Surgical management of hemorrhoids: state of the art

Abstract

Most patients with hemorrhoidal disease may be treated conservatively. Along the years several surgical options have been proposed, including closed, open and semiclosed hemorrhoidectomy (HC), radiofrequency HC (LigaSure), piles’ suture or Farag operation, manual and stapled haemorrhoidopexy (PPH) with or without excision of anal tags, doppler hemorrhoidal artery ligation with or without recto-anal mucopexy, ano-mucosal flap circumferential HC or Whitehead-Rand procedure. Randomized prospective trials and metanalyses have been carried out with the aim of finding the gold standard operation. When carried out for advanced disease, HC appears to be more effective than PPH, which achieves good results in third degree, but carries high reintervention rate in fourth degree piles. Almost all trials comparing open and closed HC show similar outcomes.

None of the costly innovations appears to be superior when compared with conventional procedures in terms of cure of the disease in the long term. PPH carries less postoperative pain and a shorter convalescence than HC. On the other hand, while carrying a higher rate of complications, it may be responsible of the so-called “PPH syndrome”, consisting of proctalgia, tenesmus and urgency. Occasional recto-vaginal fistulas have been described after PPH, if not even of rectal perforation and other life-threatening complications. Postoperative pain is very rare after Doppler hemorrhoidal arteries ligation and may be reduced following HC using nitrate ointments and botulin toxin injection, aimed at releasing anal spasm after surgery, more safely than by an internal sphincterotomy. LigaSure HC decreases the risk of severe postoperative bleeding, which may be effectively treated by rectal balloon tamponade. Permanent and gross anal incontinence are unlikely to follow both HC and PPH. Most cases of anal stricture following HC may be treated by anal dilation. Societies’ guidelines recommend a tailored surgery, i.e. the use of different procedures according to the grade of haemorrhoids, which suggests that patients should be operated by a specialist colorectal surgeon, able to perform different surgeries and to deal with complications and failures.