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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 107-113

Submucosal Hemorrhoidectomy versus Hemorrhoidectomy Utilizing an Energy Device in the Treatment of Grade III and IV Hemorrhoidal Disease


Department of General Surgery, Menoufia University, Faculty of Medicine, Shibin Al Kawm, Al Minufiyah, Egypt

Date of Submission16-Sep-2019
Date of Decision14-Oct-2019
Date of Acceptance12-Nov-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Prof. Mohamed S Amar
Department of General Surgery, Menoufia University Faculty of Medicine, Yassin Abd El Gafar Street, Shebin El-Kom, EG 32156
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_22_19

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  Abstract 


Background: Harmonic scalpel hemorrhoidectomy is associated with lesser pain postoperatively and shorter hospital stays than conventional hemorroidectomy. Objective: To compare the outcome of harmonic scalpel hemorrhoidectomy (HSH) and submucosal ligation hemorrhoidectomy (SLH) in management of Grade III and Grade IV hemorrhoids. Design: A prospective comparative study. Setting: A tertiary hospital was selected. Patients and Methods: This is a prospective randomized study that includes 120 patients with Grade III or Grade IV internal hemorrhoids who were operated in the surgical department of Menoufia University Hospital between February 2016 until December 2018. Main Outcome Measures: Demographic data, perioperative parameters, postoperative complications, and recurrence of hemorrhoids were recorded. All patients were regularly followed up after 1 month, 3 moths, 6 months, and 12 months postoperative for a year. Sample Size: One hundred and twenty patients with Grade III or Grade IV hemorrhoids were divided randomly to SLH (n = 61) and HSH (n = 59) groups. Results: Operative time was 35±12 min in Group A while 18±6 min in Group B with no significant difference between both groups regarding mean hospital stay and time to return to daily activity. Severe pain occurred in 3 cases in Group A while 9 cases in Group B with significantly higher incidence of severe pain in HSH group. The cost was highly significant in HSH group. Anal stenosis occur in 2 (3.2%) cases in Group A and 7 (11.9%) cases in Group B with significantly higher incidence of anal stenosis in HSH group. Conclusion: Both SLH and HSH were safe and effective surgical techniques for management of Grade III and Grade IV hemorrhoids. The SLH technique was associated with less incidence of severe postoperative pain, lower cost, and fewer rate of stenosis. Limitations: Prospective study design, short follow-up period, and learning curve. Conflict of Interest: None.

Keywords: Harmonic scalpel, hemorrhoidal disease, lower GI


How to cite this article:
Amar MS, Nassar MN. Submucosal Hemorrhoidectomy versus Hemorrhoidectomy Utilizing an Energy Device in the Treatment of Grade III and IV Hemorrhoidal Disease. World J Colorectal Surg 2019;8:107-13

How to cite this URL:
Amar MS, Nassar MN. Submucosal Hemorrhoidectomy versus Hemorrhoidectomy Utilizing an Energy Device in the Treatment of Grade III and IV Hemorrhoidal Disease. World J Colorectal Surg [serial online] 2019 [cited 2020 Apr 9];8:107-13. Available from: http://www.wjcs.us.com/text.asp?2019/8/4/107/274285




  Introduction Top


The dilatation of submucosal arteriovenous sinusoids in the normal anorectal region is considered hemorrhoidal disease (HD), and commonly presents with symptoms including pain, bleeding, itching, and prolapsing.[1]

According to the relationship to the dentate line, the HD is divided into internal or external types. HD can also be classified as grades (Grades 1–4), the most serious ones being Grade 3 and Grade 4. The possible causes of HD include constipation, pregnancy, heredity, or venous return obstruction with an increase in the intraabdominal pressure. Patients with hemorrhoids mostly complain of fresh rectal bleeding, protruding masses, itching, and anal discomfort or pain.[2]

The most common anorectal disorder is HD, occurring in approximately 5% of the population over 40 years of age worldwide.[3]

Treatment for hemorrhoids includes several therapeutic remedies like dietary changes, medications that improve the symptoms (Grade I and Grade II), and surgical excision techniques (Grade III and Grade IV).[2]

However, the failure of conservative treatment or the presence of associated anal problems, e.g., anal fissures, is an indication for surgery.[3]

The standard surgical treatment for HD is hemorrhoidectomy.

