Int J Colorectal Dis DOI 10.1007/s00384-015-2241-7
LETTER TO THE EDITOR
Comparison between conventional and endoscopic injection in aluminum potassium tannic acid sclerosing therapy N. Hayashi 1 & S. Sugimoto 1 & Y. Miyazaki 1 & T. Michiura 1 & S. Fujita 1 & K. Yamabe 1 & S. Miyazaki 1 & M. Nagaoka 1
Accepted: 8 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Sclerotherapy with aluminum potassium tannic acid (ALTA) has been deemed as a safe and effective technique to produce positive outcomes even for grades 3 to 4 internal hemorrhoids. Injecting proper volume to precisely appropriate sites for ALTA therapy is highly significant to avoid various complications. Although ALTA injection is conventionally recommended to perform the four-step injection therapy through a rigid anoscope, it is often difficult to observe the color of the mucosa of the anal columns and their detailed structure with a conventional a rigid anoscope, due to its restricted visual field as well as limited maneuverability. Therefore, it is supposedly troublesome to determine proper ALTA injection sites and observe the diffusion status of the injected solution. These mechanical and technical drawbacks with a conventional anoscope might be assumed to overcome by using an endoscope that provides detailed and wider images of hemorrhoids for ALTA injection sites, as well as real-time injection process with better maneuverability. We herein evaluated outcomes after ALTA injection with an endoscope (EI) compared with conventional injection using an anoscope (AI). Sixty-eight consecutive patients with symptomatic internal hemorrhoids treated with ALTA therapy were enrolled in this retrospective comparative study. The patients were divided into two equal groups; the one group, 30 patients, treated with AI, and the other one, 38 patients, with EI. Inclusion criteria were third- and fourth-degree symptomatic hemorrhoids. Patients with external hemorrhoids (which generally would
* N. Hayashi [email protected] 1
Department of Surgery, Kinan Hospital, 46-70 Shinjocho, Tanabe City, Wakayama, Japan
require a surgical hemorrhoidectomy), thrombosed hemorrhoids, anal fistula, or peri-anal abscess were excluded. All patients underwent treatment after standard colonic preparation. The four-step injection consists of injection into the submucosal layer of the upper hemorrhoid pole (first step), injection into the submucosal layer of the hemorrhoid center (second step), injection into the proper mucosal layer of the hemorrhoid center (third step), and injection into the submucosal layer of the lower hemorrhoid pole (fourth step). In AI, a conventional rigid anoscope was gently introduced in the jackknife position under local anesthesia by local injection of 20 ml of lidocaine hydrochloride 0.5 % in the anal verge and submucosa of the anal canal. EI was performed by left lateral decubitus position. An injection tube (Sumitomo Co., Tokyo, Japan) was introduced to the top of a diagnostic upper gastrointestinal endoscope (GIF-XQ230; Olympus Optical Co, Ltd, Tokyo, Japan). The four-step injection was performed in the retroflexed or forward-viewing position. After completion of injection in one site, 1-min finger massage was followed in both techniques. Surgical outcomes and postoperative complications were retrospectively compared between the two groups. Demographics were similar in each group, and there was no difference with regard to age, gender, and Golisher grade. No complication due to endoscopic procedure was observed. Although there was no significant difference in the number of injection sites or total ALTA volume injected in one operative session, surgical time was significantly different: 27±15 min for AI and 15±12 min for EI (P=0.006). Thirty patients (87 %) in AI group and 38 (100 %) patients were managed in 1-day surgery. The necessity of prolonged hospital stay was significantly higher in AI than EI (P=0.02). Four patients in AI requested further admission for complicated course (13 %): one for bleeding and three for pain or topical discomfort. The
Int J Colorectal Dis
bleeding was mild and self-limiting and did not require blood transfusion. Patients undergoing EI experienced significantly less pain or discomfort at operation day and days 1and 2 than did patients who underwent AI (P=0.03). There was no statistical difference between groups on day 8. Postoperative analgesic requirements were lower in EI group, but this difference did not achieve statistical significance. Despite the difference in the postoperative pain, the resumption of a normal work style was not significantly different between the two techniques (7.1 days in AI group vs 7.5 days in EI group). There was one patient in each group whose symptoms were not controlled in the first session of the treatment and defined as recurrence. The recurrence rate was 3.3 and 2.8 %, respectively, at 1 year. No significant difference was observed in other complications, such as local edema, hematocyte, or ulcer between the two groups. Most patients (96.7 %, 29/30 in AI and 97.4 %, 37/38 in EI) had their hemorrhoids improved in the first session. In both groups, patients had higher satisfaction with their treatment 93.3 % in the AI group 92.1 % in the EI after the first treatment session with no significant difference. The present study found that the treatment of internal hemorrhoids is easily accomplished using an endoscope with a standard injection device in the forward and retroflexed position. Among early postoperative complications, such as urgency of defecation, urinary retention, and postoperative hemorrhage, there is no difference between the two groups in our study, indicating both methods were similar with regard to efficacy and safety. In our study, although the assessment of pain on eight postoperative day showed no significant difference between the two groups, we detected significantly less pain in EI on days 1 and 2 compared to AI (P=0.03). Furthermore, three patients needed prolonged hospitalization due to topical pain. The presumable explanation for more pain laying in AI is the diffusion of ALTA solution under the sensitive transitional epithelium, attributed from erroneously too close injection to the dentate line with an anoscope.
