Hemorrhoids, Skin Tags and All Things Perianal

Text of Review

Hemorrhoids

Hemorrhoids affect millions of people worldwide. Although only a subset of patients develop symptoms such as swelling, bleeding, pain, and prolapse, the impact can be quite substantial. Internal hemorrhoids are graded as I (no prolapse), II (prolapse with spontaneous reduction), III (prolapse with manual reduction) and IV (permanently prolapsed), with treatment depending on grade.

Rubber band ligation (RBL) is one of the most commonly used office-based treatments for grades I and II hemorrhoids, with some noted success in grade III disease after repeated sessions.^[1] Pain remains the most common complication following the procedure and is increased when ≥ 2 bands are placed during a single session. Comparison between RBL and conventional hemorrhoidectomy fails to show whether RBL is as definitive a treatment, mainly due to the poor quality data available.^[2] As demonstrated in a prospective study by Komporozos et al., the failure rate remains high for patients with grade IV hemorrhoids and we would agree that patients who cannot undergo more definitive intervention should be considered for this treatment.^[1]

Sclerotherapy is a low cost, easy to perform, repeatable procedure that consists of injecting a chemical agent (phenol oil, polidocanol) into the submucosa. The subsequent inflammatory reaction leads to fibrosis, obliteration of the vascular supply, and sloughing, ultimately alleviating bleeding and tissue prolapse. Traditionally, sclerotherapy has been used for the treatment of bleeding grade I or II internal hemorrhoids, and is considered a good alternative for patients on anticoagulation medications or at high risk of bleeding where RBL is contra-indicated. Similar efficacy and decreased postprocedural pain when compared to RBL are known benefits.^[3] A report of applying this method to treat patients suffering from grades III to IV hemorrhoids as a 'bridge treatment' to elective surgery during the SARS-CoV-2 pandemic has been presented.^[4] Although this report only included 10 'urgent' patients, they all experienced resolution of bleeding and pruritus in the 4-week follow-up. Success of sclerotherapy in advanced hemorrhoidal disease has been previously reported, but heterogeneity in the technique, poor follow-up, and lack of a validated scoring system only further highlight the need for better quality data.^[5,6]

Laser therapy is another treatment for low grade hemorrhoids that can be peformed under local or no anesthesia. One systematic review of nearly 19 prospective studies evaluated laser therapy by two techniques.^[7] These include laser hemorrhoidoplasty, which sequentially delivers energy into the submucosal space above the dentate line to shrink the engorged tissue, and laser hemorrhoidal dearterialization, which delivers energy to the apex of the hemorrhoid after identifying the arterial inflow with doppler. When compared to open hemorrhoidectomy, there were lower rates of postoperative pain and bleeding for both techniques. Conclusions on recurrence rates seemed to point to lower longterm recurrences in procedures utilizing 980nm as opposed to 1470nm diodes. An additional systematic review with many overlapping studies also found laser surgery to be safe and effective for grades II and III hemorrhoidal disease with mostly minor complications and a quick recovery.^[8] However, conflicting data on the recurrence rate between the included randomized controlled trials (RCT) prevented any conclusion to be made.

Another less well-known outpatient strategy recently described attempts to minimize procedural pain by utilizing bipolar energy. A prospective pilot study of 35 patients with grade I and II symptomatic hemorrhoids who failed two weeks of conservative management reports the use of hemorrhoid energy therapy for treatment.^[9] Despite the short period of conservative management and short follow-up duration (3 months), the authors reported significant improvement in bleeding, pain, and prolapse, which might be encouraging.

Transanal hemorrhoidal dearterialization (THD), is a technique in which the hemorrhoidal arteries are ligated and prolapsed tissue is treated with suture mucopexy without tissue excision. Although it has been associated with less pain and quicker recovery time compared to traditional hemorrhoidectomy, its long-term efficacy has not been clearly delineated in the literature. A recent RCT compared minimal open hemorrhoidectomy (MOH) with THD in patients with grades II–IV hemorrhoids.^[10] MOH was described as a modified Milligan-Morgan (open hemorrhoidectomy) technique, in which the skin excision is minimized, dissection is maintained in the subdermal fascia plane to avoid trauma to the internal anal sphincter, and only part of the hemorrhoid and overlying mucosa are excised. At one year, there was no significant difference in symptoms between 48 MOH and 50 THD patients. They did however find that patients who underwent THD experienced more residual hemorrhoidal prolapse and treatment for recurrence. Although MOH patients recorded pain for a longer period and had increased pain scores when passing stool, summed average and peak scores were similar to THD patients as were use of analgesics and recovery time. The authors argue the strategies adopted for MOH technique collectively counter the usual intolerable postoperative recovery. This may be the most significant contribution of the study, warranting further investigation of MOH. The authors also comment on cost, noting the cost of THD equipment and longer operative time, even when adjusted for, led to THD being statistically more costly than MOH.

The procedure for prolapsing hemorrhoids (PPH) consists of hemorrhoidal devascularization and pexy. The procedure has fallen out of favor over recent years. This is possibly due to high recurrence rates and infrequent but severe reported complications.

