrhoids by the age of 50. It has been estimated that 58% of people over 40 years have haemorrhoids in the United States (1).


In general, there are two types of haemorrhoids: internal and external haemorrhoids. Internal haemorrhoids are classified as:

Image ch39tu1.jpg

There is no similar classification for external haemorrhoids. They are considered to be swelling of the skin and anoderm around the anus. Skin tags are later stages of external haemorrhoids (2).


Haemorrhoids are swollen blood vessels in and around the anus and lower rectum that stretch under pressure. Increased pressure and swelling may result from straining to move the bowel. Other contributing factors included pregnancy, heredity, aging, and chronic constipation or diarrhea (25).


The following physical signs may accompany haemorrhoids: bleeding, prolapse, pain, itching, rectal dysfunction, soiling.

Differential diagnosis

Differential diagnosis of haemorrhoids includes anal tags, fibrous anal polyp, anal fissure, dermatitis, perianal haematoma, rectal prolapse, and rectal tumor (6).

Treatment options for haemorrhoids include

  • Rubber band ligation
  • Infrared photocoagulation
  • Bipolar diathermy
  • Sclerotherapy
  • Cryotherapy
  • Open Haemorrhoidectomy
  • Closed haemorrhoidectomy
  • Anal dilation
  • Pile stitching
  • Stapled haemorrhoidectomy

Treatment modalities for haemorrhoids

A more conservative approach is the first line treatment for haemorrhoids in most instances. There are several treatment options available: Rubber band ligation (RBL), infrared coagulation (IRC), sclerotherapy, anal dilatation, bipolar coagulation, and direct current coagulation. Most studies have investigated the effect of rubber band ligation. Single versus multiple rubber band ligation was investigated in two randomized studies (7, 8). There was no difference in rebanding rate, complications, discomfort or pain. However, triple RBL was more cost-effective.

In comparison to sclerotherapy, RBL may cause more treatment discomfort, but RBL is considered the best treatment for 2° haemorrhoids (911). Photo- or Infrared-Coagulation may have less side effects (bleeding, pain) than RBL. Patients were often more satisfied with the treatment success of RBL (1214). Recurrence of prolapse was more often observed after IRC treatment (15). When comparing sclerotherapy with photocoagulation both therapy modalities were considered equivalent; however, after photocoagulation repeated therapy was necessary (16). Current coagulation and bipolar coagulation did not demonstrate any improvement when compared to other treatment modalities (17, 18). A recent study has investigated the use of Kamillosan ointment RBL plus anal dilation plus vaseline and showed superiority to RBL alone and RBL plus anal dilatation (19). A comparison of RBL with anal dilation has not detected a difference in outcome (20). In a recent meta-analysis of hemorrhoidal treatments it was concluded that Rubber band ligation is the initial mode of therapy for 1° to 3° haemorrhoids (21). (Table I)

Table I. Randomized studies comparing rubber band ligation, sclerotherapy, and photocoagulation.

Table I

Randomized studies comparing rubber band ligation, sclerotherapy, and photocoagulation.

Operative haemorrhoidectomy techniques have been compared in randomized studies since 1979. Anal dilation may reduce anal pressure significantly. However, in most studies anal dilation gave either poor results or anal dilation was associated with faecal incontinence (2226). The results after sphincterotomy are controversial. Sphincterotomy has been used as additional therapy in two randomized studies with good results; however, in a recent study there were more cases of anal incontinence reported after sphincterotomy (2529). Submucosal haemorrhoidectomy produced as similar outcome when compared to ligation/excision haemorrhoidectomy (30). Although there was no difference in pain diathermy excision without ligation was associated with less postoperative analgesic requirement compared to conventional scissors excision/ligation (31). Milligan-Morgan (MM) operation and diathermy had less pain and a faster canalization than closed haemorrhoidectomy (Ferguson). There was no difference in postoperative haemorrhage after MM and diathermy (32). Closed haemorrhoidectomy did not differ in pain, analgesic requirements, and length of hospital stay, from open haemorrhoidectomy; however, complete wound healing took longer after closed haemorrhoidectomy (33). Diathermy closed haemorrhoidectomy was associated with less postoperative analgesic requirement than scissors closed haemorrhoidectomy (34). In day case surgery there was no difference at all between open and closed haemorrhoidectomy (35). Two studies described less pain, faster return to normal activity, less hospital stay after stapled haemorrhoidectomy. However, there are serious concerns raised about the follow-up of patients treated by stapled haemorrhoidectomy. Persistent pain in one study lead to the dissolution of the study (3638). Studies on laser therapy, cryosurgery, bipolar or direct current coagulation did not demonstrate evidence enough to recommend these techniques in general. They may be useful in special situations. (Table II)

Table II. Randomized studies comparing open and closed haemorrhoidectomy, diathermy, anal dilation, and sphincterotomy.