In the four-step method, it is crucial that the drug solution is injected precisely into the designated site at each step of the injection, by ensuring the correct site of the needle puncture and drug diffusion into the appropriate areas, so that it can provide sufficient pharmacologic activity. However, the distant and oblique observation of the anal canal through an anoscope makes it difficult to evaluate the hemorrhoids in detail, because anoscopes are difficult to maneuver and often interfere with visualization. Inadequate examination of the mucosa could lead to erroneous injection to perform precise four-step injection, as well as missed observance of ongoing injection process. On the other hand, the endoscopic ALTA injection provides obvious advantages over conventional single-slot anoscopes in terms of visual field and maneuverability. The endoscope can facilitate optimal ALTA injection through real-time visualization of the injection sites and the status of drug diffusion in the form of direct images. Therefore, an accurate injection site and dose could be selected, according to the exact evaluation of hemorrhoids. Less pain laying in EI is supposed to be caused by more exact proximal injection and diffusion of ALTA, away from the sensitive transitional epithelium. However, further studies would be needed to determine whether such proximally injections would produce less pain with similar efficacy. The occurrence of postoperative anal discomfort, not present preoperatively, may be partially due to the technique itself, with the anal insertion of the large bore operating anoscope used in AI for more than 20 min. For optimal exposure, the anoscope has often to be fully inserted so the base of each aperture extended beyond the dentate line. The need to insert the anoscope with a wider diameter than an endoscope for treatment of multiple separate hemorrhoids leads to more pain laying in AI treatment during two postoperative days. ALTA therapy with an endoscope in the treatment of symptomatic internal hemorrhoids has the advantage in terms of surgical time and immediate postoperative pain. This method might be a good alternative for conventional ALTA therapy with a rigid anoscope.
LETTER TO THE EDITOR
Comparison between conventional and endoscopic injection in aluminum potassium tannic acid sclerosing therapy N. Hayashi 1 & S. Sugimoto 1 & Y. Miyazaki 1 & T. Michiura 1 & S. Fujita 1 & K. Yamabe 1 & S. Miyazaki 1 & M. Nagaoka 1
Accepted: 8 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Sclerotherapy with aluminum potassium tannic acid (ALTA) has been deemed as a safe and effective technique to produce positive outcomes even for grades 3 to 4 internal hemorrhoids. Injecting proper volume to precisely appropriate sites for ALTA therapy is highly significant to avoid various complications. Although ALTA injection is conventionally recommended to perform the four-step injection therapy through a rigid anoscope, it is often difficult to observe the color of the mucosa of the anal columns and their detailed structure with a conventional a rigid anoscope, due to its restricted visual field as well as limited maneuverability. Therefore, it is supposedly troublesome to determine proper ALTA injection sites and observe the diffusion status of the injected solution. These mechanical and technical drawbacks with a conventional anoscope might be assumed to overcome by using an endoscope that provides detailed and wider images of hemorrhoids for ALTA injection sites, as well as real-time injection process with better maneuverability. We herein evaluated outcomes after ALTA injection with an endoscope (EI) compared with conventional injection using an anoscope (AI). Sixty-eight consecutive patients with symptomatic internal hemorrhoids treated with ALTA therapy were enrolled in this retrospective comparative study. The patients were divided into two equal groups; the one group, 30 patients, treated with AI, and the other one, 38 patients, with EI. Inclusion criteria were third- and fourth-degree symptomatic hemorrhoids. Patients with external hemorrhoids (which generally would
* N. Hayashi [email protected] 1
Department of Surgery, Kinan Hospital, 46-70 Shinjocho, Tanabe City, Wakayama, Japan
require a surgical hemorrhoidectomy), thrombosed hemorrhoids, anal fistula, or peri-anal abscess were excluded. All patients underwent treatment after standard colonic preparation. The four-step injection consists of injection into the submucosal layer of the upper hemorrhoid pole (first step), injection into the submucosal layer of the hemorrhoid center (second step), injection into the proper mucosal layer of the hemorrhoid center (third step), and injection into the submucosal layer of the lower hemorrhoid pole (fourth step). In AI, a conventional rigid anoscope was gently introduced in the jackknife position under local anesthesia by local injection of 20 ml of lidocaine hydrochloride 0.5 % in the anal verge and submucosa of the anal canal. EI was performed by left lateral decubitus position. An injection tube (Sumitomo Co., Tokyo, Japan) was introduced to the top of a diagnostic upper gastrointestinal endoscope (GIF-XQ230; Olympus Optical Co, Ltd, Tokyo, Japan). The four-step injection was performed in the retroflexed or forward-viewing position. After