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Kolbeinsson HM, Otto M, Kogelschatz B, Virk U, Luchtefeld MA, Ogilvie JW. Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications. Am Surg 2023; 89:4681-4688. [PMID: 36154315 DOI: 10.1177/00031348221129512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding. METHODS We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use. RESULTS Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7 days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3 days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding. CONCLUSION Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding.
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Affiliation(s)
- Hordur M Kolbeinsson
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | - Maxwell Otto
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | | | - Usman Virk
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | - Martin A Luchtefeld
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
- Division of Colorectal surgery, Spectrum Health Medical Group, Grand Rapids, MI, USA
| | - James W Ogilvie
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
- Division of Colorectal surgery, Spectrum Health Medical Group, Grand Rapids, MI, USA
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Yim SK, Lee CH, Kim SH, Kim SW, Seo SY. Vaseline gauze packing for the treatment of acute hemorrhagic rectal ulcer: Two case reports. Medicine (Baltimore) 2023; 102:e33411. [PMID: 37000072 PMCID: PMC10063288 DOI: 10.1097/md.0000000000033411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
RATIONALE Acute hemorrhagic rectal ulcer (AHRU) is a relatively rare condition characterized by sudden onset, painlessness, and massive hematochezia in patients with severe underlying conditions. When AHRU is encountered, they can often be successfully controlled endoscopically, though recurrent bleeding is common and an alternative treatment must be sought if initial endoscopic treatment fails. We report 2 cases of AHRU which were successfully treated with Vaseline gauze packing after the failure of endoscopic hemostasis. PATIENT CONCERNS The first patient was an 88-year-old female that visited our emergency department with hematochezia. She was immobilized because of a left pelvic bone fracture resulting from a slip-down. The initial endoscopy showed fresh blood in her rectum with diffuse ulceration near the dentate line but no active bleeding. However, Massive hematochezia has recurred during conservation. A second patient, an 86-year-old female, debilitated because of schizophrenia, dementia, and past subdural hemorrhage, visited our emergency department, also with massive hematochezia. Her initial endoscopy showed deep ulceration near the dentate line. After admission, she experienced massive hematochezia from an AHRU with an exposed vessel but endoscopic hemostasis failed to control bleeding. DIAGNOSES Both patients were diagnosed as AHRU based on the endoscopic findings. INTERVENTIONS In both cases, Vaseline gauze packing was performed for bleeding control. OUTCOMES After Vaseline gauze packing, no further bleeding occurred and follow-up endoscopy showed definitive improvement of ulcers. LESSONS Based on these cases, we suggest that Vaseline gauze packing may be the alternative treatment for the AHRU which is located near the dentate line when endoscopic hemostasis is difficult or failed. Although further research is needed, Vaseline gauze packing has several potential advantages for the treatment of AHRU, especially in cases involving critically ill elderly patients.
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Affiliation(s)
- Sung Kyun Yim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Chang Hun Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Sang Wook Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Seung Young Seo
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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3
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Kang DW, Kim BS, Kim JH, Kim KR, Kang GS. A comparative study of rubber band ligation versus BANANA-Clip in grade 1 to 3 internal hemorrhoids. Ann Coloproctol 2023; 39:41-49. [PMID: 34879637 PMCID: PMC10009063 DOI: 10.3393/ac.2021.00717.0102] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Rubber band ligation (RBL) for grade 1 to 3 internal hemorrhoids is a well-established modality of choice. But RBL is also a kind of surgical treatment; it is not free from complications (e.g., delayed bleeding [DB], rectal stenosis). This study aimed to investigate the results of the comparative treatment of RBL and BANANA-Clip (BC; Endovision). METHODS Study participants were 632 consecutive patients with grade 1 to 3 internal hemorrhoids attended to Department of Colorectal Surgery at Wellness Hospital between January 2010 and May 2019. We retrospectively reviewed the incidence rate of complications, including DB between RBL and BC. RESULTS There were 304 male and 328 female patients, whose ages ranged from 15 to 84 years, with a mean age of 45.7 years. The common symptom and cause of treatment was prolapse (70.1%). The number of ligated sites was 1.49±0.57 in the RBL group and 1.99±0.77 in the BC group. RBL showed a significantly higher incidence of DB (3.5%) compared to BC (0%) (P=0.001). The 1-year success rate was 95.9% in the RBL group and 99.7% in the BC group (P=0.005). CONCLUSION In our study, BC was more reliable in treating grade 1 to 3 internal hemorrhoids with higher success rates and less post-ligation complications, especially DB, compared to RBL.
