Hemoroidal Hastalık Tedavisinde Ofis Prosedürleri
Özet
İnternal hemoroidal hastalık (İHH) tedavisinde poliklinik şartlarında uygulanan cerrahi dışı yöntemler ofis prosedürleri olarak adlandırılmakta olup, en sık lastik band ligasyonu (LBL), infrared koagülasyon ve skleroterapi kullanılmaktadır. Altın standart olan cerrahi hemoroidektomiye kıyasla daha kısa iyileşme süresi ve az komplikasyon oranı sunan bu işlemler, hemoroid pakesinin dolaşımını bozarak fibrozis ile fiksasyon sağlamayı amaçlar. Evre 2-3 İHH'de yaygın seçilen LBL, en etkin uzun dönemli sonuçları vermekle birlikte en önemli dezavantajı dentat çizginin proksimaline yerleştirilmediğinde veya çoklu pakeden dolayı gelişen şiddetli anal ağrıdır. Ağrıyı azaltmada nonsteroid antiinflamatuar ilaçlar, oturma banyoları ve venotonik ajanlar faydalıdır. İnfrared koagülasyon, evre 1-2 hastalıktaki pikelere ısı uygulayarak dokuyu fikse eder; LBL'ye göre daha az ağrılıdır ancak başarı oranı daha düşüktür. Skleroterapi ise peri-hemoroidal alana sklerozan madde (polidokanol vb.) enjekte edilerek inflamasyon ve fibrozis yaratılması esasına dayanır; özellikle erken evre kanamalı hemoroidlerde etkilidir. Her iki yöntem de operasyon veya anestezi gerektirmeyen, hasta konforunu artıran güvenli alternatiflerdir.
Non-surgical interventions performed under outpatient conditions for internal hemorrhoidal disease (IHD) are defined as office procedures, primarily including rubber band ligation (RBL), infrared coagulation, and sclerotherapy. Aiming to impair the circulation of the hemorrhoidal pile to induce necrosis and subsequent fixation via fibrosis, these methods offer shorter recovery times and lower complication rates compared to the gold-standard surgical hemorrhoidectomy. RBL, widely indicated for grade 2-3 IHD, provides a more durable therapeutic effect but its major disadvantage is severe anal pain, particularly when applied below the dentat line or in multiple sessions. Post-procedural pain management relies on NSAIDs, warm sitz baths, and venotonics. Infrared coagulation applies thermal energy to cause tissue necrosis and kas fixation in grade 1-2 disease, proving less painful than RBL but associated with lower long-term success rates. Sclerotherapy involves injecting sclerosants (like polidocanol) into the submucosal peri-hemorroidal space to trigger inflammatory fibrosis, mostly effective in early-stage bleeding hemorrhoids. These office procedures remain highly valuable, anesthesia-free alternatives in proctology practice.
Referanslar
Watson AJM, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet. 2016;388(10058):2375–2385. doi: 10.1016/S0140-6736(16)31803-7.
Simillis C, Thoukididou SN, Slesser AAP, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015;102(13):1603–1618. doi: 10.1002/bjs.9913.
Dekker, L et al. “Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials.” Techniques in coloproctology vol. 25,6 (2021): 663-674. doi:10.1007/s10151-021-02430-x
Blaisdell PC. Office ligation of internal hemorrhoids. Am J Surg. 1958;96:401–404.
Barron J. Office ligation of internal hemorrhoids. Am J Surg. 1963;105:563–570.
MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum. 1995;38:687–694.
Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol. 1992;87:1600–1606.
Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005;(3):CD005034.
van Tol RR, Bruijnen MPA, Melenhorst J, van Kuijk SMJ, Stassen LPS, Breukink SO. A national evaluation of the management practices of hemorrhoidal disease in the Netherlands. Int J Colorectal Dis. 2018;33(5):577–588. doi: 10.1007/s00384-018-3019-5.
Altomare DF, et al. Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years. Color Dis. 2018;20(12):1117–1124. doi: 10.1111/codi.14339.
Alemdaroğlu, K.: İnternal hemoroidlerin tedavisinde “Rubber Band Ligation” Kolon Rektum Hast. Derg. 1991, 1: 203-207
Şimşek G, Şahin A. The Role of Using Micronized Purified Flavonoid Fraction After Rubber Band Ligation in Hemorrhoidal Disease: A Retrospective Analysis. Turkish Journal of Colorectal Disease.2021;31 (4).
Corman, M. L.: Colon and Rectal Surgery.Hemorrhoids,Rubber-Ring Ligation. J. B. Lippincott Company, Philadelphia, 1984, page, 48-52
Gordon, P. H., Nivatvongs, S.: Principles and Practice of Surgery for the Colon, Rectum andAnus. Hemorrhoids, Rubber Band Ligation. Second Edition. Quality Medical Publishing,Inc. St. Louis, Missouri, 1999. page, 200-201
Lee, H. H, Spencer, R. J and Beart, R. W. Jr.: Multiple hemorrhoidal bandings in a singlesession. Dis. Colon Rectum 1994, 37: 37-41
Sajid MS, Bhatti MI, Caswell J, Sains P, Baig MK. Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis. Updates Surg. 2015;67:3–9.
Hooker GD, Plewes EA, Rajgopal C, Taylor BM. Local injection of bupivacaine after rubber band ligation of hemorrhoids: prospective, randomized study. Dis Colon Rectum. 1999;42:174–179.
Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg. 2016 Sep 27;8(9):614-620. doi: 10.4240/wjgs.v8.i9.614. PMID: 27721924; PMCID: PMC5037334.
Neiger A. Le traitement slerosant des hemorrhoides par coagulation a l’infrarouge. AnnGastr Hepat 1977, 13: 701-5.
Gupta PJ. Infrared coagulation versus rubber band ligation in early stage hemorrhoids. BrazJ Med Biol Res 2003:36:1433-9.
Cocorullo, G., Tutino, R., Falco, N., Licari, L., Orlando, G., Fontana, T., Raspanti, C., Salamone, G., Scerrino, G., Gallo, G., Trompetto, M., & Gulotta, G. (2017). The non-surgical management for hemorrhoidal disease. A systematic review. Il Giornale di chirurgia, 38(1), 5–14.
Dimitroulopoulos D, Tsamakidis K, Xinopoulos D, Karaitianos I, Fotopoulou A, Paraskevas E. Prospective, randomized, controlled, observer-blinded trial of combined infrared photocoagulation and micronized purified flavonoid fraction versus each alone for the treatment of hemorrhoidal disease. Clin Ther. 2005;27(6):746–754
Ricci MP, Matos D, Saad SS. Rubber band ligation and infrared photocoagulation for the outpatient treatment of hemorrhoidal disease. Acta Cir Bras. 2008;23(1):102–106.
Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009;104(8):2057–2064.
Ahmad A, Kant R, Gupta A. Comparative Analysis of Doppler Guided Hemorrhoidal Artery Ligation (DG-HAL) & Infrared Coagulation (IRC) in Management of Hemorrhoids. Indian J Surg. 2013;75(4):274–277.
He A, Chen M. Sclerotherapy in Hemorrhoids [published online ahead of print, 2022 Apr 20]. Indian J Surg. 2022;1-5.
Lisi G, Campanelli M, Grande S, Milito G, Grande M. Sclerotherapy with 3% polidocanol foam for third- and fourth-degree hemorrhoids as "bridge treatment" during the COVID-19 pandemic in Italy. Int J Colorectal Dis. 2021;36(6):1321–1322.
