Fig. 38.1
Stapled haemorrhoidopexy
On the basis of the Thomson theory that proposes the deterioration of the anal supporting tissue and the consequent sliding downward of the anal lining as responsible for the development of haemorrhoids, the circular stapled anopexy was developed to cut the redundant tissue and to restore the anal canal anato-physiology. All surgery is done at a safe distance from the sensitive dentate line.
A prospective, randomized, multicentre study [6] comparing haemorrhoidal artery ligation versus circular stapled anopexy for grade III haemorrhoids shows significantly less pain after ligation, with shorter hospital stays but with higher recurrence rates.
Other Procedures
Embolization using coils in the terminal branches of the superior rectal artery has also been recently covered in published data [7]. The most commonly used other treatments are summarized in Table 38.1.
Table 38.1
Commonly used treatments for haemorrhoidal disease
Technique | Grade | Complications/side effects | Results |
|---|---|---|---|
Sclerosis | I and II | Fibrosis of other surrounding tissues | 18 % recurrences (after 2 years of F-U) |
Banding | I, II, III | Anal pain that can range from minor discomfort to severely incapacitating pain Bleeding Anal sepsis | 77–80 % success |
Infrared photocoagulation | I and II | Discomfort | 81 % success 28 % recurrence |
Laser photocoagulation | I and II | Mild pain | 76–79 % success |
Evidence
There is no consensus regarding the optimal treatment to be applied to haemorrhoidal disease, given the low quality of the published studies. In general, conservative management must be the first choice. Surgery is elected if the first choice fails.
What’s New in the Treatment of Perianal Fistulas?
Treatment of complex anal fistulas remains a challenge even for the most experienced surgeon. The risk of incontinence and the high rate of recurrence show that the definitive solution has not yet been found. Keeping in mind the patient’s quality of life, these are some of the therapies being suggested [8].
Fistuloscopy
New techniques such as the fistuloscopy have emerged in the therapeutic armamentarium. A small endoscope is inserted through the external opening of the fistula to identify the main and secondary tracts. Once the tracts have being identified, they are cauterized under direct vision. The internal opening is then treated by either a single suture or an advancement flap. This technique is reinforced by the use of cyanoacrylate. The authors describe up to a 70 % rate of success (6 months of follow-up).
Mucosal Advancement Flap Combined with Platelet-Rich Plasma
The long-term outcome results [9] of patients with primary and recurrent high cryptoglandular perianal fistulas treated with a loose seton followed by mucosal advancement flap and platelet-rich plasma show an 83 % rate of success after 2 years of follow-up, with a low incontinence rate.
Fistula Laser Closure (FiLaC™, Biolitic Biomedical Technology, Jena, Germany)
Another new technique for the treatment of complex fistulas is the so-called fistula laser closure (FiLaC™). Primary closure of the tract is achieved using laser energy emitted by a radial fibre connected to a diode laser. The energy causes shrinkage of the tissue around the radial fibre with the aim being to close the tract.
The internal opening must be eliminated by a flap. The authors report a 75 % success rate in terms of healing, and no patient reported incontinence postoperatively.
Plug
This technique involves the introduction of a plug of biological material in the fistula tract. The conical-shaped plug is anchored in the anal fistula and acts as a scaffold into which new tissue can grow. A prospective study [10] from four referral centres with a mean follow-up of 68 months reports a 56 % rate of recurrence. There are some ongoing clinical trials, but currently the evidence of efficacy of anal fistula plug treatment is quite limited.
Biological Sealants/Cyanoacrylate Glue
The use of fibrin glues shown in a multicentre study [11] demonstrates a success rate of 74 %, with a 26 % rate of recurrence (mean follow-up of 6 years). New biological glues such as Vivostat® (Vivostat, Alleroed, Denmark) have shown better results than the previously marketed glues.
OTSC® Proctology (Ovesco Endoscopy, Tűbingen, Germany)
EL OTSC® Proctology is a new treatment for fistula-in-ano based on the placement of a clip that closes the tract of the fistula. In a study with ten patients recruited [12], this device was shown to have a 90 % rate of success.