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Affiliation(s)
- Dong Wan Kang
- Department of Colorectal Surgery, Wellness Hospital, Busan, Korea
| | - Byoung Soo Kim
- Department of Colorectal Surgery, Wellness Hospital, Busan, Korea
| | - Ji Hun Kim
- Department of Colorectal Surgery, Wellness Hospital, Busan, Korea
| | - Kyong Rae Kim
- Department of Colorectal Surgery, Wellness Hospital, Busan, Korea
| | - Gyong Suk Kang
- Department of Colorectal Surgery, Wellness Hospital, Busan, Korea
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Moldovan C, Rusu E, Cochior D, Toba ME, Mocanu H, Adam R, Rimbu M, Ghenea A, Savulescu F, Godoroja D, Botea F. Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review. World J Clin Cases 2023; 11:366-384. [PMID: 36686344 PMCID: PMC9850966 DOI: 10.12998/wjcc.v11.i2.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.
AIM To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.
METHODS We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.
RESULTS Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.
CONCLUSION Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.
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Affiliation(s)
- Cosmin Moldovan
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Elena Rusu
- Department of Preclinic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Daniel Cochior
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Sanador Clinical Hospital, Bucharest 010991, Romania
- Department of General Surgery, Monza Clinical Hospital, Bucharest 021967, Romania
| | - Madalina Elena Toba
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Horia Mocanu
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of Ear, Nose and Throat, Ilfov County Clinical Emergency Hospital, Bucharest 022104, Romania
| | - Razvan Adam
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of Orthopedics and Traumatology, Elias Emergency University Hospital, Bucharest 011461, Romania
| | - Mirela Rimbu
- Medical Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040317, Romania
| | - Adrian Ghenea
- Department of Coloproctology, MedLife SA Băneasa Hyperclinic, Bucharest 013693, Romania
| | - Florin Savulescu
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- 2nd Department of Surgery, Carol Davila Central Military Emergency University Hospital, Bucharest 010242, Romania
| | - Daniela Godoroja
- Department of Anesthesia, Ponderas Academic Hospital, Bucharest 014142, Romania
| | - Florin Botea
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- 2nd Department of Surgery, Fundeni Clinical Institute, Bucharest 022328, Romania
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5
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Lim SY, Rajandram R, Roslani AC. Comparison of post-operative bleeding incidence in laser hemorrhoidoplasty with and without hemorrhoidal artery ligation: a double-blinded randomized controlled trial. BMC Surg 2022; 22:146. [PMID: 35449097 PMCID: PMC9022276 DOI: 10.1186/s12893-022-01594-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The effectiveness of hemorrhoidal artery ligation supplementation in reducing the incidence of post laser hemorrhoidoplasty bleeding has not been investigated. Methods This was a double-blind, randomized controlled trial comparing post-operative bleeding incidence in patients undergoing laser hemorrhoidoplasty (LHP) only versus LHP with hemorrhoidal artery ligation (HAL). Outcome measures included post-operative bleeding and its severity (i.e. verbal rating scale and Clavien-Dindo classification), presence of perianal swelling and pain score (visual analog score) at 1-day, 1-week and 6-weeks post-operatively. Statistical tests were performed and a value of P < 0.05 was considered significant. Results Seventy-six patients were randomized. There was no difference in median operating time. The bleeding incidence was highest at 1-week post-operatively (17.1%), and decreased to 1.3% at 6-weeks. There was no significant difference in bleeding incidence between both groups at any of the measured timepoints (P > 0.05). Severity of bleeding and incidence of post-operative perianal swelling were similar in both groups (P > 0.05). There was no difference in median pain scores. Conclusion Supplementation of HAL to LHP does not reduce the post-operative bleeding incidence. LHP is sufficient as a stand-alone procedure for treating haemorrhoids. Trial registration: National Registration Number is NMRR-15-1112-24065 (IIR). The trial start date was 1st January 2015 with the ClinicalTrials.gov identifier and registration number as NCT04667169.
