LA CONSULTA SEMANAL

FEBRERO 2001

CONSULTA

Lancet 2000 Jun 24;355(9222):2253-4 [Texto completo]
Haemorrhoidectomy: painful choice.
Engel AF, Eijsbouts QA
Publication Types:
  Comment
  Letter


Eur J Gastroenterol Hepatol 2000 May;12(5):535-9
A randomized controlled trial of rubber band ligation versus infra-red coagulation in the treatment of internal haemorrhoids.
Poen AC, Felt-Bersma RJ, Cuesta MA, Deville W, Meuwissen SG
Department of Surgery, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands.
OBJECTIVE: Despite the presence of numerous non-surgical therapies for the treatment of haemorrhoids, none of these therapies has clearly been proven to be superior. The effectiveness and patient tolerance of rubber band ligation (RBL) and infra-red coagulation (IRC) in the treatment of haemorrhoids was assessed. DESIGN: Prospective randomized trial. SETTING: Academic hospital (tertiary care). PARTICIPANTS: A total of 133 consecutive patients (73 males, 60 females, mean age 48 years (range 19-82)) with internal haemorrhoids, and without concomitant anorectal disease, were randomized to rubber band ligation (RBL, n = 65) or infra-red coagulation (IRC, n = 68). INTERVENTIONS: Rubber band ligation or infra-red coagulation was performed in one or more sessions with four-week intervals until symptoms had resolved. Treatment outcome and side-effects were assessed after each treatment session and one month after the last treatment by proctological examination and a questionnaire, including a pain score (visual analogue scale from 0 to 10). Recurrence of complaints was assessed by telephone questionnaire [mean follow-up of 19.2 months (SD 7.8)]. RESULTS: Treatment outcome was assessed in 124 patients (60 RBL, 64 IRC). The mean number of treatment sessions was 1.6 (SD 0.9) for both therapies. For RBL, 58 patients (97%), and for IRC, 59 patients (92%) were symptom-free or had satisfactorily improved. Only third-degree haemorrhoids seemed to respond better to RBL (five of five patients symptom-free) than to IRC (two of four patients symptom-free). Pain following treatment was more common and more severe after RBL (VAS 5.5 +/- 3.7) than after IRC (VAS 3.3 +/- 3.3, P= 0.018). The telephone questionnaire was answered by 105 patients. Nine of 50 patients (18%) treated with RBL and 11 of 55 patients (20%, P= 0.81) treated with IRC had experienced symptomatic relapse to pre-treatment levels. CONCLUSIONS: Infra-red coagulation and rubber band ligation are equally effective in the treatment of haemorrhoids. The rate and severity of pain is higher after rubber band ligation. Infra-red coagulation should be the first-line treatment for haemorrhoids.
Publication Types:
  Clinical trial
  Randomized controlled trial


Lancet 2000 Mar 4;355(9206):782-5 [Texto completo]
Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial.
Mehigan BJ, Monson JR, Hartley JE
Academic Surgical Unit, University of Hull, Castle Hill Hospital, Cottingham, UK.
BACKGROUND: Surgical haemorrhoidectomy has a reputation for being a painful procedure for a fairly benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial. METHODS: 40 patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to Milligan-Morgan haemorrhoidectomy (n=20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3, and 6-10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure. FINDINGS: The stapled group had shorter anaesthesia time (median 18 [range 9-25] vs 22 [15-35] mins). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2.1 [0.2-7.6] vs 6.5 [3.1-8.5], 95.1% CI difference medians 1.9-4.7, p<0.0001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (-2.8 [-4.4 to 1.3] vs 0.7 [-1.8 to 3.4]. Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3-60] vs 34 [14-90]. Early and late complications, patient-assessed symptom control, and functional outcome appear similar after short-term follow-up. INTERPRETATION: The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study.
Publication Types:
  Clinical trial
  Randomized controlled trial


