Mikelangelo: переводы

→Transanal hemorrhoidal dearterialization is a valid therapeutic option in patients with hemorrhoidal disease. It can provide effective control of symptoms in the vast majority of patients. Accuracy in both dearterialization (using the “DDD” procedure) and mucopexy (repositioning the prolapsing rectal mucosa and submucosa, completely sparing the piles) seems the key to therapeutic success. However, patients must be informed about postoperative management. The limited number and severity of complications makes THD very safe. Finally, THD can be used in case of recurrent disease.

→Conclusions

→In the majority of cases of recurrent prolapse, the cause seems to be the disruption of MP suture(s) with difficult defecation early in the postoperative period or later due to chronic straining. To prevent this occurrence, an optimal diet and fiber supplements are necessary in case of constipation, or prompt treatment for IBS and IBD symptoms. Patients with recurrent prolapse can be managed conservatively if the prolapse is minimal. Re-do MP is technically possible although other strategies such as excisional hemorrhoidectomy can also be adopted.

→In case of recurrence, the treatment decision making is guided by the symptoms. Recurrence of rectal bleeding can occur in cases where the dearterialization was not successful in one or more rectal sectors. Severity of bleeding is usually less than in the initial presentation and can be easily managed with medical therapy, rubber band ligation, or new dearterialization under Doppler guidance.

→Recurrences and their management

→In the author’s experience, THD, performed according to the principles outlined above, is never followed by fecal incontinence and chronic pain. Indeed, anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by this procedure [19].

→The most common complication is tenesmus, which sometimes can turn into rectal discomfort or pain. It can be managed with analgesics and anti-inflammatory drugs as described above. However, these symptoms rapidly disappear. Rectal bleeding can occur in a very limited number of patients, usually within 2 weeks after the operation. It can be caused by trauma of the rectal mucosa involved in the surgical procedure (especially MP) during prolonged straining, passage of hard stool, or diarrhea. In fact, excessive suture traction can be generated and can lead to breakage. Moreover, the relative tissue ischemia at the level of the MP suture line can result in a limited necrosis of the mucosa/submucosa and consequent bleeding. In both cases, the removal of clots by saline solution lavage (performed with a soft catheter) can usually stop the bleeding. If bleeding continues and increases in frequency and intensity, it is necessary to perform an endoscopic or surgical hemostasis (cauterization, endoclip, and suture).

→Complications and management

→The second follow-up visit is made after 1 month. The patient’s anorectum is digitally explored and assessed. Rectal pain, discomfort, and tenesmus should no longer be present. Persistence of these symptoms should be investigated. In case of some hemorrhoidal prolapse is preset or reported, this is suspicious of suture disruption, usually secondary to defecatory dysfunction. Also intermittent, self-limited episodes of bleeding can be indicative to MP disruption. Anal continence should be fully normal. At the 3 month follow-up visit, the patient is also evaluated with anoscopy. At that time, when the procedure is successful, all symptoms are resolved. Volume and appearance of hemorrhoidal cushions are that of patients without hemorrhoidal disease. Persistent or new bleeding or prolapse will require a closer follow-up. Thereafter, patients are contacted by telephone and examined 1 year after surgery. A long-term annual follow-up may be established. If any symptom related to a possible recurrence of hemorrhoidal disease is reported, the patient undergoes digital examination and anoscopy.

→The follow-up includes 4 different time points. At the first visit, 7–10 days after the procedure, a digital anorectal examination is never carried out, but only an external inspection to avoid the risk of pulling on the stitches. At this time, particular attention is also paid to normalizing defecation with diet and laxatives. Usually, bleeding is no longer present. In a minority of patients after MP, some bloody mucus is referred, due to the early postoperative inflammatory process. Inflammation can also determine mild fever along the first 2–3 postoperative days, usually self-limited and responding to anti-inflammatory drugs. Tenesmus can be referred after MP at this time and gradually improves. Only minority of patients still require analgesics.

→Follow-up

→Tenesmus can be accompanied by a transient sensation of urge to defecate. This is usually transient, with resolution within 7–10 days, and does not give rise to any form of persistent urgency, soiling, or fecal incontinence.