A recent meta-analysis of 26 randomized control trials evaluated the outcomes for treatment of grade III and IV hemorrhoids with 14 surgical techniques, including open (Milligan-Morgan) and closed hemorrhoidectomy (Ferguson), suture ligation, THD, LigaSure™ [Medtronic, Minneapolis (MN), USA], PPH, infrared photocoagulation, and laser.^[11] The study found increased complications of bleeding, urinary incontinence, and constipation with open hemorrhoidectomy and suture ligation. These were lowest with the use of infrared photocoagulation and LigaSure™, the latter of which has previously been reported to have fewer postoperative complications compared to conventional hemorrhoidectomy. Return to work was longest in the open hemorrhoidectomy group, with THD and PPH the shortest. The highest recurrence rates were in infrared photocoagulation and THD. The authors concluded that each method has its inherent pros and cons and the option chosen should be based on the desired outcome. If decreased postoperative pain with a quick return to work is priority, THD and PPH are recommended, noting recurrence rates are high and, for PPH, rare complications are quite devastating. If the primary goal is to prevent recurrence, LigaSure™ or another energy device is recommended, acknowledging that, whereas these procedures are not free of pain or complications, there is substantial improvement when compared to excisional surgery. Even with this large meta-analysis, there is a clear need for more studies examining infrared photocoagulation, laser, and bipolar diathermy.

Anal Fissure

Anal fissure is a benign disease consisting of a split in the anal mucosa extending from the anal verge to the dentate line. It most commonly occurs in the posterior midline but can also arise anteriorly, or even laterally when associated with other diseases. It is a dreaded diagnosis as the resultant severe anorectal pain can be quite debilitating and difficult to treat.

The gold standard for the treatment of chronic anal fissure (CAF) is lateral internal sphincterotomy (LIS). Many studies have identified the highest healing and lowest recurrence rates with LIS.^[12] Yet the infrequent but devastating complication of fecal incontinence has led many surgeons to defer this procedure as a last resort option. However, incontinence secondary to LIS has been substantially reduced from 10% before 2000 to 3.4% between 2000 and 2017, as reported in the literature.^[12,13] This decrease is attributed to improved surgical technique, namely, limiting division of the internal anal sphincter to the level of the fissure as opposed to the dentate line as classically described. We concur with this assessment, as well as emphasize that proper patient selection for LIS is of upmost importance.

Topical vasodilators have been well-established as the first-line treatment of acute anal fissure, with a success rate in the literature of up to 80%. Overall, the conclusion that topical vasodilators are more effective than conservative management alone, still stands. A few studies evaluating topical diltiazem vs. nitroglycerin found comparable results to what has already been established in the literature; these agents offer similar healing rates, but diltiazem is better tolerated by patients due to its lower side effect profile.^[12,14,15]

Botox (BT) injection is currently the mainstay of second-line therapy for the treatment of CAF. When compared to topical agents, BT compares favorably with healing rates, but as expected has a higher rate of temporary incontinence and overall recurrence.^[12] One retrospective review evaluated the use of BT vs. LIS for the treatment of CAF in patients who had failed at least 8 weeks of medical management consisting of bulking laxatives and topical nitroglycerin or calcium-channel blockers.^[16] The authors describe evaluating patients in the setting of 'real world' decision-making, such as taking into consideration patients at high risk for fecal incontinence. Patients stratified as high risk were those with age > 65 years, chronic diarrhea or a history of multi-parity, previous anorectal surgery or obstetrical complications. These patients (n = 81) were selected to have BT vs. the remaining patients (n = 171) who were all treated with LIS. The authors report an increased recurrence rate for BT compared to LIS. However, the stated 15% rate is much lower than up to 50% described in the literature. The most significant finding, however, was that there was no statistical difference in incontinence between the two groups. This is different from previously published literature and the authors attribute it to utilizing a 'real world approach' of risk-stratifying patients to the appropriate procedure. Additionally, patients who were crossed over from BT to LIS after treatment failure were more likely to experience short-term incontinence when compared to patients who were initially allocated to LIS. We agree that when indicating LIS, careful evaluation of sphincter function and patient selection is of upmost importance.

Anal Fistula

Anal fistula occurs most commonly from anal abscess and consists of an epithelialized tract originating from an anal gland to the perianal skin. Anal fistula has been classified based on relationship to the anal sphincter muscles with the most common being transsphincteric and intersphincteric, followed by suprasphincteric or extrasphincteric. Anal fistulas can be difficult to treat and require multiple interventions to achieve successful closure. Ultimately, the goal to provide complete cure, whereas simultaneously preserving sphincter function has yet to be achieved.

