Il punto sulla malattia emorroidaria. Giovanni Terrosu

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1 AZIENDA OSPEDALIERO-UNIVERSITARIA S.M. della MISERICORDIA - UDINE CLINICA CHIRURGICA GENERALE Direttore: Prof. F. BRESADOLA QUARTE GIORNATE RODIGINE DI COLOPROCTOLOGIA Chirurgia retto-anale: Opinioni e Confronti ROVIGO 9-10 OTTOBRE 2008 Il punto sulla malattia emorroidaria Giovanni Terrosu

2 Quando una mucoprolassectomia 1. Prolasso muco-emorroidario 2-3 grado sintomatico 2. Prolasso circonferenziale Nelle emorroidi di III grado sintomatiche ritieni che possa essere indicata la prolassectomia: 1. Quando c èc prolasso circonferenziale 2. Quasi mai 3. Sempre (anche solo 2 gavoccioli di 2 ) 2 Consensus Conference "La malattia Emorroidaria G. Casula, V. Pezzangora, G. Rispoli, G. Leoni, A. Miro 108 SIC, Roma ottobre ,00 80,00 44,86 Sala 21, Esperti 33,64 60,00 40,00 50,00 43,18 20,00 0,00 6,

3 Attuali spazi della chirurgia tradizionale 1. (4?) grado sintomatiche 2. 3 grado a pacchetti separati sintomatiche 3. Ragade ± ipertono associati 4. Discrepanza di grado tra i diversi pacchetti Nelle emorroidi di III grado a pacchetti separati, in caso d indicazione chirurgica, proponi più frequentemente: 1. Dearterializzazione con guida doppler 2. Emorroidectomia (Milligan-Morgan Morgan Classica, Radiofrequenza, Ultrasuoni, etc.) 3. Prolassectomia Consensus Conference "La malattia Emorroidaria G. Casula, V. Pezzangora, G. Rispoli, G. Leoni, A. Miro 108 SIC, Roma ottobre ,54 Sala 44, Esperti 38,64 48,6 56, ,

4 Il punto sull evidenze scientifiche Practice parameters for the management of haemorrhoids. by A.S.C.R.S. Cataldo et al., Dis Colon Rectum 2005, 48, 189 Medline Hemorrhoidectomy should be reserved for patients refractory to office procedures, unable to tolerate office procedures, patients with large external hemorrhoids or patients with combined internal and external hemorrhoids with significant prolapse (grade III and IV). Level of evidence I Grade of recommendation B Stapled hemorrhoidopexy is a new alternative available for individuals with significant hemorrhoidal prolapse.

5 Il punto sull evidenze scientifiche Stapled versus conventional surgery for hemorrhoids (Review) S Jayaraman, Cochrane Database Syst Rev 2006 oct 18, 4 Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also likely to be associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the gold standard in the surgical treatment of internal hemorrhoids.

6 Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemmorrhoids compared with conventional excisional hemorrhoid surgery Comparison or Outcome No. Studies No. Participants Odds Ratio (95% CI) P Value No hemorrhoidal symptoms at final follow-up [0.33, 1.29] NS No hemorrhoidal symptoms at follow-up >1 year but <2 years [0.3, 1.53] NS Hemorrhoidal bleeding at final follow-up [0.81, 2.08] NS Bleeding at follow up >1 year but <2 years [0.76, 3.02] NS Bleeding at follow-up >2 years [0.29, 2.54] NS Hemorrhoidal prolapse at final follow-up [1.33, 6.58] Prolapse at follow-up >1 year but <2 years [0.98, 7.34] 0.05 Pruritus ani at final follow-up [0.16, 2.9] NS Pruritus ani at follow-up >2 years [0.01, 36.25] NS Soiling or difficulty with hygiene or continence [0.55, 3.85] NS Fecal urgency [0.35, 2.34] NS Hygiene/continence problems at follow-up >1 year but <2 years [0.22, 5.31] NS Fecal urgency at follow-up >2 years [0.38, 3.58] NS Skin tags at final follow-up [0.61, 2.96] NS Skin tags at follow-up >1 year but <2 years [0.64, 2.55] NS Pain related to hemorrhoids at final follow-up [0.31, 3.32] NS Pain at follow-up >1 year but< 2 years [0.35, 1.6] NS Recurrent internal hemorrhoids seen at final follow-up [1.47, 10.07] Recurrent hemorrhoids at follow-up >1 year but< 2 years [1.24, 10.49] 0.02 Difficulty voiding because of outlet obstruction or anal stenosis [0.17, 1.52] NS Further surgeries [0.61, 4.05] NS S. Jayaraman, Dis Colon Rectum 2007; 50:

7 Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy Test for heterogeneity Comparison or No. of No. of Outcome studies pts. Statistical method Effect size P 2 P I2 I2 (%) Total complication rate RR (fixed), 95% c.i (0 80, 1 45) Postoperative haemorrhage RR (fixed), 95% c.i (1 06, 2 33) 0 023* Additional proc. for haemorrhage RR (fixed), 95% c.i (0 64, 2 01) Requirement for transfusion 5 48 RR (fixed), 95% c.i (0 35, 4 14) Sphincter damage RR (random), 95% c.i (1 19, 5 32) 0 016* < Recurrent prolapse (total) RR (fixed), 95% c.i (1 57, 3 33) <0 001* <1 year of of follow-up RR (fixed), 95% c.i (1 41, 6 07) 0 004* year of of follow-up RR (fixed), 95% c.i (1 33, 3 20) 0 001* Thrombosed haemorrhoids RR (fixed), 95% c.i (0 89, 3 55) Persistent wound discharge RR (fixed), 95% c.i (0 06, 0 27) < Anal stenosis RR (fixed), 95% c.i (0 58, 1 71) Residual skin tags RR (fixed), 95% c.i (1 11, 2 20) 0 011* Anal fissure RR (fixed), 95% c.i (0 42, 2 45) Acute urinary retention RR (fixed), 95% c.i (0 67, 1 24) Faecaloma RR (fixed), 95% c.i (0 27, 0 82) Pruritus RR (random), 95% c.i (0 49, 2 24) < *Significantly favours conventional haemorrhoidectomy Significantly favours stapled haemorrhoidopexy W.J. Shao, British Journal of Surgery 2008; 95: 147

