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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 90 | Multiple Hemorrhoidal Ligation [2003년 2월 DCR] | 2011-11-17 | 4867 |
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Prospective, Randomized Trial Evaluating a New Technique
David N. Armstrong, M.D., F.R.C.S.
From the Georgia Colon & Rectal Surgical Clinic, Atlanta, Georgia
PURPOSE: A modified anoscope was developed, with lateral apertures at the left lateral, right anterior, and right posterior quadrants, to enable synchronous exposure and ligation of all three internal hemorrhoids. Results were compared with those for conventional multiple ligation.
METHODS: Postligation pain, complications, and outcomes were compared between synchronous ligation with the new anoscope (synchronous group) and three-quadrant ligation with a conventional anoscope with similar overall dimensions (conventional group). RESULTS: Twenty-five patients were prospectively randomized to each group. Postligation pain and analgesic requirements were recorded up to 28 days, and postligation complications and outcomes
were evaluated for a minimum of 6 months. Narcotic requirements were lower in the synchronous group, but this difference did not achieve statistical significance (P > 0.05, Student’s t-test). Secondary hemorrhage occurred in 1 patient (4 percent) in the conventional group but resolved spontaneously. The synchronous group experienced significantly less pain during the ligation procedure and for 2 days afterward (P < 0.01, Wilcoxon’s test). External hemorrhoidal thrombosis developed in 4 percent of the synchronous group and 12 percent of conventionally treated patients, all of whom responded to conservative treatment. Repeat ligation was required less often in the synchronous group (16 percent) than with conventional ligation (28 percent). Surgery (completion hemorrhoidectomy for external thrombosis) was necessary in one patient (4 percent) in each group. Anal stenosis developed in one patient in the synchronous group. CONCLUSION: The new anoscope provides improved exposure of all three internal hemorrhoids
and permits optimal placement of the rubber bands; this may account for the decreased postligation pain and lower repeat ligation rates. Synchronous hemorrhoidal ligation is a less painful method of multiple hemorrhoidal ligation and may improve outcomes compared with conventional multiple ligation. Rubber band ligation of internal hemorrhoids is an effective and cost-efficient means of treating
symptomatic internal hemorrhoids. The concept of ligating the internal hemorrhoidal complex was originally introduced by Blaisdell in 1958. The original technique used a silk “slippage” knot to strangulate the internal hemorrhoid, causing ischemic necrosis of the entrapped tissue, which was subsequently sloughed. Because the original silk ligatures lacked the necessary elastic properties to effectively obstruct blood flow, the technique was frequently unsuccessful. In 1963, the method was modified by Barron, who used rubber band rings cut at 1-mm increments from a latex urinary catheter. The bands were mounted on a modified umbilical cord ligator with the familiar cone device still used today. Barron’s original technique has seen multiple modifications, but the principle remains unchanged. Recent attention has focused on the practice of ligating multiple internal hemorrhoids at the same time,
compared with the traditional practice of ligating individual hemorrhoids over a period of several weeks. Barron originally recommended individual hemorrhoidal ligation repeated every three to four weeks until all three hemorrhoids had been eradicated. Two decades later, in 1984, Goligher endorsed the practice of ligating one, two, or three hemorrhoids at the same time but emphasized the need to place the rubber band proximally in the anal canal “at the level of the anorectal ring” to avoid undue discomfort. Several authors have subsequently recommended ligation of multiple hemorrhoids in a single session as a “safe and cost-effective alternative.” Multiple hemorrhoidal ligation at a single session is much more convenient for patients, who routinely prefer that option over three individual ligations. Although three synchronous ligations almost certainly cause more discomfort than a single ligation, the total duration of the pain is proportionately diminished, and time to eradication of all three hemorrhoids is reduced by a factor of three.
Because of the discomfort associated with the insertion of a conventional single-slot anoscope three
times, a modified anoscope was designed and developed to enable synchronous ligation of all three internal hemorrhoids with a single insertion. The modified anoscope incorporates three lateral apertures in the left lateral, right anterior, and right posterior quadrants to expose all three internal components at the same time(Fig. 1).  All three hemorrhoids can then be ligated without the need to remove and reinsert the scope. Overall dimensions of each anoscope (e.g., length and tapering diameter) were similar. A prospective, randomized study was conducted to evaluate discomfort and outcomes after synchronous hemorrhoidal
ligation with the modified anoscope compared with multiple conventional ligations with a single-slot anoscope.   |
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