problemi non risolti in coloproctologia: emorroidectomia o ... · problemi non risolti in...

Dr. Michele Schiano di Visconte

Problemi non risolti in coloproctologia: emorroidectomia o

emorroidopessi?

U.O.S. di Colonproctologia

Ospedale“S.MariadeiBattuti”U.O.C.ChirurgiaGenerale(Dir.:G.Munegato)

Conegliano(TV)

Problemi non risolti in coloproctologia: emorroidectomia o emorroidopessi?

Edward Thomas Campbell Milligan

Milligan ETC, Morgan CN, Jones LE, Officer R

Surgical anatomy of the anal canal, and the operative treatment of haemorrhoids.

Lancet 1937; 233:1119-1124

Antonio LongoLongo A

Treatment of Hemorrhoid Disease by Reduction of Mucosa and Hemorrhoid Prolapse with a Circular-

Suturing Device: a New Procedure.

Proceedings of the 6th World Congress of Endoscopic Surgery, pp. 777–84.

Rome, Italy, June 3–6, 1998

Emorroidectomia vs Emorroidopessi


Fisiopatologia della malattia emorroidaria

Età, familiarità, stili di vitaAumento della pressione addominale (stipsi, gravidanza, ecc.)

Cedimento del tessuto connettivo di supporto

PROLASSO

Alterato ritorno venoso

CONGESTIONE

Fragilità dei plessi (← flogosi)

SANGUINAMENTO

Emorroidectomia

Anopessi

BMJ 2008;336:380-383

Gastroenterology 2004;126:1463–1473

Doppia PPH 03

Emorroidectomia: tecnica

APERTA(Milligan-Morgan, 1937)

A partire dalla metà degli anni cinquanta diverse varianti tecniche sono state proposte al fine di ridurre ildiscomfort postoperatorio. Per lo stesso scopo, in anni più recenti, sono stati ideati dispositivi per la dissezionechirurgica sempre più sofisticati (Harmonic ScalpelTM, laser, LigasureTM, ecc.).

SOTTOMUCOSA(Parks, 1956)

CHIUSA(Ferguson, 1959)

DIATERMICA (Loder-Phillips, 1993)

diathermy excision without ligation open tecnique


excision-ligation open technique

Emorroidopessi con stapler (PPH): tecnica

Anche la tecnica dell’emorroidopessi con stapler nasce dall’esigenza di offrire alpaziente un trattamento chirurgico meno doloroso. Tuttavia il meccanismo d’azione sucui si basa (riduzione del prolasso muco-emorroidario) è radicalmente diverso rispettoall’emorroidectomia (asportazione del prolasso muco-emorroidario).

Corman ML et al. Stapled haemorrhoidopexy: a consensus position paper by an international working party – indications, contra-indications and technique. Colorectal Dis 2003;5:304–310


Linee guida a confronto

I grado Terapia medicaNational UK audit

Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids

with good short-term outcomes. Long-term follow up is

required perhaps through a compulsory national register

II grado Terapia medica

III grado

Terapia ambulatoriale(legatura elastica)

oppure Terapia chirurgica

(emorroidectomia)

“Stapled hemorrhoidectopexy is a new alternative available for individuals with

significant hemorrhoidal prolapse”

IV grado Terapia chirurgica(emorroidectomia)

Dis Colon Rectum 2005;48:189-194Tech Coloproctol 2006;10:181-186

Colorectal Disease 2008;10:440–445


NICE Recommendation 2007

“Stapled haemorrhoidopexy, using acircular stapler specifically developedfor haemorrhoidopexy, isrecommended as an option for peoplein whom surgical intervention isconsidered appropriate for thetreatment of prolapsed internalhaemorrhoids”.

Emorroidectomia vs Emorroidopessi: outcomes

§ Dolore postoperatorio

§ Complicanze acute (emorragia, ritenzione urinaria, secrezione anale

persistente, trombosi emorroidaria esterna, ecc.)

§ Degenza e ripresa dell’attività lavorativa

§ Costi

§ Complicanze tardive (incontinenza fecale, stenosi, disturbi della defecazione,dolore cronico, ecc.)

§ Recidiva (sanguinamento/prolasso)


Analisi della letteratura: outcomes

OutcomesNo.

metanalisi Emorroidopessi Emorroidectomia NS

Dolore postoperatorio 8 ●●●●●●● ●Emorragia postoperatoria (reintervento) 6 ● ●●●●●Ritenzione urinaria 7 ● ●●●●●●Durata della degenza 8 ●●●●●●● ●Ripresa dell’attività lavorativa 6 ●●●●● ●Secrezione anale/guarigione 7 ●●●●●● ●Soddisfazione del paziente (QoL) 6 ●● ●●●●Costi 2 ●●Stenosi 9 ●●●●●●●●●Incontinenza 9 ● ●●●●●●●●Recidiva 8 ●●●●●● ●●● = metanalisi favorevole