completion of injection in one site, 1-min finger massage was followed in both techniques. Surgical outcomes and postoperative complications were retrospectively compared between the two groups. Demographics were similar in each group, and there was no difference with regard to age, gender, and Golisher grade. No complication due to endoscopic procedure was observed. Although there was no significant difference in the number of injection sites or total ALTA volume injected in one operative session, surgical time was significantly different: 27±15 min for AI and 15±12 min for EI (P=0.006). Thirty patients (87 %) in AI group and 38 (100 %) patients were managed in 1-day surgery. The necessity of prolonged hospital stay was significantly higher in AI than EI (P=0.02). Four patients in AI requested further admission for complicated course (13 %): one for bleeding and three for pain or topical discomfort. The
Int J Colorectal Dis
bleeding was mild and self-limiting and did not require blood transfusion. Patients undergoing EI experienced significantly less pain or discomfort at operation day and days 1and 2 than did patients who underwent AI (P=0.03). There was no statistical difference between groups on day 8. Postoperative analgesic requirements were lower in EI group, but this difference did not achieve statistical significance. Despite the difference in the postoperative pain, the resumption of a normal work style was not significantly different between the two techniques (7.1 days in AI group vs 7.5 days in EI group). There was one patient in each group whose symptoms were not controlled in the first session of the treatment and defined as recurrence. The recurrence rate was 3.3 and 2.8 %, respectively, at 1 year. No significant difference was observed in other complications, such as local edema, hematocyte, or ulcer between the two groups. Most patients (96.7 %, 29/30 in AI and 97.4 %, 37/38 in EI) had their hemorrhoids improved in the first session. In both groups, patients had higher satisfaction with their treatment 93.3 % in the AI group 92.1 % in the EI after the first treatment session with no significant difference. The present study found that the treatment of internal hemorrhoids is easily accomplished using an endoscope with a standard injection device in the forward and retroflexed position. Among early postoperative complications, such as urgency of defecation, urinary retention, and postoperative hemorrhage, there is no difference between the two groups in our study, indicating both methods were similar with regard to efficacy and safety. In our study, although the assessment of pain on eight postoperative day showed no significant difference between the two groups, we detected significantly less pain in EI on days 1 and 2 compared to AI (P=0.03). Furthermore, three patients needed prolonged hospitalization due to topical pain. The presumable explanation for more pain laying in AI is the diffusion of ALTA solution under the sensitive transitional epithelium, attributed from erroneously too close injection to the dentate line with an anoscope.
In the four-step method, it is crucial that the drug solution is injected precisely into the designated site at each step of the injection, by ensuring the correct site of the needle puncture and drug diffusion into the appropriate areas, so that it can provide sufficient pharmacologic activity. However, the distant and oblique observation of the anal canal through an anoscope makes it difficult to evaluate the hemorrhoids in detail, because anoscopes are difficult to maneuver and often interfere with visualization. Inadequate examination of the mucosa could lead to erroneous injection to perform precise four-step injection, as well as missed observance of ongoing injection process. On the other hand, the endoscopic ALTA injection provides obvious advantages over conventional single-slot anoscopes in terms of visual field and maneuverability. The endoscope can facilitate optimal ALTA injection through real-time visualization of the injection sites and the status of drug diffusion in the form of direct images. Therefore, an accurate injection site and dose could be selected, according to the exact evaluation of hemorrhoids. Less pain laying in EI is supposed to be caused by more exact proximal injection and diffusion of ALTA, away from the sensitive transitional epithelium. However, further studies would be needed to determine whether such proximally injections would produce less pain with similar efficacy. The occurrence of postoperative anal discomfort, not present preoperatively, may be partially due to the technique itself, with the anal insertion of the large bore operating anoscope used in AI for more than 20 min. For optimal exposure, the anoscope has often to be fully inserted so the base of each aperture extended beyond the dentate line. The need to insert the anoscope with a wider diameter than an endoscope for treatment of multiple separate hemorrhoids leads to more pain laying in AI treatment during two postoperative days. ALTA therapy with an endoscope in the treatment of symptomatic internal hemorrhoids has the advantage in terms of surgical time and immediate postoperative pain. This method might be a good alternative for conventional ALTA therapy with a rigid anoscope.