LIFT (Ligation of Inter-sphincter Fistula Tract)
Described by Rojanasakul in 2007 [13], LIFT is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the inter-sphincter approach. Essential steps of the procedure include incision at the groove, identification of the inter-sphincter tract, ligation of inter-sphincter tract, and closure of the internal. A prospective study of 26 patients [14] with high trans-sphincter fistula showed successful results in 77 % without postoperative incontinence.
Some others [15] have used this technique not only in high, trans-sphincter fistulas but also in supra-sphincter fistulas with a more than 70 % success rate.
Stem Cells
Using autologous adipose-derived stem cells is a novel approach for the management of complex fistula-in-ano. Human Adipose-Derived Stem Cells emerge as key regulators of immune/inflammatory responses in vivo and as attractive candidates for cell-based therapies to treat sepsis and hence to improve healing. In a phase II clinical trial [16] that included patients with Crohn’s perianal fistulas, the success rate was of 71 %.
Faecal Incontinence
Faecal incontinence (FI) is defined as the inability to hold a bowel movement until one has reached a toilet as well as passing stool into one’s underwear without being aware of this happening. Faecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control. It affects men and women of all ages, and it is estimated to affect as much as 15 % of elderly people.
The most common cause of bowel incontinence is damage to the muscles around the anus due to obstetric injuries. Anal surgery can also damage the anal sphincters or nerves, leading to bowel incontinence. Throughout history, many treatments and techniques have been developed in an attempt to improve the quality of life of these patients.
The first step of any treatment for faecal incontinence is to modify dietary habits, to eat the right amount of fibre, and to start pelvic floor muscle training by means of biofeedback. Rectal sensitivity also improves with biofeedback.
Another new treatment for FI is the perianal injection of bulking agent. There are different substances that can be used; however, the ideal agent should be biologically compatible and easy to apply. The agent could be injected into the sub-mucosal or inter-sphincter space, and some studies [17] have shown better results when the injection is ultrasound guided.
The major problem of these substances is the rejection of the agent with complications such as anal pain, ulceration, itching, sepsis, or even migration.
A Cochrane review [18] concluded that using Dextranomer in stabilized hyaluronic acid as a perianal injectable bulking agent improves continence for a little over half of patients in the short term.
Sacral neuro-modulation (also termed sacral nerve stimulation) was described in 1995 by Matzel et al. [19]. It has shown good results in terms of improvement of incontinence and quality of life. In addition, sacral neuro-modulation has been described for the management of low anterior resection syndrome after total mesorectal excision.
An alternative to sacral nerve stimulation that follows the same principles is transcutaneous electrical nerve stimulation. It was proposed in 1975 by Melzack [20] and Wall as a new pain treatment method. In 1983, Nakamura et al. [21] demonstrated the efficacy of transcutaneous stimulation of the posterior tibia nerve (PTN) in controlling urinary incontinence and the overactive bladder.
In the management of faecal incontinence, Shafiq [22] reported an improvement in 78.2 % of patients and Queralto [23] in 60 % of those patients that were treated by PTN. The main advantage of this approach is its simplicity. It is a non-invasive technique that can be performed by the patient at home.
Colon and Rectal Cancer
Surgery for Rectal Cancer and Evidence-Based Medicine (EBM)
Total Mesorectal Excision
In 1982, Heald et al. [24] published the results of the technique of total mesorectal excision (TME) for the management of rectal cancer. They reported a 4 % rate of local recurrence. Afterward, different multicentre studies showed that the implementation of the TME decreased the rate of local recurrence and improved survival. In short, TME became the gold standard surgical technique for tumours located in the middle and lower rectum. Currently, rectal cancer should be managed by a multidisciplinary team where each case is treated individually.
Surgical Reconstruction After Low Anterior Resection
One of the problems that arises after total mesorectal excision is determining what type of reconstruction should be carried out [25]. Over the years, anastomotic techniques have been refined. Keeping in mind that most of us are using primarily mechanical stapled colorectal anastomosis, the so-called Colon Ring, a staple-free technique based on a ring of titanium and nickel that produces compression with a consistent force at the end-to-end anastomosis, was marketed a few months ago.