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Affiliation(s)
- Shu Yu Lim
- Department of Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Retnagowri Rajandram
- Department of Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - April Camilla Roslani
- Department of Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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6
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Langenbach MR, Florescu RV, Köhler A, Barkus J, Ritz JP, Quemalli E, Siegel R, Zirngibl H, Lefering R, Bönicke L. OUP accepted manuscript. BJS Open 2022; 6:6594076. [PMID: 35639947 PMCID: PMC9154318 DOI: 10.1093/bjsopen/zrac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
Background Symptomatic haemorrhoids are a common anorectal disorder. The aim of the study was to investigate whether the omission of tamponade dressings after haemorrhoidectomy reduces postoperative pain without increasing the risk of severe bleeding. Method This was an open-label, randomized clinical trial conducted at 14 German hospitals. All patients with third- or fourth-degree haemorrhoids undergoing haemorrhoidectomy were considered eligible for selection in the intervention (no dressing) or control group (tamponade applied). Two co-primary outcomes were analysed by testing hierarchically ordered hypotheses. First, maximum pain intensity within 48 h after surgery was compared between the groups (superiority). This was followed by an analysis of severe bleeding complications, defined as any bleeding requiring surgical re-intervention within 7 days (non-inferiority). Secondary outcomes included health-related quality of life, patient satisfaction, haemoglobin levels, and adverse events. Results Out of 950 patients screened, 754 were randomized and 725 received intervention (366 patients in the intervention and 359 patients in the control group). In the group with tamponade dressings, median pain intensity on the 0 to 10 scale was 6 (interquartile range (i.q.r.) 4–7). Patients without tamponade dressings reported significantly less pain (median 5 (i.q.r. 3–7), P < 0.001). In each group, five patients (1.4 per cent) experienced severe bleeding. The absolute difference for the severe bleeding rate was −0.03 per cent with the 90 per cent confidence interval ranging from −1.47 per cent to +1.41 per cent, in line with the non-inferiority aim. No significant between-group difference was found for secondary outcomes. Conclusions The practice of inserting tamponade dressings after haemorrhoidectomy correlates with increased postoperative pain and does not provide benefits in terms of reduced postoperative bleeding. Registration number DRKS00011590
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Affiliation(s)
- Mike Ralf Langenbach
- Correspondence to: Mike Ralf Langenbach, Ev. Krankenhaus Lippstadt, Department of Surgery II, University of Witten-Herdecke, Wiedenbrücker Straße 33, 59555 Lippstadt, Germany (e-mail: )
| | - Razvan-Valentin Florescu
- Helios St. Elisabeth Klinik Oberhausen, Department of Surgery II, University of Witten/Herdecke, Oberhausen, Germany
| | | | - Jörg Barkus
- Helios Klinikum Niederberg, Velbert, Germany
| | | | | | | | - Hubert Zirngibl
- Helios Klinikum Wuppertal, Department of Surgery II, University of Witten/Herdecke, Wuppertal, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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7