The most effective and common surgical treatments are the Milligan-Morgan hemorrhoidectomy (MMH; open) and Ferguson hemorrhoidectomy (FH; closed). These methods are similar and conventional.[4]

Hemorrhoidectomy complications include pain, postoperative bleeding, urine retention, anal stenosis, fecal incontinence, and recurrence.[5]

Since 1998, Longo introduced the use of stapler hemorrhoidopexy

(SH) in prolapsed HD.[6] As observed in five randomized studies conducted in 2000, the initial results of SH compared with conventional hemorrhoidectomy were encouraging.[7],[8],[9],[10],[11]

The aim of SH is to restore the prolapsed mucosa of the rectum and anal canal with subsequent normal mucosa and underlying muscle.[6]

SH is associated with less pain postoperatively and shorter hospital stay than conventional methods because it involves the rectum instead of the anoderm, where the pain sensation is absent.[12]

Two devices using advanced bipolar energy, Harmonic Scalpel™ and LigaSure™ were developed to become a part of the treatment. LigaSure™ (LSH) can seal vessels up to 7 mm with minimal adhesion, less postoperative bleeding, and less thermal damage of up to 2 mm. This causes rapid healing (half that caused by bipolar systems) as well as fewer fumes, which decrease the neuromuscular simulation with subsequent lower postoperative pain.[4],[5],[13]

The Harmonic Scalpel™ (HSH) simultaneously cuts and coagulates tissues by producing vibration of 55.5 kHz and can seal vessels up to 5 mm. Several studies have revealed that HSH and LSH are effective, fast, and safe techniques when compared with conventional methods.[13]


  Patients and Methods Top


This was a prospective randomized study that included 120 patients with Grade III or Grade IV internal hemorrhoids who were operated in the surgical department at Menoufia University Hospital between February 2016 and December 2018. The study excluded patients who had any previous surgery in the anal canal; HD associated diseases, such as anal fissures or anal fistula; and/or presence of malignant colorectal diseases.

The ethical approval for this study was granted by the Faculty of Medicine, Menoufia University Ethical Committee according to the Declaration of Helsinki.

All patients were divided randomly into two groups based on the surgical technique used in their treatment. The two groups were as follows:

  1. Group A included 61 patients operated by submucosal excision of hemorrhoids (SLH)
  2. Group B included 59 patients operated by harmonic scalpel excision of hemorrhoids (HSH).


All patients underwent preoperative evaluation, including history taking, physical examination, and routine laboratory investigations. The laboratory investigations conducted were as follows:

  • Complete blood count (CBC)
  • Kidney function
  • Liver function
  • Prothrombin time and concentration
  • Serum albumin
  • Random blood sugar.


In addition, a chest x-ray was taken and to exclude concomitant diseases, a colonoscopy was conducted in suspected cases.

All patients were informed about all the possible complications associated with the surgery and consent was taken.

Preoperative mechanical colonic preparation was conducted in the following way:

  1. Patients were allowed to consume liquids for 3 days before surgery with no solid diet
  2. Two days before surgery, they were given enema every 8 h
  3. Prophylactic single-dose third-generation cephalosporin and Flagyl vial were given at the induction of anesthesia.


The operative technique for SLH was the following:

  1. Lithotomy position, under spinal anesthesia
  2. To expose the anus, the tape was attached to both sides of the buttocks
  3. Per rectum, an examination performed
  4. Insertion of anoscope into the anal canal to examine the anal canal
  5. Incision at the mucocutaneous junction [Figure 1]
  6. Separation of hemorrhoids from the internal sphincter was performed using monopolar electrocautery [Figure 2] until the dentate line
  7. Elevation of the mucosa [Figure 3] and [Figure 4] 1 cm above the anal verge to separate it from hemorrhoids until dentate line
  8. Excision and ligation of hemorrhoidal pedicle [Figure 4], [Figure 5], [Figure 6] at the dentate line
  9. The elevated mucosa later is sutured to the skin [Figure 7] using Vicryl 3-0 to cover raw area
  10. No gauze drain was needed as there was no raw area [Figure 8]
  11. Operative time was recorded.
Figure 1: Incision at the mucocutaneous junction

