Research Article
Comparative Study of Outcome of Conventional versus Ultrasonic Coagulation Hemorrhoidectomy
Mohamed Yehia Elbarmelgi*# and Ahmed Farag Ahmed Farag#
Department of General Surgery, Cairo University, Egypt
#These two authors equally contributed
*Corresponding author: Mohamed Yehia Elbarmelgi, Department of General Surgery, Medicine Cairo University, Kasr Alaini Street, Cairo, Egypt
Published: 09 Dec, 2016
Cite this article as: Elbarmelgi MY, Farag AFA.
Comparative Study of Outcome
of Conventional versus Ultrasonic
Coagulation Hemorrhoidectomy. Clin
Surg. 2016; 1: 1242.
Abstract
Purpose: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy
using ultrasonic coagulation versus conventional hemorrhoidectomy.
Methods: Twenty patients with grade 3 to 4 piles were randomly assigned using closed envelope
method to receive 1) Modified Milligan-Morgan hemorrhoidectomy using scissors excision-ligation
technique followed by hemostasis using diathermy or 2) Ultrasonic coagulation hemorrhoidectomy.
The patient was not aware of the technique used at operation. Patients were followed up weeks
after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative
hospital stay; 4) pain score; 5) wound healing duration 6) wound infection.
Results: There was high statistical difference between ultrasonic coagulation over conventional
hemorrhoidectomy regarding intraoperative blood loss, operative time, wound healing and
duration, post operative pain in day 1 & 2, no difference was shown in post operative pain after 1
week.
Conclusion: The study shows that the ultrasonic coagulation is superior to the conventional
hemorrhoidectomy regarding intraoperative blood loss, operative time, and wound healing and
early post operative pain.
Keywords: Harmonic scalpel; Ultrasonic coagulation; Hemorrhoidectomy; Milligan & Morgan
Introduction
Piles (known also as Hemorrhoids) are part of the normal anatomy of the anal canal. When
they become swollen or inflamed they are considered pathological. They are cushions composed
of arterio-venous channels with connective tissue that helps easy passage of fecal matter. The
symptoms of pathological hemorrhoids differ according to the type. Painless rectal bleeding is the
main presentation of internal hemorrhoids while pain, bleeding and/or prolapse are characteristic
for external hemorrhoids [1].
Hemorrhoids are vascular cushions that lie beneath the epithelial lining of the anal canal; they
consist of arterio venous communications mainly between branches from superior rectal artery and
others from superior hemorrhoidal artery, or may be between branches from inferior and middle
hemorrhoidal arteries. They are usually found in three main locations: right anterior, right posterior
and left lateral portions [2]. Proposed etiologic factors include vascular congestion that could be
derived from prolonged straining or increase intra-abdominal pressure due to pregnancy, obesity or
ascites and mucosal prolapse that may develop from derangement of the internal sphincter or aging
that cause weakness of the anatomic structures that support the muscularis submucosa leading to
prolapse of the hemorrhoidal tissues [3,4].
Hemorrhoids may be (1) external that originate below dentate line arising from the inferior
hemorrhoidal plexus, and are lined with modified squamous epithelium, which is richly innervated
with somatic pain fibers. (2) Internal hemorrhoids that originate above the dentate line, arising
from the superior hemorrhoidal plexus, and are covered with mucosa. (3) Mixed hemorrhoids
arising from both the inferior and superior hemorrhoidal plexi, they are covered by mucosa
superiorly and skin inferiorly [5]. Patients with hemorrhoidal disease may experience any of the
following symptoms: Bleeding, painful mass, anal swelling, discomfort and discharge, soiling and
purities. However, the most frequent complaint is painless bleeding, which usually appears early
in the progress of the disease, also some patients with grade III to IV may experience functional
bowel symptoms which is associated with irritable bowel syndrome,
that’s need to be taken into consideration when selecting treatment
[6]. Recommended treatment consists of increasing oral fluids to
maintain hydration, fiber intake, sitz baths, NSAIDS analgesics
and rest. Surgery is reserved for resistant cases that fail to improve
following these measures [7]. Other nonsurgical methods of treatment
include Sclerotherapy [8], rubber band ligation and infrared
coagulation [9]. Surgical management includes Ferguson’s (closed)
hemorrhoidectomy [5] Milligan-Morgan (open) hemorrhoidectomy,
Harmonic and LigaSure hemorrhoidectomy and Doppler guided
hemorrhoidal artery ligation [10,11]. The search of the most effective
and less painful technique for the treatment of hemorrhoids is still
a major concern for colorectal surgeons. Ultrasonic coagulation is
an evolving technique that uses the ultrasonic coagulation device
in performing the classic Milligan and Morgan hemorrhoidectomy.