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Chen CW, Lu TJ, Hsiao KH. Surgical Outcomes of LigaSure Hemorrhoidectomy in the Elderly Population: A retrospective cohort study. BMC Gastroenterol 2021; 21:413. [PMID: 34715801 PMCID: PMC8555163 DOI: 10.1186/s12876-021-01969-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background This study aims to assess the association between age and outcomes in patients undergoing hemorrhoidectomy. Methods This is a population-based cohort study. A retrospectively collected database with consecutive patients whose symptomatic prolapsed hemorrhoids managed by the LigaSure hemorrhoidectomy between Jan. 2015 and May 2017 was reviewed. Among 1238 patients, 1075 were under 65 years old (group 1), and 163 were 65 years old or older (group 2). Both groups were compared regarding baseline characteristics and surgical outcomes. Results All patients tolerated the whole course of the operation in the prone jackknife position without anesthetic-associated complications. There was no significant difference between these two groups regarding sex, hemorrhoids grade, operation time, duration of hospital stays, postoperative pain score, analgesic consumption, total postoperative complications, re-admission rate, reoperation rate and follow-up times. The multivariate logistic regression analysis that may contribute to postoperative complications revealed no significant difference for all complications between both groups. Conclusion The LigaSure hemorrhoidectomy for elderly patients is safe and effective without significant difference in short-term operative outcomes and all complication rates, compared with younger patients.
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Affiliation(s)
- Chuang-Wei Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.).,School of Medicine, Tzu Chi University, Hualien, Taiwan (R.O.C.)
| | - Tzung-Ju Lu
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.)
| | - Koung-Hung Hsiao
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.).
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8
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Wlodarczyk JR, Yoon D, Lai R, Ault G, Ortega A, Lee SW, Cologne KG, Koller S. LigaSure™ haemorrhoidectomy and the risk of postoperative bleeding. Colorectal Dis 2021; 23:2699-2705. [PMID: 34252247 DOI: 10.1111/codi.15808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/07/2021] [Accepted: 07/06/2021] [Indexed: 02/08/2023]
Abstract
AIM LigaSure™ is an electro-surgical device that has increasingly been utilized in haemorrhoid surgery. However, recent literature has highlighted a possible increased risk of delayed postoperative bleeding following LigaSure haemorrhoidectomy (LH). We aim to evaluate the rates of postoperative bleeding following LigaSure compared to Ferguson (closed) haemorrhoidectomy (FH). METHODS A retrospective cohort study was undertaken at our single academic safety-net county hospital from August 2016 through July 2019 evaluating patients who received FH or LH. Patient demographics, surgical data, postoperative emergency department visit for pain or bleeding within 30 days and resulting transfusion requirement, and rates of readmission and interventions within 30 days were collected. RESULTS Sixty-one FH and 66 LH patients were identified. The groups had no difference in demographics. The LH group and FH group had similar rates of postoperative emergency department visits (29% vs. 23%, P = 0.454), as well as visits for bleeding (20% vs. 11%, P = 0.204). The average operating time was also significantly shorter with LH (14.5 min vs. 24.9 min, P ≤ 0.001). On multivariate analysis, male sex (OR 7.28, 95% CI 1.88-28.25) and haemorrhoid grade ≤2 (OR 4.64, 95% CI 1.31-16.49) were significantly associated with postoperative bleeding on multivariate analysis. Use of LH was not independently associated with postoperative bleeding risk (OR 1.89, 95% CI 0.70-5.11). CONCLUSIONS LH and FH have similar risks for postoperative bleeding and other complications. Male sex and haemorrhoid Grades 1 or 2 may be associated with increased postoperative bleeding risk. Excisional haemorrhoidectomy should be undertaken with caution for male patients with lower internal haemorrhoid grades.
