Procedure for Prolapse and Hemorrhoids (PPH)

Scott D. Goldstein M.D.

Content
Hemorrhoids and Treatment Options PPH Overview How PPH Works Benefits of PPH Risks and Complications Conclusion

Hemorrhoidal Disease Epidemiology

More than 50%* of the population will develop symptomatic hemorrhoids in their lifetime. The incidence increases with age. Some patients will need surgical treatment.

*Source: www.fascrs.org (The American Society of Colon and Rectal Surgeons)

Hemorrhoids and the Most Common Treatments

Classifications 1st Degree Bleeding without prolapse TREATMENT OPTION Over-the-counter topical medications such as creams, suppositories, or wipes Sitz bath Dietary Sclerotherapy Infrared Coagulation Sclerotherapy Infrared Coagulation Rubber Band Ligation Procedure for Prolapse and Hemorrhoids (PPH) * Rubber Band Ligation Hemorrhoidectomy Procedure for Prolapse and Hemorrhoids (PPH) Hemorrhoidectomy Procedure for Prolapse and Hemorrhoids (PPH)

2nd Degree Prolapse without spontaneous reduction

3rd Degree Prolapse with manual reduction

4th Degree Irreducible Prolapse

Overview of PPH
PPH involves the repositioning of the internal and external hemorrhoids to their anatomical position through the excision of a strip of excess prolapsed mucosa above the dentate line. PPH is not a hemorrhoidectomy in principle; it is a hemorrhoidopexy. However, part of the internal hemorrhoids may be excised along with the prolapsed rectal mucosa.

How PPH Works

Before PPH

Repositioning

The surgeon will bring up the prolapsed mucosa into its original position, lifting the hemorrhoidal tissue into place.

Retracting

The surgeon will utilize the PPH device to retract excess mucosal tissue.

Restoring

Once the excess tissue is retracted, the device then removes the excess tissue and reconnects and restores the anal canal wall.

Reducing

Benefits of PPH
The key benefits of PPH compared to conventional hemorrhoidectomy are:

The PPH Effect

Less Pain

Source: 1. Roswell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled hemorrhoidectomy): randomized, controlled trial. The Lancet, Vol. 355, Mar 4, 2000;779-781.

Quicker Recovery
25 20 15 10 5 0
PPH Hemorrhoidectomy

Days off Work

Procedure
Source: Stapled vs Excision Hemorrhoidectomy, Long-term Results of a Prospective Randomized Trial, Hetzer N, Demartines N, Handschin AE, 2002, Archives of Surgery.

PPH Patient Indications and Contraindications

Indications: 2nd degree hemorrhoids, after failure of other therapies 3rd and 4th degree hemorrhoids Rectal mucosal prolapse Contraindications: Absolute: abscess, full thickness rectal prolapse Relative: non-reducible prolapsed hemorrhoids on the perianal skin, acute thrombosed internal hemorrhoids, previous rectal surgery (because scarring may cause difficulties in various stages of the procedure)

PPH Risks and Complications

As with any surgical procedure, there are risks that accompany PPH: 1. 2. If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall, resulting in inflammation or infection. The internal muscle of the sphincter may be damaged, resulting in short-term dysfunction, such as severe pain or incontinence.

Conclusion
PPH offers less pain and a quicker recovery to patients in comparison to conventional hemorrhoid techniques PPH can be performed on patients with 2nd (after failure of other therapies), 3rd, and 4th degree hemorrhoids