This operation is the most used surgical option in treatment of grade
III and IV hemorrhoids and is still considered the most effective
treatment in term of hemorrhoid relapse [12].
Although this technique is considered as invasive as traditional
diathermy Milligan and Morgan excision it has been demonstrated
to improve significantly postoperative pain, bleeding and, therefore,
in-hospital stay compared to Milligan–and Morgan, besides it has
a fast learning curve [13]. The benefits mentioned above makes the
operation easier, safer and quicker which justify the increased price
of ultrasonic device compared to the diathermy [13]. Ultrasonic
Coagulation and Cutting Devices use energy generated from
ultrasonic vibration. Ultrasonic energy is an efficient alternative to
electro surgery. The device cuts and coagulates by using much lower
temperatures than those produced by traditional diathermy or lasers.
Moreover, no electricity goes to or through the patient [14]. The
ultrasonically activated scalpel (UAS) has the benefit of its ability to
cut and coagulate tissues simultaneously with relatively limited lateral
thermal injury. The UAS has been used in laparoscopic surgeries and
open surgeries of the lung and liver [14].
The Harmonic scalpel is a cutting instrument used during surgical
procedures to simultaneously cut and coagulate tissue.
Figure 1
Figure 2
Methodology
Patients
This was a prospective study that included 20 patients of 3rd or
4th degree hemorrhoids of age ranging twenty to fifty years old and
from both sexes attending to faculty of medicine hospital (Kasr El-
Aini) during the period from July 2010 till April 2011. The patients
will randomly allocated into two groups each included ten patients,
first group had had conventional hemorrhoidectomy (Milligan and
Morgan), the second group had hemorrhoidectomy by ultrasonic
coagulation using harmonic scalpel.
Methods
Proper history taking and full examination to exclude other
causes of anal pain.
The following was monitored in both conventional and ultrasonic
coagulation hemorrhoidectomy
During operation
• Length of the procedure
• Blood loss
Postoperative
• Postoperative pain
• Wound healing
• Duration of hospital stay
As regarding pain
A day before surgery, the patients will be instructed how to
complete the 0 to 10 visual analog scale (VAS) interview. The
intensity of postoperative pain will be measured every 8 hours
during the first 24 hours by means of a 0 to 10 visual analog scale
(VAS: 0….no pain and 10…maximum pain experienced) and during
weekly follow up visits. The patient selects a number (verbal version)
or marks the scale (written version), corresponding to the pain. A
newer innovation is a picture scale. This tool consists of a series of
four to six faces depicting different expressions ranging from a happy
smiling face to a sad teary face. Patients reportedly prefer to use the
face scale over the NRS or VAS scales because it is easier and may be
particularly useful in the patient with a communication problem (e.g.,
hard of hearing, language fluency). Thus, pain is assessed before the
operation or intervention and again immediately after the operation;
it is subsequently measured at regular intervals. Repeated pain
assessment is a fundamental tool for improving the quality of acute
pain management.
Analgesia used
Patients of both groups will receive both local anesthesias before
operation and NSAIDs at regular interval (every 8 hours).
