Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis.

Ugo Grossi,Gian Luca Di Tanna,Francesco Cinetto,Marcello Rattazzi,Elisa Galasso,Umberto Bracale,Andrea Kazemi Nava,Martino Zucchella,Giacomo Zanus,Gaetano Gallo,Carla Felice,Mattia Ballo

doi:10.3390/jcm11030709

Abstract

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn’s disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2–70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14–77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3–16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5–16%) vs. 5% (0–13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.

Highlights

Introduction conditions of the Creative CommonsHemorrhoids are clusters of smooth muscle, vascular, and connective tissue arranged in three columns along the anal canal, which contribute to continence mechanisms of healthy individuals
Inflammatory bowel diseases (IBDs) are characterized by repetitive episodes of inflammation of the gastrointestinal tract caused by an abnormal immune response to gut microflora
It was originally suggested that symptomatic hemorrhoids rarely occur in patients with Crohn’s disease (CD) and that in many cases skin tags are really being treated instead of hemorrhoidectomy [22]

Summary

Introduction

Introduction conditions of the Creative CommonsHemorrhoids are clusters of smooth muscle, vascular, and connective tissue arranged in three columns along the anal canal, which contribute to continence mechanisms of healthy individuals. Hemorrhoidal disease (HD) refers to a pathologic or symptomatic. Process involving hemorrhoids and represents one of the most common problems leading patients to doctors all around the world, in the Western countries, with a prevalence of 5–35% in the overall population [1,2]. Anal swelling, prolapse, discomfort, pain, discharge, hygiene problems, and pruritus are the most common complaints [3]. The predominance or concomitance of one or more symptoms may reflect the large spectrum of pathological alterations of the internal or external hemorrhoids (i.e., laying above or below the dentate line, respectively). Inflammatory bowel diseases (IBDs) are characterized by repetitive episodes of inflammation of the gastrointestinal tract caused by an abnormal immune response to gut microflora. IBDs encompass two idiopathic intestinal diseases: ulcerative colitis (UC)

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