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Figure 2: Elevation of the hemorrhoid

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Figure 3: Separation of the mucosa from the hemorrhoid using monopolar electrocautery

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Figure 4: Elevation of the mucosa

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Figure 5: Clamping of the submucosal hemorrhoid

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Figure 6: Transfixation of the submucosal hemorrhoid

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Figure 7: Suturing the mucosa to the skin

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Figure 8: Complete mucosa sutured to the skin

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The operative technique for HSH was the following:

  1. All the above steps performed using a harmonic scalpel
  2. Except that, there is raw area after excision of hemorrhoids and overlying mucosa
  3. Between each excised hemorrhoids there were intact mucosa about 8-10 mm to decrease the incidence of anal stenosis
  4. Gauze drain is needed, as there is a raw area
  5. Operative time was recorded.


Postoperatively, all the patients were put under observation for:

  1. Pain measured using a visual analog scale (VAS). The VAS score range was 0 to 10 (0 = no pain and 10 = severe pain)
  2. Bleeding
  3. Wound breakdown
  4. Urine retention
  5. Sitz baths in the early morning until gauze drain slipped


The patients were discharged early morning and for a year, they were followed up at 1, 3, 6, and 12 months to check for recurrences, anal stenosis, perianal fistula, or fecal incontinence [Figure 9] and [Figure 10].
Figure 9: After 3 months

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Figure 10: After 6 months

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Statistical analysis

The collected data were organized, tabulated, and statistically analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 21 (SPSS Inc. USA). Data were described using mean and standard deviation (SD), and frequencies were defined according to the type of data (quantitative or categorical, respectively). Chi-square and Fisher's exact tests were used for comparison of qualitative variables. We used a one-way analysis of variance (ANOVA) test to compare the means of categorical to numerical data. Significance level (P value) was adopted, i.e. P< 0.05 for interpretation of significant test results.


  Results Top


In both groups, the majority of our patients were male, with a mean age of 46.1 ± 6.5 in the SLH group and 46.8 ± 6.2 in the HSH group. There was no significant difference between age and sex between both groups [Table 1].
Table 1: Demographic and perioperative parameters

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Operative time was 35 ± 12 min in Group A while it was 18 ± 6 min in Group B, with highly significant prolonged operative time in Group A. There was no significant difference between both groups in terms of mean hospital stay and time to return to daily activity [Table 1].

In terms of postoperative pain, three cases in Group A and nine cases in Group B experienced severe pain, with a significantly higher incidence of severe pain in the HSH group [Table 1]. In addition, the cost of surgery was highly significant in the HSH group [Table 1].

There was no significant difference between both groups regarding the postoperative complications, except anal stenosis, which occurred in two (3.2%) cases in Group A and seven (11.9%) cases in Group B, with a significantly higher incidence of anal stenosis in the HSH group [Table 2].
Table 2: Postoperative complications (short- and long-term)

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  Discussion Top


Hemorrhoids are one of the most common anorectal diseases and are classified into four grades—I, II, III and IV.

Conservative management is the standard treatment in Grade I and II hemorrhoids while Grade III and Grade IV need surgical management.

The first described surgery was hemorrhoidectomy using electrocautery. Since then, several techniques have developed, such as using advanced bipolar devices (harmonic scalpel) or stapler, showing improvement in the hemorrhoid surgery results.

In our study, we modified a new technique regarding conventional surgery, which aims to preserve the anal canal mucosa to cover the raw area created after hemorrhoidal excision (SLH). Then, we compare this new modification with HSH as the latter shows better results than the conventional surgery.

In our study, there were more male than female patients in both groups. Also, there was no significant difference between male and female ratio between both groups as HD is a disease affecting both men and women.