→Urinary retention develops in about 10 % of patients, especially those who undergo MP and males. To prevent this, restriction of excessive intravenous infusion of fluids is advisable. Treatment should consist only in temporary bladder catheterization.

→The severity of pain and tenesmus could be dependent not only on the surgical procedure but also on the patient’s tolerance level to pain; in that case, their management of these symptoms should be specially tailored. Patients who undergo dearterialization alone usually suffer minor pain and/or rectal discomfort, lasting from a few hours to a few days. In these patients, anti-inflammatory drugs and/or analgesics can be prescribed “as needed.” Patients who had MP more frequently report tenesmus and pain. In these patients, non-steroidal anti-inflammatory drugs (NSAIDs) should be given around the clock for at least 3 days, and other analgesics when requested. With these measures, in the author’s experience, both edema and related symptoms are reduced. Usually, patients can discontinue this postoperative regimen after a few days, and only a minority of them needs it for more than 7 days.

→Postoperative care should be strongly directed toward the control of pain and tenesmus. The source of these symptoms is the surgical site (not the hemorrhoidal cushions) and is related to the plication of the rectal mucosa/submucosa. This can cause an inflammatory response (with edema and inflammatory reaction) associated with relative ischemia of those tissues, which causes both pain and tenesmus. As a consequence of the inflammatory process, MP patients can have a mucous, sometimes bloody, anal discharge for a few days. When both piles and the sensitive mucosa of the anal pecten are spared during MP (as described above), these are not the source of pain and tenesmus, unless a hemorrhoidal thrombosis has developed.

→Scrupulous adherence to a dietary protocol is usually recommended during the first 2–3 postoperative months, and the patient is encouraged to continue a high residue diet after this time period. Patients with either chronic diarrhea or irritable bowel syndrome should be put on a very carefully controlled diet and pre-/probiotics. On the other hand, those with either chronic inflammatory bowel disease or chronic radiation proctitis must continue the specific therapy as prescribed; a sudden worsening of their condition should be diagnosed early and treated.

→A diet rich in fluids (oral intake of at least 2 l of water per day) and fiber is established, eventually supplemented by oral assumption of stool softeners. Use of laxatives is advisable. In fact, especially in patients who underwent MP, not only constipation but also diarrhea and increased frequency of bowel movements could cause an early disruption of the rectal sutures and, then, possible bleeding from the mucopexy suture(s) and early recurrence of prolapse.

→Postoperative management

→Following the identification of the hemorrhoidal artery, the proctoscope is again pushed fully inside the distal rectum, and a “Z-stitch” is made as a proximal “fixation point” of MP. The circular device pivot can be used to do this. The proximal end of MP is not standard, depending on the length of prolapsing mucosa and submucosa. Then, the knot is tied (Fig. 7). Thereafter, the main proctoscope remains in place, and only its sliding part is moved back, exposing the rectal mucosa so that MP can be performed under direct vision. MP is carried out with a continuous suture, including the redundant and prolapsing mucosa and submucosa, in a proximal-to-distal direction, along a longitudinal axis (Figs. 5, 8). The recommended distance between each suture is approximately 0.5 cm, which is optimal in order to avoid sutures that are too tight (a shorter distance has a lesser plicating effect as well as increased risk of tissue ischemia) or too loose (a longer distance with consequent formation of wide enfolding of rectal mucosa/submucosa and increased risk of early postoperative rupture of the running suture). While performing MP, when the “marker point” is visualized, the surgeon takes care to make a passage of the running suture above and another below the “marker point,” in order to entrap the hemorrhoidal artery within the running suture and accomplish the dearterialization according to the DDD principle (Fig. 9). Each vertical row should be spaced from the adjacent one in order to guarantee enough blood outflow from the hemorrhoids via the venous plexus. In fact, a circumferential obliteration of rectal tissue might create a significant obstacle for the blood and consequently an increased risk of postoperative thrombosis. The MP running suture is stopped at the proximal apex of the internal hemorrhoid, avoiding its inclusion in the mucopexy. When performed this way, the THD method can effectively be considered a hemorrhoid-sparing procedure. Finally, the suture is gently tied (Fig. 10).

→Technique