Exclusion criteria
• Patients suffering from other anal conditions e.g. (anal
fistula, anal fissure, pilonidal sinus, etc...)
• Patient’s stool or gas incontinence
• Patients with recurrent hemorrhoids
• Patients with chronic pain syndrome and neurologic
deficits
The statistics
Data were statistically described in terms of range, mean±standard
deviation (±SD), median, frequencies (number of cases) and
percentages when appropriate. Comparison of quantitative variables
between the study groups was done using Mann Whitney U test for
independent samples. For comparing categorical data, Chi square (χ2)
test was performed. Exact test was used instead when the expected
frequency is less than 5. P values less than 0.05 was considered
statistically significant. All statistical calculations were done using
computer programs Microsoft Excel 2007 (Microsoft Corporation,
NY, and USA) and SPSS (Statistical Package for the Social Science;
SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows.
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Results
Gender distribution
Patients were divided according to gender in each group as
shown in Table 1. Using Chi-square tests the 2 groups where found to
be matched for gender distribution in Table 2.
Blood loss
Patients were divided according to blood loss in each group as
shown in Table 3. Chi-square test shows significant difference in
blood loss in both groups as shown in Table 4.
Postoperative hospital stay
Patients of both groups are sorted according to hospital stay as
shown in Table 5. Chi-square test shows no difference between both
groups regarding postoperative hospital stay as shown in Table 6.
Wound healing duration
Patients within both groups are divided according to wound
healing duration as shown in Table 7. Chi-square test shows high
statistical difference between both groups according to wound healing
duration as shown in Table 8.
Discharge & infection
Patients within both groups are divided according to wound
discharge and infection as shown in Table 9. Chi-square test shows
statistical difference between both groups regarding wound infection
and discharge as shown in Table 10.
Postoperative pain
Both Groups are sorted according to preoperative pain and post
operative pain after 1 day, 2 days and 1 week as shown on Table 11.
Mann-witney U test shows statistical difference between both groups
in postoperative pain in which the group, which perform ultrasonic
coagulation hemorrhoidectomy, experiences less postoperative pain
in day 1 and day 2 than the group which perform conventional
hemorrhoidectomy. There is no difference in both groups in
postoperative pain after 1 week. This is shown in Table 12. Table 13
shows mean, median, standard deviation in both groups regarding
age, Intraoperative time, wound healing duration, hospital stay,
and postoperative pain. Table 14 shows Mann-Whitney test for
age, intra operative time, hospital stay, wound healing duration,
postoperative pain for both groups. Table 15 shows test statistics for
Mann- Whitney test for both groups regarding age, wound healing
duration, intraoperative time, hospital stay, postoperative pain shows
statistical difference in wound healing duration, intraoperative time,
and postoperative pain in day 1 and day 2, no statistical difference in
postoperative pain after 1 week.
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Discussion
Analysis of the results obtained from this study showed that
the ultrasonic coagulation hemorrhoidectomy is better than the
congenital Milligan & Morgan hemorrhoidectomy regarding
Intraoperative time which was ranging between 15 to 20 minutes
in the ultrasonic coagulation hemorrhoidectomy while it ranges
between 30 to 35 minutes in the conventional hemorrhoidectomy.
Also ultrasonic coagulation results in less Intraoperative bleeding in
comparison to the conventional hemorrhoidectomy in which there
was a high statistical difference between both groups as shown in the
last chapter Table 4. Regarding wound healing duration, the ultrasonic
coagulation leads to more rapid wound healing ranging between 2
to 3 weeks while in conventional hemorrhoidectomy wound healing
duration ranges between 4 to 5 weeks. Regarding wound infection
discharge, ultrasonic coagulation hemorrhoidectomy shows much
less wound infection and discharge in comparison to the conventional
hemorrhoidectomy which shows high statistical difference as shown
in the last chapter Table 10. Regarding postoperative pain patients
who undergo ultrasonic coagulation hemorrhoidectomy experiences
less post operative pain in day 1 and day 2 compared to patients who
undergo conventional hemorrhoidectomy. There was high statistical
difference between both groups in post operative pain during day 1
and 2 but there was no clear difference in post operative pain after 1
week from the operation. This was shown in the last chapter Table 11
and 12. The results of this study appeared to be nearly the same as other
studies. In 2002, Ramadan E, Vishne T and Dersnic Z described less
post operative pain, less post operative hospitalization and decreased
duration of surgery with ultrasonic coagulation hemorrhoidectomy
compared to conventional Milligan and Morgan hemorrhoidectomy
[15].