Table II

Randomized studies comparing open and closed haemorrhoidectomy, diathermy, anal dilation, and sphincterotomy.

In summary, rubber band ligation is the treatment of choice for 1° to 3° haemorrhoids. Other treatment modalities may be used as adjunct therapy. In case rubber band ligation is not successful or 3° to 4° haemorrhoids operative haemorrhoidectomy is indicated. Open or closed haemorrhoidectomy show similar results. Diathermy excision of haemorrhoids seems to have the advantage of less analgesic requirement and faster procedure time. It is too early to announce a recommendation for stapled haemorrhoidectomy, although there are two randomized studies with promising results. However, the follow up of these studies is too short and there are alarming reports on pain and complications with regard to the use of stapled haemorrhoidectomy (39) (Grade A-C).

Additional treatment for haemorrhoids

Haemorrhoid treatment, especially haemorrhoidectomy or RBL, is associated with treatment discomfort. Several randomized studies were performed to reduce the pain and analgesic requirement after haemorrhoid treatment. Lactulose given four days preoperatively (40) and high fiber diet (41) may effectively reduce pain. Special dressings may help to reduce pain at the time of removal of rectal packing (42). Locally injected bupivacaine had no effect on pain or analgesic requirement after haemorrhoidectomy (43). The effect on pain after RBL is only short-term (44). Wound infiltration with lignocaine prolongs the postoperative analgesia after haemorrhoidectomy with spinal anaesthesia (45). Topical applied anaesthesia followed by local anesthetic injection, however, may be as effective as general anaesthesia (46). Transdermal fentanyl injection reduces the postoperative requirement of narcotics and may thereby improve the transition to outpatient management (47). A local ischiorectal fossa block decreased postoperative pain after haemorrhoidectomy (48). Similar results were achieved, when a transcutaneous electrical nerve stimulation was applied after haemorrhoidectomy; however, further studies need to confirm this result and the clinical feasibility (49). Ketorolac has been investigated in pain control after haemorrhoidectomy and anorectal surgery (50, 51). Pain and analgesic requirements were significantly reduced, patients were more satisfied and there was no urinary retention observed. A comparison of 2% lignocaine, 0.5% bupivacaine, 2% lignocaine + morphine sulfate, morphine sulfate and no injection demonstrated that postoperative analgesic requirement was best reduced by morphine and morphine + lignocaine resulting in a longer analgesic period. However, the number of patients requiring postoperative opiates was not affected by any treatment modality (52). Other analgesic compounds investigated were nimesilide versus naproxen; both drugs were equally effective in reducing pain and edema after haemorrhoidectomy (53). An effective pain treatment may be the addition of metronidazole three times daily for seven days (54). Anal sphincter relaxation by trimebutine was not effective in reducing postoperative pain (55), despite a 35% reduction in anal pressure. The use of cortisone has reduced postoperative pain, but only during the first 24 hours (56).

Urinary retention is a possible complication of haemorrhoidectomy. It has been suggested that patient's anxiety may induce urinary retention. However, anxiolytic treatment (midazolam) had no effect on urinary retention (57).

Bleeding, another complication after haemorrhoid treatment may be influenced by high fibre diet (58) or micronized flavonoids (59, 60). Dressing does not influence postoperative haemorrhage (42).

In summary, there is evidence that pretreatment with metronidazole, lactulose and high-fibre diet may help to overcome some of the side effects of haemorrhoid operations. Local injection of anaesthetics may prolong the analgesic time postoperatively.

In conclusion, randomized studies in haemorrhoid treatment have been performed already more than 20 years ago, adding evidence to haemorrhoid treatment. Unfortunately many studies do not classify the haemorrhoids treated. Follow-up often is short and the number of studied patients small. Nevertheless, haemorrhoid treatment appears to be based on firm evidence when compared to other surgical diseases.


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Bookshelf ID: NBK6995


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