Gesundheitsbezogene Lebensqualität nach operativer Hämorrhoidaltherapie – Ergebnisse, Methoden und Probleme

Zusammenfassung

Bei einer Hyperplasie des Corpus cavernosum recti und Vorliegen einer analen Beschwerdesymptomatik, die aus transanaler Blutung, perianalem Pruritus, Nässen, Stuhlschmieren oder der Wahrnehmung eines Druck- oder Fremdkörpers bestehen kann, spricht man von einem Hämorrhoidalleiden. Je nach morphologischer Veränderung unterscheidet man zwischen Hämorrhoiden I°, II°, III° und IV°. Die Therapieoptionen werden an den Schweregrad der Erkrankung angepasst und bestehen in den frühen Stadien aus konservativen Maßnahmen wie Stuhlregulation, Sklerosierung und Gummibandligaturen, in den fortgeschrittenen Stadien werden operative Verfahren (z. B. die Segmentexzision und die Staplerhämorrhoidopexie) angewendet. Die gesundheitsbezogene Lebensqualität wird zunehmend häufiger als Qualitätsmerkmal einer konservativen oder operativen Therapie definiert. Nicht nur die morphologische und funktionelle Wiederherstellung von Körperstrukturen oder -funktionen, sondern die subjektive Einschätzung der Beschwerdebesserung durch den Patienten wird als relevanter Behandlungserfolg gewertet. Entsprechend wird dieses Kriterium zunehmend als primärer oder sekundärer Endpunkt klinischer Studien gewählt. Trotz der hohen Inzidenz des Hämorrhoidalleidens, die mit jährlich 4 % in Industrienationen angegeben wird, und aus der in Deutschland 40 000–50 000 operative Eingriffe und ca. 3,5 Millionen Behandlungsfälle pro Jahr resultieren, liegen nur sehr limitierte Daten zur Beeinflussung der Lebensqualität durch diese Erkrankung vor. Auch aus gesundheitspolitischen Aspekten gewinnt die Kosten-Nutzwert-Analyse unter Verwendung des Maßes der lebensqualitätsadjustierten Lebensjahre zunehmend an Bedeutung. In der vorliegenden Arbeit werden Definitionen der gesundheits- und krankheitsbezogenen Lebensqualität erläutert. Die zur Verfügung stehenden psychometrischen Instrumente zur Lebensqualitätsmessung werden dargestellt und deren Qualitätskriterien und Grenzen diskutiert. 

Abstract

In patients suffering from haemorrhoidal disease a hyperplasia of the corpus cavernosum recti is accompanied by various symptoms such as anal bleeding and minor continence disorders as well as itching, soiling and burning. According to the morphological findings, haemorrhoids are staged from grade I up to IV. Therapy strategies are adjusted to this staging. Early stages are treated by conservative measures, such as regulation of defaecation, sclerosis and rubber band ligations. Advanced stages require operative methods, such as segmental excision and stapled haemorrhoidopexy. Since patients demand a greater regard to the subjective experience of their disease and its treatment, quality of life evaluation has become an important issue in medical care. Therefore health-related quality of life is increasingly becoming a relevant primary or secondary end point of clinical studies. Since up to 4 % of the general adult population in industrial nations is annually diagnosed to suffer from haemorrhoidal disease, in Germany per annum 3.5 Mio patients seek medical advice due to this condition and 40 000–50 000 surgical procedures are performed. Nevertheless only very few studies have been carried out to investigate the influence of this widespread disease on the quality of life of those patients. Additionally cost-effectiveness analyses measuring quality-adjusted life years are becoming more and more decisive in health politics. The present article discusses the definitions of health-related as well as disease-related quality of life. Different psychometric tests applied to evaluate the quality of life are summarised, quality criteria are outlined and limitations discussed. Several studies were analysed in regard to the quality of life in patients with haemorrhoidal disease and the specific influence of different operative techniques was reviewed. 

Schlüsselwörter

Lebensqualität (GIQLI) - Hämorrhoiden - Hämorrhoidalleiden - Lebensqualität (SF 36) - operative Therapie

Key words

qualitiy of life (GIQLI) - haemorrhoids - haemorrhoidal disease - life quality (SF 36) - surgical therapy