The age of patients ranged between 21 and 68 years with the mean age 46.1 and 46.8, respectively, in both groups and there was no significant difference in terms of age.

HD is considered common in middle-aged group and our study results were in accordance with the same.

The operative time was 35 min and 18 min in Group A and B, respectively, with significantly lower operative time in the HSH group, which can be explained by the fact that SLH needs more time to separate hemorrhoidal vessels from the overlying mucosa.

The mean hospital stay was 1.6 and 1.4 days while the time for return to daily normal activity was 9.1 and 8.7 days in Group A and B, respectively, with lower hospital stay and early return to daily normal activity in HSH group. However, there was no significant difference here as we need more postoperative time to follow-up the mucosa and more rest to avoid sloughing or retraction of preserved mucosa, which can occur with daily activity's movement and friction.

According to the VAS scores, the pain within the first 24 h postoperatively was mild in 24 patients (39.3%), moderate in 16 patients (26.2%), and severe in 3 patients (4.8%) in the SLH group. While in the HSH group, there was mild pain in 21 patients (35.5%), moderate pain in 14 patients (23.7%), and severe pain in 9 patients (15.3%). In terms of mild and moderate pain, there was no significant difference between both groups. However, severe pain was significantly higher in the HSH group.

Analgesia was needed by 17 (27.8%) patients in the SLH group and 20 (33.9%) patients in the HSH group, with no significant difference in both groups. This is because there is no raw area in the SLH group which, in turn, decreases the pain postoperatively and during defecation. This is also reflected in decreasing use of additional analgesics.

The cost was significantly higher in the HSH group as we used a harmonic scalpel handpiece, which is expensive and using it requires maintenance and changing the connecting wire after certain number of cases while in SLH we used the ordinary tools and electrocautery.

All the patients followed-up every 1 month until 12 months to demonstrate short- and long-term complications.

In terms of short-term complications, there was wound infection in 10 and 8 cases in Group A and B, respectively, with no significant difference. However, the incidence of infection was lower in the HSH group as leaving the raw area allow better wound care and no foreign body (sutures), which enhance infection, also leaving raw area to heal by secondary intention so there are no cases of wound breakdown in HSH while presence of sutured wound increases the chance of wound breakdown, which occured in two cases in the SLH group without significant difference between both groups.

The rate of postoperative bleeding was lower in the SLH group as compared with the HSH group ranging from 8 (13.1%) and 9 (15.2%), respectively, with no significant difference. This can be explained by the fact that the less raw the area is, the less bleeding.

There were three and five cases of urine retention in Group A and B, respectively, with no significant difference; however, the incidence rate in the SLH group was lower because when severe pain is less, it decreases the incidence of urine retention. Nonetheless, all urine retention cases were conservatively managed.

During the long-term follow-up, there were two cases of recurrence in the SLH group and one case in the HSH group with no significant difference.

There were two cases and 7 cases of stenosis in Group A and B, respectively, with a significantly lower rate of stenosis in SLH group because of the absence of any raw area in SLH.

There were no cases of incontinence in the HSH group while there was one case of incontinence in SLH group without any significant difference between both groups. The incidence of incontinence comes from more dissection, which may affect the external sphincter.

There were no cases of perianal fistula in the HSH group while there was one case of perianal fistula in SLH group as the presence of a sutured wound in the SLH group increases the liability of submucosal abscess formation with subsequent perianal fistula; however, there was no significant difference between both groups.


  Conclusion Top


Both SLH and HSH are safe and effective surgical techniques for the management of Grade III and Grade IV hemorrhoids. The SLH technique is associated with less incidence of severe postoperative pain, lower cost, and fewer rates of stenosis over the long run. It protects the patient from being exposed to other anal problems, which may require another surgical intervention.

Ethical approval

Granted for the study by Faculty of Medicine, Menoufia University Ethical Committee according to the Declaration of Helsinki.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Longo A. Treatment of hemorrhoid disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: A new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery (June 3–6, 1998), Rome.  Back to cited text no. 6
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2]



 

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