PPH – short-term outcomesYear No. Pain Hospital

StayNormal Activity

Cx’s

Ho 2000 119Mehigan 2000 40Rowsell 2000 22Ganio 2001 100Shalaby 2001 200Boccasanta 2001 80Pavlidis 2002 80Ortiz 2002 55Correa-Rovelo 2002 84Hetzer 2002 40Kairaluoma 2003 60Palimento 2003 74

Better Same Not recorded

012345678910

1 3 5 7 9 11 14

SielezneffPersonaleSenagore

A.G. Senagore et al. - DCR 2004; 47:1824-1836 (Ferguson)

Sielezneff I et al: J.Chir. (Paris). 1997 Nov; 134(5-6):243-47 (71% pz severo)

giorni

V

A

S

Rilevazione personale (54 Ferguson – 54 Milligan-Morgan)

Valutazione del dolore postoperatorio in pt. sottoposti a Milligan & Morgan

Content of meta - analysis

Meta-analysis for following outcomes: persistent urgency, persistentpain, skin tags, internal analsphincter damage as well as patientsatisfaction was not performed due to methodological problems (inhomogeneity of studies and types of measurements)

Meta-analysis for following outcomes:

• 1. postoperative anal incontinence, • 2. anal stenosis, • 3. bleeding at stool, • 4. recurrence of prolapsing hemorrhoids• 5. incidence of re-prolapse related redo-surgery

Review: PPH_U1411Comparison: 01 PPH versus MM Outcome: 01 Anal Incontinence

Study PPH MM RR (random) Weight RR (random)or sub-category n/N n/N 95% CI % 95% CI Quality

01 Small studies Au-Yong 1/11 2/9 23.43 0.41 [0.04, 3.82] D v.d.Stadt 0/20 0/20 Not estimable D Subtotal (95% CI) 31 29 23.43 0.41 [0.04, 3.82]Total events: 1 (PPH), 2 (MM)Test for heterogeneity: not applicableTest for overall effect: Z = 0.78 (P = 0.43)

02 large studies Racalbuto 0/50 3/50 14.55 0.14 [0.01, 2.70] D Gravie 6/52 5/57 62.02 1.32 [0.43, 4.05] D Subtotal (95% CI) 102 107 76.57 0.65 [0.08, 5.26]Total events: 6 (PPH), 8 (MM)Test for heterogeneity: Chi² = 2.04, df = 1 (P = 0.15), I² = 50.9%Test for overall effect: Z = 0.40 (P = 0.69)

Total (95% CI) 133 136 100.00 0.72 [0.22, 2.36]Total events: 7 (PPH), 10 (MM)Test for heterogeneity: Chi² = 2.49, df = 2 (P = 0.29), I² = 19.6%Test for overall effect: Z = 0.53 (P = 0.59)

0.1 0.2 0.5 1 2 5 10

Favours PPH Favours MM

Incontinenza Fecale

Stenosi AnaleReview: PPH_U1411Comparison: 01 PPH versus MM Outcome: 03 Stenosis


01 Small studies Au-Yong 2/9 2/8 61.66 0.89 [0.16, 4.93] D v.d.Stadt 0/20 2/20 20.44 0.20 [0.01, 3.92] D Subtotal (95% CI) 29 28 82.09 0.61 [0.14, 2.71]Total events: 2 (PPH), 4 (MM)Test for heterogeneity: Chi² = 0.78, df = 1 (P = 0.38), I² = 0%Test for overall effect: Z = 0.65 (P = 0.52)

02 large studies Racalbuto 0/50 0/50 Not estimable D Gravie 0/52 1/57 17.91 0.36 [0.02, 8.76] D Subtotal (95% CI) 102 107 17.91 0.36 [0.02, 8.76]Total events: 0 (PPH), 1 (MM)Test for heterogeneity: not applicableTest for overall effect: Z = 0.62 (P = 0.53)

Total (95% CI) 131 135 100.00 0.56 [0.15, 2.14]Total events: 2 (PPH), 5 (MM)Test for heterogeneity: Chi² = 0.86, df = 2 (P = 0.65), I² = 0%Test for overall effect: Z = 0.85 (P = 0.40)

0.1 0.2 0.5 1 2 5 10


Sanguinamento post-operatorioReview: PPH_U1411Comparison: 01 PPH versus MM Outcome: 07 Bleeding at stool


01 small studies Au-Yong 5/11 4/9 35.70 1.02 [0.39, 2.71] D Smyth 5/20 4/16 29.97 1.00 [0.32, 3.12] D v.d.Stadt 5/20 6/20 34.33 0.83 [0.30, 2.29] D Subtotal (95% CI) 51 45 100.00 0.95 [0.52, 1.72]Total events: 15 (PPH), 14 (MM)Test for heterogeneity: Chi² = 0.09, df = 2 (P = 0.95), I² = 0%Test for overall effect: Z = 0.18 (P = 0.86)