• Literatur

• Herold A. Hämorrhoiden. In: Brühl W, Herold A, Wienert V. Aktuelle Proktologie. 3. Aufl. Bremen: UNI-MED Science; 2008
• Joos AK, Herold A. Hämorrhoidalleiden. Neue konservative und operative Therapien für ein weit verbreitetes Leiden. Z Gastroenterol 2010; 5: 326-335
• Stelzner F, Staubesand J, Machleidt H. Das corpus cavernosum recti – die Grundlagen der inneren Hämorrhoiden. Langenbeck‘s Arch Chir 1962; 299: 202-312
• Rohde H. Was sind Hämorrhoiden? Sammelbegriff, Symptom oder Erkrankung?. Dtsch Artzebl 2005; 102: 209-213
• Tjandra J, Chan MK. Systematic review of the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 2007; 50: 878-892
• AWMF-Leitlinie Hämorrhoidalleiden Leitlinie Nr. 081–007, Stand 07–2008. Im Internet: http://www.awmf.org (Stand: 11.11.10)
• Hasse C, Sitter H, Brune M et al. Haemorrhoidectomy: conventional excision versus resection with the circular stapler. Prospective, randomized study. Dtsch Med Wochenschr 2004; 129: 1611-1617
• Schmidt MP, Fischbein J, Shatavi H. Stapler-Hämorrhoidektomie versus plastisch-rekonstruktive Verfahren – OP-Verfahren im klinischen Vergleich. Zentralbl Chir 2002; 127: 15-18
• Giordano P, Gravante G, Sorge R et al. Long-term outcomes of stapled hemorrhoidopexy versus conventional hemorrhoidectomy. Arch Surg 2009; 144: 266-272
• Shao WJ, Li GC, Zhang Z et al. Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. Br J Surg 2008; 95: 147-160
• Stratmann H, Kaminski M, Lauschke H et al. Plastic surgery of the anorectal area. Indications, technique and outcome. Zentralbl Chir 2000; 125: 161-165
• Sutherland L, Burchard A, Matsuda K et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002; 137: 1395-1406
• Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled hemorrhoidectomy) versus conventional hemorrhoidectomy; randomized controlled trial. Lancet 2000; 355: 779-781
• Altomare DF, Milito G, Andreoli R et al. Ligasure™ precise vs. conventional diathermy for Milligan-Morgan hemorrhoidectomy: a prospective, randomized, multicenter trial. Dis Col Rectum 2008; 51: 514-519
• Kolbert GW, Raulf F. Evaluation of Longo‘s technique for haemorrhoidectomy by doppler ultrasound measurement of the superior rectal artery. Zentralbl Chir 2002; 127: 19-21
• Narro JL. Hemorrhoid therapy with Doppler guided hemorrhoidal artery ligation via proctoscope KM – a new alternative to hemorrhoidectomy and rubber band ligation?. Zentralbl Chir 2004; 129: 208-210
• Wilson MS, Pope V, Doran HE et al. Surgical treatment of hemorrhoids: prospective, randomized trial comparing closed excisional hemorrhoidectomy and the Harmonic Scalpel technique of excisional hemorrhoidectomy. Dis Colon Rectum 2001; 44: 845-849
• Testa MA, Simson DC. Assessment of quality of life outcomes. N Engl J Med 1996; 334: 835-840
• Sailer M, Bussen D, Fuchs KH et al. Quality of life of patients with fecal incontinence. Langenbecks Arch Chir 1998; 115: 973-975
• Häuser W, Grandt D. Lebensqualitätsmessung in der Gastroenterologie – Konzepte, Instrumente und Probleme. Z Gastroenterol 2001; 39: 475-481
• Determann MM. Analysis of quality of life: quality management or illusion?. Zentralbl Chir 2008; 133: 31-34
• Eypasch E, Williams JI, Wood-Dauphinee S et al. Gastrointestinal quality of life index: development, validation and application of a new instrument. Br J Surg 1995; 82: 216-222
• Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF 36) – Conceptual framework and item selection. Med Care 1992; 30: 473-479
• Dinnendahl V. Hämorrhoidalmittel. In: Schwabe U, Paffrath D. Arzneimittelreport 2009. 1. Aufl. Berlin, Heidelberg, New York: Springer Verlag; 2009
• Sailer M, Bussen D, Debus ES et al. Quality of life in patients with benign anorectal disorders. Br J Surg 1998; 85: 1716-1719
• Schmidt C, Bestmann B, Lindemann H et al. Quality of life and sexuality after surgery for rectal cancer – a follow-up study. Zentralbl Chir 2002; 127: 775-780
• Harisi R, Bodoky G, Borsodi M et al. Rectal cancer therapy: decision making on basis of quality of life?. Zentralbl Chir 2004; 129: 139-148
• Langenbach M, Stippel D, Beckurts KT et al. Patients‘ subjective experiences after liver transplantation. Zentralbl Chir 2003; 128: 842-848
• Friedrich J, Niebel W, Erhard J. Assessing the quality of life after pancreaskidney transplantation. Zentralbl Chir 1999; 124: 739-742
• Westphal T, Piatek S, Schubert S et al. Quality of life after foot injuries. Zentralbl Chir 2002; 127: 238-242
• Khan S, Pawlak SE, Eggenberger JC et al. Surgical treatment of hemorrhoids: prospective, randomized trial comparing closed excisional hemorrhoidectomy and the Harmonic Scalpel technique of excisional hemorrhoidectomy. Dis Colon Rectum 2001; 44: 845-849
• Wilson MS, Pope V, Doran HE et al. Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial. Dis Colon Rectum 2002; 45: 1437-1444
• Thaha MA, Irvine LA, Steele RJ et al. Haemorrhoidectomy: conventional excision versus resection with the circular stapler – prospective, randomized study. Dtsch Med Wochenschr 2004; 129: 1611-1617
• Martinsons A, Narbuts Z, Brunenieks I et al. Correlation of histology with anorectal function following stapled hemorrhoidectomy. Dis Colon Rectum 2005; 48: 1437-1441
• Smyth EF, Baker RP, Wilken BJ et al. Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. Lancet 2003; 361: 1437-1438
• Ho YH, Seow-Choen F, Tsang C et al. Randomized trial assessing anal spincter injuries after stapled hemorrhoidectomy. Br J Surg 2001; 88: 1449-1455
• Ho YH, Cheong WK, Tsang C et al. Stapled hemorrhoidectomy – cost and effectiveness. Randomized, controlled, trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three month. Dis Colon Rectum 2000; 43: 1666-1675
• Peng BC, Jayne DG, Ho Y-H. Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Colon Rectum 2003; 46: 291-297
• Kam MH, Mathur P, Peng XH et al. Postdefaecation pain syndrome after circular stapled anopexy is abolished by oral Nifedipine. Br J Surg 2005; 92: 208-210