Functional and Structural Abnormalities After Milligan Hemorrhoidectomy

Johannsson, Helgi Örn; Påhlman, Lars; Graf, Wilhelm

doi:10.1097/dcr.0b013e31828deb6d

Cited by 24 publications

(17 citation statements)

References 16 publications

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“…Sphincter injuries were detected in 8 (40%) of 20 subjects and 5 of them had lesions of the external anal sphincter. These data are similar to those of other papers which provide useful suggestion for understanding the pathophysiology of incontinence [11]. Excision of hemorrhoids may lead to reduced resting anal pressure because of loss of the anal cushions and when this is combined with internal anal sphincter injuries passive fecal incontinence can occur.…”

Section: Hemorrhoidectomysupporting

confidence: 88%

Post-surgical fecal incontinence

Pucciani

2017

Updates Surg

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The primary endpoint of this work was to understand the pathophysiology of fecal incontinence manifested after rectal and anal surgery. A retrospective cohort study with negative colonoscopy patients was created and 169 postoperative incontinent patients were analyzed (114 women and 55 men: mean age 58.9 ± 6.3): clinical evaluation, endoanal ultrasound and anorectal manometry reports were scanned. The duration of incontinence was very long, with a mean of 21.7 months. The mean number of bowel movements/week was 18.2 ± 7.2. Urge incontinence was present in 82.2% of patients, mixed with passive incontinence in 44 patients. Patients' Fecal Incontinence Severity Index (FISI) score was 27.0 ± 6.6. Operated patients had significantly lower anal resting pressure (P < 0.01) than controls while patients with colo-anal anastomosis and those who underwent Delorme operation had lowest values (P < 0.01). Maximal tolerated volume and rectal compliance were significantly impaired in operated patients with rectum involvement (colo-anal anastomosis, Delorme, restorative procto-colectomy and STARR). External anal sphincter (EAS) defects were present in 33.1% of all patients and internal anal sphincter (IAS) was damaged in 44.3%: a combined lesion of anal sphincters was detected in 39 patients (23.0%). A positive correlation was found between patients' FISI score and thickness of both sphincters (EAS: ρ 73; IAS: ρ = 81). Malfunctioning continence factors may induce fecal incontinence involving each time, in a different way, the volumetric capacity and/or the motility of the rectum, the perception of the fecal bolus and anal sphincter contraction.

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Section: Hemorrhoidectomysupporting

confidence: 88%

Post-surgical fecal incontinence

Pucciani

2017

Updates Surg

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“…42 Incontinence after hemorrhoidectomy is associated with a high incidence of partial or full-thickness internal anal sphincter injury and occasionally external sphincter defects. [43][44][45] Incontinence has also been seen with intact sphincters, as the hemorrhoidal cushions are known to provide 15% of the patient's resting anal tone, and removal can unmask issues with incontinence that were being aided by these cushions. Excision of hemorrhoids with secondary healing may also cause decreased sensitivity and reduced capacity for rectoanal discrimination.…”

Section: Fecal Incontinencementioning

confidence: 99%

Complications Following Anorectal Surgery

Kunitake

Poylin

2016

Clinics in Colon and Rectal Surgery

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Anorectal pathology is prevalent throughout the world, with most anorectal complaints being transient and without the need for formal medical evaluation. For those that do require surgical intervention for their anorectal pathology, the surgery can usually be done safely in the outpatient setting with minimal morbidity. However, no intervention is without risk, and complications frequently arise after anorectal surgery, with rates upward of 50% in some studies. 1 The purpose of this chapter is to review the short-and long-term complications that can arise after anorectal surgery, including the diagnostic approach, interventions, and prevention strategies for these complications. Short-Term/Acute Complications Postoperative HemorrhageMinor bleeding after anorectal surgery is common. Since we expect patients to continue with normal bowel function, the already disturbed anorectal mucosal becomes further irritated with activity and bowel movements. Since some bloody discharge is normal, the patient should be appropriately counseled on what to expect so as to avoid unnecessary anxiety and phone calls. It may also be helpful to remove/wash out clots from the rectum while still in the operating room to minimize confusion after surgery. However, major bleeding can also occur, albeit rarely, and may require further intervention. While the presentation of major bleeding is not uniform, patients often report frequent passing of small to moderate amounts of clot and bright red blood starting after the first bowel movement.Hemorrhoid surgery involves the vascular cushions of the anus, so not surprisingly, hemorrhoidectomy is associated with higher rates of bleeding when compared with other anorectal procedures. 1-3 Bleeding after other anorectal procedures such as procedures for anal fistula or fissure is very low (0.4-1.2%). 4,5 Rates of clinically significant bleeding after hemorrhoid surgery vary based on type of the procedure. For conventional hemorrhoidectomy (Milligan-Morgan and Ferguson) and bipolar energy device hemorrhoidectomy (Ligasure), rates of clinically significant hemorrhage has been reported in the range of 0.3 to 6%, with an average of around 2%. 1-3,6,7 There does not seem to be a significant difference in rates of bleeding between conventional hemorrhoidectomy and bipolar energy device assisted procedures.The timing of bleeding after hemorrhoidectomy varies, and can be generally divided into immediate and delayed. 5 Immediate bleeding occurs within 24 to 48 hours of a procedure and is likely related to loss of control of the vascular pedicle. Delayed bleeding is defined as bleeding reported up to 2 weeks postprocedure, and is more often related to infection or local trauma. 4,5 Delayed bleeding may be influenced by post-operative pain medications. Hemorrhoidectomy is associated with significant postoperative pain, and multimodality management is routinely employed to help alleviate discomfort. NSAIDS are an integral part of this pain management and can increase the incidence of bleeding. 8 Keywords ► anor...

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“…Incontinence after hemorrhoidectomy is usually associated with partial-or full-thickness internal (and occasionally external) anal sphincter injury, but it can occur also with intact sphincters, as the hemorrhoidal cushions are known to provide 15% of the patient's resting anal tone, and their removal can be functionally disadvantageous. Excision of hemorrhoids with secondary healing may also cause decreased sensitivity and reduced capacity for rectoanal discrimination [196].…”

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confidence: 99%

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

et al. 2020

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Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication. The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE. These guidelines are inclusive and not prescriptive. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

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Functional and Structural Abnormalities After Milligan Hemorrhoidectomy

Abstract: In the group of patients reporting incontinence after hemorrhoidectomy, there was a proportion with sphincter defects and impaired sphincter function. These results indicate a need for cautious patient selection and improved or alternative surgical techniques.

Cited by 24 publications

References 16 publications

Post-surgical fecal incontinence

Post-surgical fecal incontinence

Complications Following Anorectal Surgery

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

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