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Affiliation(s)
- Jordan R Wlodarczyk
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dong Yoon
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rachel Lai
- School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Glenn Ault
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Adrian Ortega
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sang W Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sarah Koller
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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9
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Lee XL, Hsu KF, Jin YD, Huang PW, Yeh LC, Lai CL. Doppler-guided hemorrhoidal artery ligation with suture mucopexy compared with LigaSure™-assisted pile excision for the treatment of grade III hemorrhoids: a prospective randomized controlled trial. Minerva Surg 2021; 76:264-270. [PMID: 34080821 DOI: 10.23736/s2724-5691.20.08429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Doppler-guided hemorrhoid artery ligation and stapled hemorrhoidopexy have been used in surgical practices to avoid post-hemorrhoidectomy pain. Our study compared Doppler-guided hemorrhoid artery ligation with suture mucopexy (DGHAL-SM) and ligature-assisted pile excision (LAP) for greater than three grades of internal hemorrhoids. METHODS Eighty patients with greater than 3 grades of internal hemorrhoids were selected (age range: 20-28 years; average age: 23 years) between January and June 2015. The patients were randomly divided into group A (DGHAL-SM) and group B (LAP); each group had 40 patients. RESULTS With respect to the postoperative cure rate and anal skin tags, group A was inferior to group B, but the postoperative pain assessment and satisfaction were better than group B (P<0.001). CONCLUSIONS The DGHAL-SM cure rate was high; the postoperative pain was mild; 97.5% of the patients did not return to hospital because of pain. LAP has a higher cure rate than DGHAL-SM, but the postoperative pain and return rate within 6 h was as high as 65%, and the postoperative satisfaction assessment was lower than DGHAL-SM. Therefore, we recommend that DGHAL-SM for outpatient surgery in patients with greater than three grades of internal hemorrhoids.
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Affiliation(s)
- Xiao-Lun Lee
- Emergency Department, Hengchun Tourism Hospital, Taiwan, China.,Department of Health and Welfare, Hengchun Tourism Hospital, Taiwan, China
| | - Kuo-Fang Hsu
- Emergency Department, Hengchun Tourism Hospital, Taiwan, China.,Department of Health and Welfare, Hengchun Tourism Hospital, Taiwan, China
| | | | - Ping-Wun Huang
- Emergency Department, Changhua Show-Chwan Memorial Hospital, Changhua, China
| | - Li-Chun Yeh
- Emergency Department, Hengchun Tourism Hospital, Taiwan, China - .,Department of Health and Welfare, Hengchun Tourism Hospital, Taiwan, China.,Emergency Department, Chang Bing Show-Chwan Memorial Hospital, Changhua, China
| | - Chung-Liang Lai
- Emergency Department, Puzi Hospital, Taiwan, China.,Department of Health and Welfare, Puzi Hospital, Taiwan, China
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10
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Maemoto R, Tsujinaka S, Miyakura Y, Machida E, Fukui T, Kakizawa N, Tamaki S, Ishikawa H, Rikiyama T. Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery. Cureus 2021; 13:e14983. [PMID: 33996339 PMCID: PMC8115195 DOI: 10.7759/cureus.14983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 01/21/2023] Open
Abstract
Introduction Surgery for patients taking antithrombotic drugs for the prevention and treatment of cardiovascular disease, including anticoagulants and antiplatelet drugs, is increasing because of the aging society. In patients with moderate to high risk for cardiovascular events, receiving antiplatelet therapy, and requiring noncardiac surgery continuing antiplatelet drugs perioperatively is recommended. To date, there have been limited reports on the risk of secondary bleeding after proctological surgery in patients who are administered antithrombotic drugs. The purpose of this study was to identify the incidence and severity of secondary bleeding after proctological surgery for patients with or without antithrombotic therapy. Methods We retrospectively identified 113 patients who underwent proctological surgery in our hospital from March 2009 to February 2019. In general, antiplatelet drugs were continued and anticoagulant drugs were either substituted or withdrawn prior to surgery. The severity of secondary bleeding was classified as mild, moderate, or severe. Results Eighteen patients underwent antithrombotic therapy (A group) and 95 patients did not undergo antithrombotic therapy (N group). Secondary bleeding was observed in nine patients (8.0%) and patients in the A group exhibited a significantly higher rate of secondary bleeding than those in the N group (39% vs. 2.4%, P < 0.01). The median interval from surgery to the onset of secondary bleeding was five days (range: 0-11). The severity of bleeding was the highest in patients administered direct oral anticoagulants (DOAC) and was the lowest in those administered aspirin. There was no mortality or cardiovascular event. Conclusion Antithrombotic therapy carries a high risk of secondary bleeding after proctological surgery. Delaying the postoperative resumption of anticoagulants is considered while balancing the risk of postoperative thromboembolic complications against secondary bleeding.