02 large studies Racalbuto 0/50 8/50 100.00 0.06 [0.00, 0.99] D Subtotal (95% CI) 50 50 100.00 0.06 [0.00, 0.99]Total events: 0 (PPH), 8 (MM)Test for heterogeneity: not applicableTest for overall effect: Z = 1.97 (P = 0.05)

0.1 0.2 0.5 1 2 5 10


Conclusion of the Meta-analysis in terms of anal incontinence, anal stenosis and bleeding at stool

• Meta-analysis showed less numeric incidence of the anal incontinence as well as the anal stenosis in favor of stapler hememorrhoidopexy compared to MM but without statistical significance.

• Meta-analysis for bleeding at stool showed numeric similar incidence rate in the subgroup of 3 small studies without statistical significance.

• The trial Racalbuto et al. 2004 showed statistically significant less incidence of symptom - bleeding at stool- in favor of PPH.

Recidiva del prolasso/malattia emorroidaria

Reinterventi Review: PPH_U1411Comparison: 01 PPH versus MM Outcome: 12 Re-surgery due to prolapse


01 small studies Au-Yong 1/11 0/9 32.13 2.50 [0.11, 54.87] D v.d.Stadt 4/20 0/20 37.51 9.00 [0.52, 156.91] D Subtotal (95% CI) 31 29 69.64 4.98 [0.61, 40.62]Total events: 5 (PPH), 0 (MM)Test for heterogeneity: Chi² = 0.37, df = 1 (P = 0.54), I² = 0%Test for overall effect: Z = 1.50 (P = 0.13)

02 large studies Racalbuto 1/50 0/50 30.36 3.00 [0.13, 71.92] D Subtotal (95% CI) 50 50 30.36 3.00 [0.13, 71.92]Total events: 1 (PPH), 0 (MM)Test for heterogeneity: not applicableTest for overall effect: Z = 0.68 (P = 0.50)

Total (95% CI) 81 79 100.00 4.27 [0.74, 24.60]Total events: 6 (PPH), 0 (MM)Test for heterogeneity: Chi² = 0.44, df = 2 (P = 0.80), I² = 0%Test for overall effect: Z = 1.63 (P = 0.10)

0.1 0.2 0.5 1 2 5 10


Conclusion of the Meta-analysis II

• In terms of recurrence of prolapsing hemorrhoids,statistical significant borderline superiority (p=0.05, CI-95%) in favor of MM was noted.

• In terms of the incidence of the re-prolapse related redo-surgery, the meta-analysis showed no statisticallysignificant difference between either type of treatment.

Conclusion of the Systematic review (Metaanalysis)

The superiority of Milligan-Morgan hemorrhoidectomy compared to PPH regarding long-term outcomes such as

• incidence of impaired anal continence • anal stenosis, • bleeding at stool as well as the• definitive surgical resolution of hemorrhoidal symptoms,

(redo surgery of prolapsing hemorrhoids) could not be confirmed.

The superiority of MM compared to PPH could be confirmed regarding

• incidence of recurrence of prolapsing hemorrhoids.


Le ragioni degli insuccessi

1. Complicanza (immediata o tardiva)

propriamente detta

2. Inadeguatezza dell’indicazione

all’impiego dell’una o dell’altra

metodica

3. Inadeguatezza dell’esecuzione

tecnica dell’una o dell’altra

metodica

Emorroidopessi: complicanze life-threatening

“The following represents the consensus of the working party as minimal requirements:

Dis Colon Rectum 2003;46:116-7


§ experience with anorectal surgery and an understanding of anorectal anatomy is a requisite;§ experience with circular stapling devices is essential;§ the surgeon must attend a formal course.”

Colorectal Dis 2003;5:304–310


Necrotizing fasciitis and streptococcal toxic shock syndrome after hemorrhoidectomyCozar Ibañez A, del Olmo Escribano M, Jiménez Armenteros F, Moreno Montesinos JM

Rev Esp Enferm Dig 2003;95:68-70


Emorroidectomia: complicanze life-threatening


Dis Colon Rectum 1994;37:185–9

“Sepsis after conservative or operative treatment is uncommon, but it may becatastrophic… Both established and newer techniques should be taught and mastereddiligently, and unnecessary treatment avoided.”

Br J Surg 2003;90:147–156

CONCLUSIONI

• Meno dolore• Veloce ripresa attività lavorativa• Eseguibile in One Day Surgery• Minor incidenza di complicanze a lungo

termine rispetto MM• Attualmente > recidiva del prolasso nel lungo

termine ma……§ Per entrambe le tecniche è comunque necessaria

una adeguata formazione ed esperienza.

problemi non risolti in coloproctologia: emorroidectomia o ... · problemi non risolti in...

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