Fistulotomy, with or without marsupialization, as the primary treatment of anal fistula is considered definitive therapy due to its low recurrence rate.^[17] However, fistulotomy is an unenthusiastic option for many surgeons as division of the anal sphincter carries an inherent risk of incontinence. Although seton use remains a basis for the treatment of anal fistula, particularly when associated with sepsis to allow for proper drainage, very few advancements have been described. A cutting seton is scarcely used due to risk of incontinence. The old montage of placing an indwelling seton for a prolonged amount of time to allow for migration and subsequent superficial fistulotomy is still described.^[18] However, this approach is not one we support as definitive surgery is it causes unnecessary delay in patients with a simple anal fistula. The use of a 'knotless' seton made of silicone that uses an insert with two arrow shaped hooks to connect each end is quite appealing.^[19] Its applications could prove particularly useful in patients requiring long-term seton use for complex anal fistula, which is beyond the scope of this review.

Use of an anal fistula plug to promote healing via a scaffold for tissue ingrowth has been described. Recently, the fistula-in-ano trial (FIAT) reported their findings.^[20] Patients with transsphincteric anal fistula were randomized to either fistula plug or surgeon's preference. The latter included advancement flap, cutting seton, fistulotomy, or ligation of internal fistula tract (LIFT). All patients had at least 6 weeks of a prior draining seton. Although the surgeon's preference group initially had improved success rates, at 1year there was no difference between the groups [54% of patients who had a fistula plug and 55% of patients who had surgeon's preference arm clinically healed (P = 0.83)]. Additionally, complications were significantly more frequent in the fistula plug group, including plug extrusion. These findings are similar to those described by Tao et al. .^[21] They also noted plug failure was associated with a history of anal fistula for>6 months.

Updates on endorectal advancement flap are scarce, with one retrospective study reporting 10-year follow-up data combining its use with fistulectomy.^[22] The success rate was 76.2% with most recurrences occurring during the first year. Of note, continence worsened in 16.9% of cases, a finding authors describe as a 'mild deterioration'. We would argue any change in continence is significant and its clinical impact can be devastating to the patient.

Another procedure aimed at maintaining continence is the LIFT procedure, which entails identifying and dividing the fistula tract in the intersphincteric plane.^[23] Although the initial reported success rate for transphincteric fistula was 94.4%, a subsequent pooled analysis of several series revealed this high rate irreproducible and instead found it to be 76.4% (40–94%), with significant variability among the studies.^[24] This is partially because the LIFT procedure can be technically difficult and has a steep learning curve. Meticulous dissection in the intersphincteric plane is required for identification of secondary tracts, removal of granulation tissue, and complete fistula ligation. The addition of platelet-richplasma to facilitate fistula healing has even been proposed in a prospective randomized trial with a higher healing rate, shorter healing time, and less pain.^[25]

Submucosal ligation of fistula tract (SLOFT), a modification of LIFT, is technically less difficult because it avoids dissection in the intersphincteric plane.^[26] In an observational study of 47 patients undergoing SLOFT, the fistula closure success rate was 80.9%.^[27] These data are encouraging and, given the greater simplicity of the approach compared to LIFT, might be considered as an alternative option to the LIFT procedure.

Another modification of LIFT is video-assisted ligation of intersphincteric fistula tract (VA-LIFT).^[28] VA-LIFT combines video-assisted technology to visualize the fistula tract during cautery/curettage of granulation tissue and LIFT to close the internal opening in the intersphincteric space. The authors note that use of the fistuloscope is advantageous because it can identify secondary tracts or abscesses, ensure complete debridement of the tract, and can be used at the end of the LIFT procedure to confirm complete ligation. This in turn potentially increases the success rate of LIFT. In a prospective review treating complex anal fistulas, VA-LIFT was compared to the conventional LIFT procedure. Complex anal fistulas were defined as high transphincteric, semi-horseshoe, and horseshoe. VA-LIFT had a higher rate of primary healing for complex anal fistula when compared to LIFT (84.5% vs. 65.4%, P < 0.001) at a median follow-up of 28 months. Although the findings of this study are encouraging for the treatment of complex anal fistulas, the procedures were performed at two different time periods. Therefore, the lower success rate of LIFT could be attributed to inadequate surgeon experience as VA-LIFT was implemented after a surgeon had been through the learning curve.

Fistula tract laser closure [FiLaC, Biolitec, Germany] is a minimally invasive technique utilizing a radial emitting laser probe to destroy the epithelial layer of the fistula tract and obliterate the internal and external openings.^[29] Since the effects are confined to the lumen of the fistula, FiLaC is yet another sphincter preserving procedure. Wolicki et al. performed a retrospective review of patients treated at their institution with FiLaC for transsphincteric and intersphincteric fistulas.^[30] The primary healing rate was 74.7%with a mean follow-up period of 41 months. This is slightly higher than the 66.8–67.3% primary healing rate reported in other evaluations.^[31,32] Lower rates of success have been reported.^[33] Small sample sizes, variability in follow-up time, and heterogeneity in patient populations account for conflicting results.

We would like to acknowledge the significant advancements made regarding the use of stem cells for the treatment of perianal fistula, with a focus on complex disease due to issues such as Crohn's and radiation, among others. These developments warrant their own review and are beyond the scope of our evaluation of cryptoglandular disease.