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Affiliation(s)
- Ryo Maemoto
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Shingo Tsujinaka
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Yasuyuki Miyakura
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Erika Machida
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Taro Fukui
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Nao Kakizawa
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Sawako Tamaki
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Hideki Ishikawa
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Toshiki Rikiyama
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
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Langenbach MR, Seidel D. Tamponade dressings versus no tamponade after hemorrhoidectomy: study protocol for a randomized controlled trial. Trials 2019; 20:188. [PMID: 30940201 PMCID: PMC6444871 DOI: 10.1186/s13063-019-3280-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Symptomatic hemorrhoids are one of the most common anorectal disorders. Many surgeons use tamponades after open hemorrhoidectomy to manage postoperative bleeding. The question of whether a tamponade is necessary and beneficial after hemorrhoidectomy has not yet been conclusively answered. A previously conducted single-center pilot trial included 100 patients after Milligan–Morgan hemorrhoidectomy. The data indicated that insertion of an anal tamponade after hemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. The findings of this pilot trial are now to be verified by means of a multicenter randomized clinical study called NoTamp. Methods We plan to include 953 patients after Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study. The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to postoperative bleeding, and that the patients report less pain. Primary endpoints of the trial are the maximum postoperative pain within 48 h and the incidence of severe postoperative bleeding that requires surgical revision within 7 days after the surgical procedure. Secondary endpoints of the study are the use of analgesics in the postoperative course, the lowest hemoglobin documented within 7 days, quality of life and patient satisfaction. Safety analysis includes all adverse and serious adverse events in relation to the study treatment. Further information can be found in the registration at the German Registry of Clinical Studies (DRKS00011590) and on the study webpage (https://notamp.de/en-GB/trial/main/setLocale/en_GB/). The study is financed by the HELIOS research funding. Discussion The study received full ethics committee approval. The first patient was enrolled on 3 May 2017. This trial will finally answer the question whether the insertion of a tamponade after open hemorrhoidectomy is necessary and beneficial. Trial registration German Clinical Trials Register (Deutsches Register Klinischer Studien (DRKS), DRKS00011590. Registered on 12 April 2017.
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Affiliation(s)
- Mike Ralf Langenbach
- Klinik für Allgemein-/Viszeralchirurgie und Koloproktologie, Helios St. Elisabeth Klinik, Josefstr. 3, 46045, Oberhausen, Germany
| | - Dörthe Seidel
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimerstraße 200 Haus 38, 51109, Köln, Germany.