Also in 2002, Chung CC et al. [16] conducted a prospective, double
blinded study, comparing different excision techniques: Harmonic
Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy,
and regular scissors. The study population included 89 patients with
grade 4 hemorrhoidal disease. The study showed that the Harmonic
Scalpel was as efficient as were bipolar scissors in terms of reducing
postoperative hemorrhage. Harmonic Scalpel was superior to the other
methods in terms of postoperative pain and, consequently, patient
satisfaction. Recovery time was similar with all the techniques. In
2001, David N Armstrong et al conducted a prospective, randomized
study on the same topic which demonstrates significantly reduced
postoperative pain after harmonic scalpel hemorrhoidectomy
compared to the electro cautery controls. They stated that reduced
post operative pain in ultrasonic coagulation hemorrhoidectomy
likely results from the avoidance of the lateral thermal injury [17]. In
2008, Abohashem AA, Sarhan A, Aly AM conducted a single blinded
randomized trial at Zagazig University hospital during the period from
July 2007 to December 2008. Patients underwent surgical excision of
complex grade III or grade IV hemorrhoids. They were divided into
two groups: (A) ultrasonic coagulation Hemorrhoidectomy group
and (B) Bipolar Electro-cautery Hemorrhoidectomy group. Pain
levels scoring and postoperative complications were analyzed. This
study demonstrates significantly reduced postoperative pain after
ultrasonic coagulation Hemorrhoidectomy compared with bipolar
electro-cautery Hemorrhoidectomy. Most likely, this result came
from the avoidance of excessive lateral thermal injury caused by
bipolar electrocautery [18]. In 2007, Ivanov Dejan et al. [19] made
as study on seventy-seven (77) patients suffering from hemorrhoidal
disease, stage III and IV, and underwent surgery during the last five
years. The postoperative pain was determined using the visual analog
scale on the 1st, 2nd and 7th postoperative days. Patients were divided
into two groups in regard to the surgical procedure applied. The data
were statistically processed using the Statistical 7.0 software. They
concluded that ultrasonic coagulation hemorrhoidectomy, due to less
thermal damage, statistically significantly reduced postoperative pain
with better hemostasis, compared with Milligan-Morgan's method
of treating hemorrhoidal disease. On the other hand Khan S et al.
[20] conducted prospective study that compared Harmonic Scalpel
hemorrhoidectomy with traditional closed hemorrhoidectomy,
Hear ultrasonic coagulation hemorrhoidectomy did not show any
advantage in postoperative pain, fecal incontinence, operative time,
quality of life, or other complications compared with traditional
closed hemorrhoidectomy. Also in 2001, Tan JJ and Seow-Choen F in
a prospective randomized trial comparing diathermy and ultrasound
coagulation hemorrhoidectomy concluded that there is there was no
statistical difference between pain scores recorded by both groups
[21].
Table 13
Table 14
Table 15
Conclusion
Patients who perform ultrasonic coagulation hemorrhoidectomy experiences less post operative pain in day 1 & 2 but no difference after 1 week. Faster wound healing occurs with ultrasonic coagulation hemorrhoidectomy. Ultrasonic coagulation hemorrhoidectomy has less Intraoperative time. Ultrasonic coagulation hemorrhoidectomy has less Intraoperative bleeding.
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