Tailored Approach in der Therapie der Hämorrhoidalleiden

Zusammenfassung

Das symptomatische Hämorrhoidalleiden ist einer der häufigsten Gründe für das Aufsuchen einer koloproktologischen Einrichtung. Neben der typischen Anamnese ist der Untersuchungsbefund inkl. Proktoskopie wegweisend. Die überwiegende Mehrheit der Patienten kann konservativ mit sehr gutem Ergebnis hinsichtlich der Lebensqualität behandelt werden. Insbesondere durch Basistherapie mit Stuhlregulation, korrektem Stuhlverhalten und Sklerosierungstherapie kann stadienunabhängig eine gute Symptomkontrolle erreicht werden. Bei Versagen der konsequenten konservativen Therapie stehen verschiedene operative Verfahren zur Verfügung. Entscheidend für die Auswahl des Verfahrens ist der individuelle Befund des Patienten im Sinne eines Tailored Approachs. Neben den klassischen segmental resezierenden sowie zirkulär pexierenden Operationen gehören auch neuere, z. T. weniger invasive Methoden wie Hämorrhoidalarterienligatur mit und ohne Rectoanal Repair (HAL-RAR), Infrarottherapie (IRT), Lasertherapie (LT) und Radiofrequenzablation (RFA) zum chirurgischen Repertoire. Blutung, Schmerz, Inkontinenz sowie Rezidiv stellen mögliche Risiken der operativen Therapie dar.

Abstract

One of the most common reasons to consult a coloproctologist is symptomatic haemorrhoids. Typical signs and symptoms as well as a specialised examination, including proctoscopy, are essential for the correct diagnosis. The vast majority of patients can be treated conservatively with excellent results in terms of quality of life. Sclerotherapy provides good control of symptoms at any stage of haemorrhoidal disease. If conservative treatment fails, there are various surgical options. A tailored approach is mandatory. Besides well-known procedures such as Fergusson, Milligan-Morgan procedure or haemorrhoidopexy (Longo) there are less invasive options such as HAL-RAR, IRT, LT and RFA. Postoperative bleeding, pain and faecal incontinence are rare complications after surgery.