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Abstract
PURPOSE Delayed post-hemorrhoidectomy bleeding (DPHB) is a rare but serious complication. We investigated the incidence and risk factors of DPHB in patients undergoing hemorrhoidectomy using the LigaSure device or the Ferguson procedure. METHODS This retrospective study included 382 consecutive patients with symptomatic grades II to IV hemorrhoids who received either LigaSure (184 patients) or Ferguson (198 patients) hemorrhoidectomy procedures. Thirty-two patients who experienced DPHB after discharge were followed up. RESULTS Significantly fewer Ferguson group patients had DPHB compared to the LigaSure group (5.1% vs. 11.9%; P = 0.015). In the overall population, the risk of DPHB was higher in (1) males compared to that of females (OR = 3.39; 95% CI 1.50-7.69, P = 0.003); (2) in the LigaSure group compared to the Ferguson group (OR = 2.77; 95% CI 1.23-6.24, P = 0.01); and (3) in patients with constipation (OR = 6.59; 95% CI 2.73-15.89, P < 0.0001). Males in the LigaSure group had a significantly higher rate of delayed bleeding than those in the Ferguson group (20% vs. 5.8%, P = 0.004); no significant differences were found in females (4.9% vs. 4.5%, P = 0.878). Subgroup analysis showed that in males, risk of DPHB increased significantly with postoperative constipation (OR = 4.73, 95% CI 1.45-15.43, P = 0.010) and the LigaSure procedure (OR = 3.99, 95% CI 1.37-11.62, P = 0.011). In females, the risk of DPHB was significantly associated with postoperative constipation (OR = 8.80, 95% CI 2.24-34.54, P = 0.002). CONCLUSIONS The LigaSure procedure and constipation are independent risk factors for DPHB in patients undergoing hemorrhoidectomy and can be used as predictors of outcome.
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Affiliation(s)
- Ko-Chao Lee
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301, Taiwan
| | - Chia-Cheng Liu
- Department of Surgery, Pingtung Christian Hospital, Pingtung, Taiwan
| | - Wan-Hsiang Hu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301, Taiwan
| | - Chien-Chang Lu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301, Taiwan
| | - Shung-Eing Lin
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301, Taiwan
| | - Hong-Hwa Chen
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301, Taiwan.
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Abstract
BACKGROUND Hemorrhoid operations are performed frequently in Germany. After the operation severe complications can occur that require appropriate management. OBJECTIVE Presentation of current complications and suitable therapeutic options. MATERIAL AND METHODS Data including operative procedures and complications that have been collected in an electronic online-based survey of all resident, affiliated and private practice German surgeons during the period from 1 December 2009 to 31 January 2010 are presented. A review of the current literature in a PubMed search is given. RESULTS Stapled hemorrhoidopexy has several benefits during the early postoperative phase in comparison to conventional hemorrhoidectomy; however, patients should be informed about the possibility of postoperative defecation disorders, elevated recurrence and reoperation rates and rare life-threatening complications. CONCLUSION The aim should be to keep risks at a low level by means of prevention, patient selection, careful analysis of indications and relevant expertise. In cases of complications early recognition and direct initiation of adequate treatment are crucial.
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Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient? Tech Coloproctol 2016; 20:461-6. [PMID: 27170327 PMCID: PMC4920854 DOI: 10.1007/s10151-016-1481-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/28/2016] [Indexed: 01/01/2023]
Abstract
Background Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation. Methods During a 53-month period (February 2009–July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery. Results During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455–3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study’s 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049). Conclusions These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.
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Abstract
Anorectal surgery is well tolerated. Rates of minor complications are relatively high, but major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avoid significant patient morbidity. The most common acute complications include bleeding, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and even mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.
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Affiliation(s)
- Hiroko Kunitake
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Vitaliy Poylin
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Nally C, Singer M. Reoperative surgery for complications of hemorrhoidectomy. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tamponade dressings may be unnecessary after haemorrhoidectomy: a randomised controlled clinical trial. Int J Colorectal Dis 2014; 29:395-400. [PMID: 24292489 DOI: 10.1007/s00384-013-1800-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Bleeding after haemorrhoidectomy is common. Many surgical textbooks recommend insertion of an anal tampon in order to reduce postoperative bleeding. This practice, however, is bothersome and probably painful for patients. The effect of using a tamponade has not been validated in randomised controlled trials. METHODS The study included 100 patients who were scheduled for Milligan-Morgan haemorrhoidectomy. During surgery, patients were randomly assigned to receive or not to receive an anal tampon at the end of the procedure. Data on pain, complications and wound care were collected. The trial was registered (DRKS00003116) and all analyses were by intention-to-treat. RESULTS There were 48 patients in the group with tamponade, and 52 patients were left without tamponade. The trial's primary outcome and maximum pain intensity, averaged 6.1 and 4.2 in the two groups (P = 0.001). In the group with tamponade, a complication was recorded in seven patients (15 %), which was similar to the group without tamponade (21 %). Severe anal bleeding occurred in two and five patients, respectively. Bandage changes were less necessary often in the group treated without tamponade (P = 0.013). Hospital stay was 4 days in both groups. CONCLUSIONS Data indicate that insertion of an anal tampon after haemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. After haemorrhoidectomy, anal tampons should not be used routinely but may be considered when specific indications justify its use.