8 Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy Test for heterogeneity Comparison or No. of No. of Outcome studies pts. Statistical method Effect size P 2 P I2 I2 (%) Operating time (min) WMD (random), 95% c.i ( 18 26, 4 59) < Inpatient stay (days) WMD (random), 95% c.i ( 1 32, 0 59) < < Return to to normal activity (days) WMD (random), 95% c.i ( 21 42, 2 08) < Patient satisfaction % satisfaction RR (fixed), 95% c.i (1 03, 1 17) Visual analogue scale WMD (random), 95% c.i ( 0 29, 1 09) Pain score During bowel movement SMD (fixed), 95% c.i ( 0 63, 0 26) < < h after surgery SMD (random), 95% c.i ( 4 25, 1 35) < < weeks after surgery SMD (random), 95% c.i ( 3 10, 0 06) < Analgesic consumption SMD (random), 95% c.i ( 4 76, 1 20) < Incontinence (total) RR (fixed), 95% c.i (0 38, 1 35) <6 months follow-up RR (fixed), 95% c.i. n.e. n.e. n.e. n.e. n.e. 6 months follow-up RR (fixed), 95% c.i (0 38, 1 35) Requiring further surgery for recurrence RR (random), 95% c.i (0 63, 5 95) *Significantly favours conventional haemorrhoidectomy Significantly favours stapled haemorrhoidopexy W.J. Shao, British Journal of Surgery 2008; 95:

9 Il punto sull evidenze scientifiche Grado di raccomandazione Tipo emorroidi A B C D 1 grado 2 grado Legatura elastica HAL THD Dieta e terapia farmacologica Legatura elastica Scleroterapia Fotocoagulazione Emorroidopessi Scleroterapia 3 grado Emorroidopessi Emorroidectomia Hal THD Legatura elastica 4 grado Emorroidectomia Emorroidopessi Singola emorroide esterna Emorroidectomia The treatment of hemorrhoids: guidelines of the Italian Society of Colorectal Surgery. Altomare D., Roveran A., Pecorella G., Gaj F., Stortini E. Tech Coloproctol Oct;10(3):181-6.

10 Persistenza di malattia emorroidaria post Milligan-Morgan: Morgan: limite della procedura o errore tecnico? 1. Limite della procedura (ponti) 2. Scelta dell operatore di asportare solo 1 o 2 pacchetti 3. Errore tecnico se non legatura alta

11 Come rimediare alle sequele delle Mucoprolassectomie? 1. Persistenza/recidiva prolasso: legatura o MM (THD?) 2. Rimozione di skin tags 3. Granulomi: asportazione agraphes 3 diatermy haemorrhoidectomy 1 excision 1 rubber band ligation 1 rubber band ligation 1 restapling 1 rubber band ligation 1 diathermy dissection 1 rubber band ligation 3 diathermy dissection 12 procedures (?) 3 diathermy haemorrhoidectomy, 3 rubber band ligation, 1 excision under local anesthesia 2 rubber band ligation 5 diathermy hemorrhoidectomy W.J. Shao, British Journal of Surgery 2008; 95:

12 Tecniche chirurgiche alternative: sono supportate dalle evidenze scientifiche? Autore Anno Studio N. Paz. Risoluzione sintomi % Follow-up months Tecnica Morinaga 1995 / % 1 HAL Sohn 2001 / % / THD Shelygin 2003 / % 12 HAL Lienert 2004 / % / HAL CharùaGuindic 2004 Prospettico / Tagariello 2004 / % / THD Felice 2005 / % 11 (3-18) / Ramirez 2005 / / Greenberg 2006 Prospettico % 3 HAL Scheyer 2006 / % 18 HAL Abdeldaim 2007 Prospettico % 18(12-24) HAL Dal Monte 2007 / % 46 (22-79) THD Walega 2007 / % 12 HAL Wallis de Vries 2007 / % 8 HAL Cantero 2008 Prospettico % 12 THD Faucheron 2008 / % 36 HAL Wilkerson 2008 Prospettico % 30 HAL

13 Early results Tecniche chirurgiche alternative: sono supportate dalle evidenze scientifiche? Group A hemorrhoidectomy (n= 30) Group B DG-HAL (n= 30) Need for minor analgesics (doses) <0.005 Length of hospital postoperative stay (h) < Return to normal daily activities (days) < Late results Group A hemorrhoidectomy (n= 30) Group B DG-HAL (n= 30) Evacuation problems 0 0 / Stricture 0 0 / Incontinence 0 0 / Failure (at 6 th week p.o.) 4 (13.3%) 5 (16.6%) n.s. Recurrent symptom (at 1 year) 4 (13.3%) 4 (13.3%) n.s. Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study Bursics A. Int J Colorectal Dis (2004) 19: In conclusion, both the closed scissors hemorrhoidectomy and the DG-HAL procedure proved effective in treating hemorrhoids in both the short and the long term. The 1-year results of DG-HAL procedure do not differ from those of the closed scissors hemorrhoidectomy. The short hospital stay, the low complication rate, and the minimal postoperative pain make the DG-HAL procedure ideal for 1-day surgery and is in accordance with the requirements of minimally invasive surgery.

14 Mucoprolassectomie e follow-up: è giunto il tempo di un bilancio?

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