Lancet 2000 Mar 4;355(9206):779-81[Texto completo]
Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial.
Rowsell M, Bello M, Hemingway DM
Department of Gastrointestinal and General Surgery, Leicester Royal Infirmary, UK.
BACKGROUND: Haemorrhoidectomy is commonly an inpatient procedure because it is frequently associated with postoperative pain. Day case haemorrhoidectomy is a similar operation to that used on inpatients but with different strategies for managing postoperative pain. Circumferential mucosectomy (stapled haemorrhoidectomy) may be associated with less postoperative pain than conventional haemorrhoidectomy. We compared stapled haemorrhoidectomy with conventional haemorrhoidectomy in patients with third degree haemorrhoids. METHODS: We randomly assigned 22 patients to conventional haemorrhoidectomy by the diathermy dissection or to stapled haemorrhoidectomy with the use of an intraluminal stapling device. Patients were discharged when free of pain, took co-codamol as required, completed visual analogue charts each day, and were assessed at 1 and 6 weeks postoperatively for symptom control. FINDINGS: All patients received the assigned treatment. Mean inpatient stay was lower in the group assigned to stapled as opposed to conventional haemorrhoidectomy (1.09 [0.3] vs 2.82 [0.09] nights, p<0.001), experienced less pain overall (p=0.003), and returned to normal activities sooner (8.1 [1.53] vs 16.9 [2.33] days, p<0.005). Stapled haemorrhoidectomy controlled symptoms of prolapse, discharge and bleeding in all patients. INTERPRETATION: Stapled haemorrhoidectomy is an effective treatment for third degree haemorrhoids with significant advantages for patients compared with conventional haemorrhoidectomy.
Publication Types:
  Clinical trial
  Randomized controlled trial


Lancet 2000 Mar 4;355(9206):768-9
Early promise of stapling technique for haemorrhoidectomy.
Fazio VW
Department of Colorectal Surgery, Cleveland Clinic Foundation, OH 44195, USA.
Publication Types:
  Comment


Rev Gastroenterol Mex 1998 Jul-Sep;63(3):163-8
[Current concepts in the treatment of hemorrhoids].
[Article in Spanish]
Munoz-Juarez M, Luque-de Leon E, Moreno-Paquetin E, Young-Fadok T
Departamento de Cirugia General, Hospital American British Cowdray, Mexico, D.F.
Hemorrhoidal disease is a common problem that affects a large number of patients. Usually multiple remedies are used by those patients without medical advise and for several reasons consultation with a specialist is often delayed. The large prevalence of popular misconception adds to this and occasionally makes adequate treatment difficult. Herein we present a brief and useful review of current relevant concepts in the management of patients with hemorrhoidal disease.
Publication Types:
  Review
  Review, tutorial


Rev Hosp Clin Fac Med Sao Paulo 1997 Jul-Aug;52(4):175-9
[Surgical treatment outcome of hemorrhoidal in 475 patients].
[Article in Portugese]
Nahas SC, Sobrado Junior CW, Araujo SE, Imperiale AR, Habr-Gama A, Pinotti HW
Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de Sao Paulo.
Despite feared by patients and reserved for the minority of patients suffering from hemorrohoids, hemorrhoidectomy remains as the most effective approach to this condition. To analyse results from 475 hemorrhoidectomies performed at University of Sao Paulo Hospital das Clinicas between 1984 and 1995, a retrospective chart review regarding gender, age, associated anorectal conditions, surgical technique, complications and their management and follow-up was addressed. Two hundred and seven (43.6%) were male. Age between fourth and sixth decades were observed for 70.8%. Associated anorectal conditions were diagnosed in 18.9%. Chronic anal fissure was the commonest one. Milligan-Morgan operation was performed in the majority of patients (91.2%) and Ferguson technique in 6.7%. There were no intraoperative complications postoperative complications occurred in 38 (8%) patients regardless of employed surgical technique. Urinary retention was the commonest postoperative complication. Mean follow-up was 5.8 years for 70% of patients. Surgical hemorrhoidectomy remains as a treatment with excellent results in the management of hemorrhoid disease for selected patients. Produces erradications of the disease in all cases in spite of low morbidity.