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Aigner F, Conrad F, Haunold I, Pfeifer J, Salat A, Wunderlich M, Fortelny R, Fritsch H, Glöckler M, Hauser H, Heuberger A, Karner-Hanusch J, Kopf C, Lechner P, Riss S, Roka S, Scheyer M. [Consensus statement haemorrhoidal disease]. Wien Klin Wochenschr 2012; 124:207-19. [PMID: 22378598 DOI: 10.1007/s00508-011-0107-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 11/07/2011] [Indexed: 12/16/2022]
Abstract
Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.
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Affiliation(s)
- Felix Aigner
- Univ.-Klinik für Visceral-, Transplantations- und Thoraxchirurgie, Medizinische Universität Innsbruck, Innsbruck, Austria.
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Yano T, Matsuda Y, Asano M, Kawakami K, Nakai K, Nonaka M, Kimura K, Yoshihara K. The outcome of postoperative hemorrhaging following a hemorrhoidectomy. Surg Today 2009; 39:866-9. [PMID: 19784725 DOI: 10.1007/s00595-009-3971-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 01/16/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative hemorrhage (PH) is rare, but it is widely recognized as a postoperative complication of a hemorrhoidectomy. The assessment of this complication may provide information which can be used to improve the clinical outcome of a patient who has undergone a hemorrhoidectomy. METHODS Between January 2006 and December 2007, a total of 1294 patients with symptomatic hemorrhoids underwent a hemorrhoidectomy at our hospital. The patient records were retrospectively analyzed. RESULTS In this study, 23 patients had suffered from PH and had undergone a second operation (1.7%). The bleeding points were located as follows: 14 anterior,7 right laterally, 8 left laterally, and 2 posteriorly. Of these patients with early hemorrhage, 1 case was at the anterior, 1 was left lateral, and 2 were posterior. A significant correlation was observed between the period and the location of postoperative hemorrhage (P = 0.0023). From one to four piles were excised (1 in 264 patients, 2 in 240 patients, 3 in 702 patients, 4 in 88 patients). A significant correlation was also observed between the number of piles and the occurrence of PH (P = 0.032). CONCLUSIONS At the posterior wall, a late period hemorrhage is less likely to be found than an early period hemorrhage. It was found that the more piles that were excised, the greater the occurrence of PH.
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Affiliation(s)
- Takaaki Yano
- Matsuda Hospital Colo-Proctological Institute, 753 Irino-cho, Nishi-ku, Hamamatsu, Shizuoka 432-8061, Japan
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Hourigan J, Luchtefeld M. Excisional Hemorrhoidectomy. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2007.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jutabha R, Miura-Jutabha C, Jensen DM. Current medical, anoscopic, endoscopic, and surgical treatments for bleeding internal hemorrhoids. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2001. [DOI: 10.1053/tgie.2001.27859] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Cirocco WC, Golub RW. Local epinephrine injection as treatment for delayed hemorrhage after hemorrhoidectomy. Surgery 1995; 117:235-7. [PMID: 7846631 DOI: 10.1016/s0039-6060(05)80092-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- W C Cirocco
- Department of Surgery, State University of New York, Health Science Center at Brooklyn
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