Schlüsselwörter

chirurgische Therapie - Tailored Approach - Hämorrhoiden - konservative Therapie

Keywords

hemorrhoids - conservativ therapy - surgery - tailored approach

Publikationsverlauf

Eingereicht: 05. März 2023

Angenommen nach Revision: 28. März 2023

Artikel online veröffentlicht:
02. Juni 2023

• Literatur

• 1 Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 1990; 98: 380-386
• 2 Deutsche Gesellschaft für Koloproktologie e.V. (DGK). S3-Leitlinie-Hämorrhoidalleiden, 2019 (AWMF-Registernummer: 081/007). Zugriff am 17. April 2023 unter: https://www.verwaltung.awmf.org/uploads/tx_szleitlinien/081–007l_S3__H%C3%A4morrhoidalleiden_2019–07_01.pdf
• 3 Murie JA, Sim AJ, Mackenzie I. The importance of pain, pruritus and soiling as symptoms of haemorrhoids and their response to haemorrhoidectomy or rubber band ligation. Br J Surg 1981; 68: 247-249
• 4 Weyandt G, Breitkopf C, Werner RN. et al. S1-Leitlinie-Diagnostik und Therapie des Analekzems. J Dtsch Dermatol Ges 2020; 18: 648-657
• 5 Allan A, Samad AJ, Mellon A. et al. Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids. Colorectal Dis 2006; 8: 41-45
• 6 Blanchard C. A Text-book of Ambulant Proctology. Youngstown, Ohio: Medical Success Press; 1928
• 7 Das Hämorrhoidalleiden. Blond H. Leipzig/Wien: Franz Deuticke; 1936
• 8 Davies RB, Lee-Kong SA, Migaly J. et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018; 61: 284-292
• 9 Herrold A, Kirsch JJ. Komplikationen nach Stapler-Hämorrhoidektomie. Ergebnisse einer Umfrage in Deutschland. Coloproctology 2001; 23: 8-16
• 10 Kraemer M, Bussen D, Leppert R. et al. Country-wide survey of therapeutic procedures in hemorrhoids and anal fissure. Chirurg 1998; 69: 215-218
• 11 Argov S. Ambulatory radical hemorrhoidectomy. Personal experience with 1,530 Milligan-Morgan operations with follow-up of 2–15 years. Dig Surg 1999; 16: 375-378
• 12 Labas P, Ohradka B, Cambal M. et al. Haemorrhoidectomy in outpatient practice. Eur J Surg 2002; 168: 619-620
• 13 Mathai V, Ong BC, Ho YH. Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy. Br J Surg 1996; 83: 380-382
• 14 Ceulemans R, Creve U, van Hee R. et al. Benefit of emergency haemorrhoidectomy: a comparison with results after elective operations. Eur J Surg 2000; 166: 808-812
• 15 Jones CB. A comparative study of the methods of treatment for haemorrhoids. Proc R Soc Med 1974; 67: 51-53
• 16 Argov S, Levandovsky O, Yarhi D. Milligan-Morgan hemorrhoidectomy under local anesthesia – an old operation that stood the test of time. A single-team experience with 2,280 operations. Int J Colorectal Dis 2012; 27: 981-985
• 17 Patti R, Almasio PL, Arcara M. et al. Long-term manometric study of anal sphincter function after hemorrhoidectomy. Int J Colorectal Dis 2007; 22: 253-257
• 18 Seow-Choen F, Ho YH, Ang HG. et al. Prospective, randomized trial comparing pain and clinical function after conventional scissors excision/ligation vs. diathermy excision without ligation for symptomatic prolapsed hemorrhoids. Dis Colon Rectum 1992; 35: 1165-1169
• 19 Eu KW, Seow-Choen F, Goh HS. Comparison of emergency and elective haemorrhoidectomy. Br J Surg 1994; 81: 308-310
• 20 Denis J, Dubois N, Ganansia R. et al. Hemorrhoidectomy: Hospital Leopold Bellan procedure. Int Surg 1989; 74: 152-153
• 21 Uba AF, Ihezue CH, Obekpa PO. et al. Open haemorrhoidectomy revisited. Niger J Med 2001; 10: 185-188
• 22 Sayfan J, Becker A, Koltun L. Sutureless closed hemorrhoidectomy: a new technique. Ann Surg 2001; 234: 21-24
• 23 Kolbert G W, Raulf F. [Evaluation of Longo’s technique for haemorrhoidectomy by doppler ultrasound measurement of the superior rectal artery]. Zentralbl Chir 2002; 127: 19-21
• 24 Aigner F, Bonatti H, Peer S. et al. Vascular considerations for stapled haemorrhoidopexy. Colorectal Dis 2010; 12: 452-458
• 25 Simillis C, Thoukididou SN, Slesser AAP. et al. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg 2015; 102: 1603-1618
• 26 Sutherland LM, Burchard AK, Matsuda K. et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002; 137: 1395-1406
• 27 Tjandra JJ, Chan MKY. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 2007; 50: 878-892
• 28 Ortiz H, Marti J, Jaurrieta E. et al. Lord’s procedure: a critical study of its basic principle. Br J Surg 1978; 65: 281-284
• 29 Laughlan K, Jayne DG, Jackson D. et al. Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review. Int J Colorectal Dis 2009; 24: 335-344
• 30 Sakr F, Moussa MM, Elserafy M. Ligasure hemorrhoidectomy versus stapled hemorrhoidopexy: a prospective, randomized-clinical trial. Minerva Chir 2010; 65: 251-258
• 31 Theodoropoulos GE, Sevrisarianos N, Papaconstantinou J. et al. Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III–IV haemorrhoids: a multicenter prospective study of safety and efficacy. Colorectal Dis 2010; 12: 125-134
• 32 Walega P, Romaniszyn M, Kenig J. et al. Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease. ScientificWorldJournal 2012; 2012: 324040
• 33 Scheyer M, Antonietti E, Rollinger G. et al. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol 2015; 19: 5-9
• 34 Brown SR, Tiernan JP, Watson AJM. et al. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet 2016; 388: 356-364
• 35 Neiger A. Infrared-photo-coagulation for hemorrhoids treatment. Int Surg 1989; 74: 142-143
• 36 Neiger A. [Management of hemorrhoids using infrared coagulation]. Schweiz Rundsch Med Prax 1982; 71: 171-176
• 37 Gupta PJ. Novel technique: radiofrequency coagulation--a treatment alternative for early-stage hemorrhoids. MedGenMed 2002; 4: 1
• 38 Gupta PJ. Radio-ablation of advanced grades of hemorrhoids with radiofrequency. Curr Surg 2003; 60: 452-458
• 39 Tolksdorf S, Tübergen D, Vivaldi C. et al. Early and midterm results of radiofrequency ablation (Rafaelo® procedure) for third-degree haemorrhoids: a prospective, two-centre study. Tech Coloproctol 2022; 26: 479-487
• 40 Trelles M A, Rotinen S. He/Ne laser treatment of hemorrhoids. Acupunct Electrother Res 1983; 8: 289-295
• 41 Laubert T, Kahlke V. Hämorrhoidenoperationen. Kontraindiziert oder nicht gewünscht: was nun?. Coloproctology 2020; 42: 30-36