Am J Gastroenterol 1998 Feb;93(2):179-82
The outpatient evaluation of hematochezia.
Segal WN, Greenberg PD, Rockey DC, Cello JP, McQuaid KR
San Francisco Veterans Affairs Hospital, University of California San Francisco, USA.
OBJECTIVE: The objective of this study was to determine whether specific clinical symptoms associated with hematochezia are predictive of important GI pathology and whether full colonoscopic examination is necessary. METHODS: A total of 103 outpatients (> or = 45 yr) with hematochezia, defined as the passage of bright red blood per rectum, underwent anoscopy and colonoscopy. Before endoscopy, patients completed a detailed interview, quantitating the amount and frequency of bleeding, weight loss, use of aspirin/NSAIDs, change in bowel habits, family history, and prior GI illnesses. Based on this information, physicians were asked to predict whether the bleeding was from a perianal or more proximal site. At colonoscopy, pathology was stratified as either proximal or distal to the sigmoid/descending junction. Substantial pathology was defined as one or more adenomas > 8 mm, carcinoma, or colitis. RESULTS: Anoscopy demonstrated internal and external hemorrhoids in 78 and 29 patients, respectively. On colonoscopy, 36 patients had 43 substantial lesions. Thirty-seven of these lesions were distal to the junction of the descending and sigmoid colons and six were proximal lesions. Four patients had cancer; all were distal lesions. Patients with substantial lesions were more likely to give a history of blood mixed within their stool (p = 0.03), to have more episodes of hematochezia per month (p = 0.008), and to have a significantly shorter duration of bleeding before medical evaluation (p = 0.02) than did patients without such lesions. However, the physician's clinical assessment did not predict reliably which patients were likely to have substantial pathology. CONCLUSIONS: In patients with hematochezia, clinicians were unable to distinguish between those patients with and those without significant colonic lesions by history alone. Flexible sigmoidoscopy would have demonstrated most (95%) substantial lesions. The lesions that flexible sigmoidoscopy missed were an unlikely cause of bleeding in this small group of patients.


Can J Surg 1997 Feb;40(1):14-7
Comparison of hemorrhoidal treatments: a meta-analysis.
MacRae HM, McLeod RS
Department of Surgery, Mount Sinai Hospital, Toronto, Ont.
OBJECTIVE: To determine whether any method of hemorrhoid therapy has been shown to be superior in randomized trials. METHOD: A meta-analysis of all randomized controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. MAIN OUTCOME MEASURES: Response to therapy, the need for further therapy, complications and pain. RESULTS: Eighteen trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilatation of the anus (p = 0.0017) and associated with less need for further therapy (p = 0.034), no significant difference in complications (p = 0.60) but more pain (p < 0.001). Patients who underwent hemorrhoidectomy had a better response to treatment than did patients who were treated with rubber-band ligation (p = 0.001), although complications were greater (p = 0.02), as was pain (p < 0.0001). Rubber-band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (p = 0.005) and for hemorrhoids stratified by grade (grades 1 and 2, p = 0.007, grade 3, p = 0.042), with no difference in the complication rate (p = 0.35). Patients treated with sclerotherapy (p = 0.031) or infrared coagulation (p = 0.0014) were more likely to require further therapy than those treated with rubber-band ligation, although pain was greater after rubber-band ligation (p = 0.03 for sclerotherapy, p < 0.0001 for infrared coagulation). CONCLUSIONS: Rubber-band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response, it is associated with more complications and pain than rubber-band ligation. Thus, it should be reserved for patients whose hemorrhoids fail to respond to rubber-band ligation.
Publication Types:
  Meta-analysis


Emerg Med Clin North Am 1996 Nov;14(4):757-88
Anorectal disorders.
Janicke DM, Pundt MR
Department of Emergency Medicine, State University of New York at Buffalo,
Millard Fillmore Hospitals, USA.
Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.
Publication Types:
  Review
  Review, tutorial


Surg Clin North Am 1994 Dec;74(6):1277-92
Hemorrhoids, fissures, and pruritus ani.
Mazier WP
Ferguson-Blodgett Digestive Disease Institute, Grand Rapids, Michigan.
The diagnosis and management of hemorrhoids, fissures, and pruritus ani probably accounts for more than 81% of the complaints centered on this part of the human anatomy. This brief treatise offers a safe and practical approach to the management of these three diseases.
Publication Types:
  Review
  Review, tutorial