First studies [26] on the subject show that the compression technique is surgically feasible, easy to use, and without significant complication rates; however, a large randomized controlled trial is needed in order to determine the actual benefits of the Colon Ring over traditional stapling techniques.
Colonic Pouch
Other important technical advances in rectal surgery thanks to the improvement of the anastomotic technique are the sphincter-saving procedures that have become the standard treatment in the surgical approach to most cancers of the middle and lower third of the rectum. When the total rectum is removed, straight colo-anal anastomosis is related to the well-known anterior resection syndrome characterized by increased stool frequency, urgency, and incontinence mostly due to loss of the reservoir function. In order to improve functional outcome, the construction of a colonic J-pouch from the distal colon was proposed. The distal section of the colon is formed into a J-shaped pouch in order to replace the function of the rectum and store stool until it can be eliminated. A significant number of studies [27] that compared the J-pouch with straight end-to-end colo-anal anastomosis have shown functional superiority of the pouch, especially in the first 2 years after surgery, with similar morbidity. However, up to one out of four patients complains of evacuator dysfunction which is related to an oversized reservoir. Currently, it is recommended that the reservoir be fashioned no larger than 5–6 cm. From a technical point of view, it is not difficult to make a colonic J-Pouch; what is sometimes a challenge is to down it through a narrow pelvis, which is the norm in obese male patients.
Transverse Coloplasty and Side-to-End Anastomosis
As seen before, while colonic J-pouch anastomosis is able to eliminate some of the functional problems of straight colo-anal anastomosis, it comes with the problem of pouch evacuation. Hence, in an attempt to improve functional results, alternative techniques, such as transverse coloplasty pouch and side-to-end colo-anal anastomosis, have been suggested.
In a randomized controlled study [28], transverse coloplasty reconstruction after rectal cancer resection and colo-anal anastomosis is functionally similar to colonic J-pouch both in short- and long-term outcomes. The coloplasty technique does not seem to improve significantly the incomplete defecation symptom with respect to the J-pouch. The same outcomes are reported when compared to side-to-end anastomosis. This last technique has as a major advantage in that it is the easiest and fastest to perform.
With reference to quality of life issues, it is very difficult to extract any conclusion. There are few studies, most of them based on a smaller number of patients. Studies such as that of Hallbook and Furst [29], using the NHP and EORTC questionnaires, respectively, found no differences when straight anastomosis was compared to colo-anal reservoir. On the contrary, more recent papers, such as the one by Sailer [30], that use the GIQL, C30, and CR38 questionnaires, found that patients with a reservoir presented with a better quality of life.
In any case, and keeping in mind the lack of proper evidence, it seems that those reconstructive techniques that offer a “neo-rectum” are associated with a better quality of life.
Is It Mandatory to Have a Protective Defunctioning Stoma After Rectal Resection?
If there is a major postoperative issue that all colorectal surgeons are afraid of, it is anastomotic dehiscence. It is very well known that the anastomotic leakage rate rises as it comes close to the pelvic floor. In order to minimize the morbidity, a protective ostomy is recommended for many. This preventive manoeuvre, however, is not free of morbidity by itself: in some studies nearly 50 % [31] of cases present a complication related to the protective ostomy. Hence, an ostomy should be performed when the risk of dehiscence is high enough to justify it. In this context, it seems reasonable to add a protective ostomy to the low anterior rectal resection if the patient has received neo-adjuvant treatment.
Whether to use a colostomy or an ileostomy to protect the anastomosis could be left to the surgeon’s preferences. However, there are some RCT that point out that the ileostomy is linked to a lower morbidity rate in terms of prolapse and sepsis.
Lastly, some authors perform [32] the so-called ghost-ileostomy. It is done by placing a removable Silastic band (vascular loop) around the ileum which is exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. In case of an anastomotic complication, the ileostomy is performed under local anaesthesia. Ghost-ileostomy allows selective ileostomy formation; however, current evidence tells us that this kind of ileostomy should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neo-adjuvant therapy.
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