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Procedure for Prolapse and Hemorrhoids(PPH)

Scott D. Goldstein M.D.

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ContentHemorrhoids and Treatment Options

PPH Overview

How PPH Works

Benefits of PPH

Risks and Complications

Conclusion

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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)

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Hemorrhoids and theMost Common Treatments

TREATMENT OPTION1st Degree

Bleeding without prolapse Over-the-counter topical medications such as

creams, suppositories, or wipes

Sitz bath

Dietary

SclerotherapyInfrared Coagulation

2nd Degree

Prolapse without spontaneous reduction Sclerotherapy

Infrared Coagulation

Rubber Band Ligation

Procedure for Prolapse and Hemorrhoids (PPH) *

3rd Degree

Prolapse with manual reduction Rubber Band Ligation

Hemorrhoidectomy

Procedure for Prolapse and Hemorrhoids (PPH)

4th Degree

Irreducible Prolapse Hemorrhoidectomy

Procedure for Prolapse and Hemorrhoids (PPH)

Classifications

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Overview of PPHPPH 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.

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How PPH Works

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Before PPH

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Repositioning

The surgeon will bring up the prolapsed mucosa into its original

position, lifting the hemorrhoidal tissue into place.

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Retracting

The surgeon will utilize the PPH device to retract excess

mucosal tissue.

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Restoring

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

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Reducing

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Benefits of PPHThe key benefits of PPH compared to conventional

hemorrhoidectomy are:

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The PPH Effect

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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.

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Quicker Recovery

0

5

10

15

20

25

Days off

Work

PPH Hemorrhoidectomy

Procedure

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

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PPH Patient Indications andContraindications

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)

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PPH Risks and ComplicationsAs with any surgical procedure, there are risks that accompany PPH:

1. If too much muscle tissue is drawn into the device, it can result in damage to the

rectal wall, resulting in inflammation or infection.

2. The internal muscle of the sphincter may be damaged, resulting in short-termdysfunction, such as severe pain or incontinence.

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ConclusionPPH 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