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CASE PRESENTATION A. PATIENT IDENTITY Name : Mr. S Age : 73 years old Sex : Male Address : Cupang Religion : Moslem Marital Status : Married B. ANAMNESIS Main Grievance Having lump on the rectal Historical of Present Disease The patient came to the hospital of Arjawinangun because there was a lump on his rectal since 2 months ago. The patient complained of increasingly enlarged lump on his rectal. The patient complained that he got bowel problems, that’s disturb his activity because he was founded a movement disorder and continuously pain around of his genital area.

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Page 1: PRESKAS BEDAH

CASE PRESENTATION

A. PATIENT IDENTITY

Name : Mr. S

Age : 73 years old

Sex : Male

Address : Cupang

Religion : Moslem

Marital Status : Married

B. ANAMNESIS

Main Grievance

Having lump on the rectal

Historical of Present Disease

The patient came to the hospital of Arjawinangun because there

was a lump on his rectal since 2 months ago. The patient complained of

increasingly enlarged lump on his rectal. The patient complained that

he got bowel problems, that’s disturb his activity because he was

founded a movement disorder and continuously pain around of his

genital area. In addition to these symptoms, patient has no other

complaints.

Historical of Past Disease

Hipertension (-)

Diabetes Melitus (-)

Historical of Family Disease

Hipertension (-)

Diabetes Melitus (-)

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The patient said there was no other family member that have

same disease like him

C. MEDICAL EXAMINATION

Present Status

General Condition: Moderate

Awareness : Composmantis

Blood Pressure : 120/80

Pulse : 72x/minute

Breathing : 20x/minute

Temperature : 35,9 ºC

General Status

Head

Form : Normal, Simetrical

Hair : Black colour, No hair fall

Eye

Anemic Conjungtival, -/-

Icteric Sclera, -/-

Light Reflect, (+)

Isocor Pupil, right = left

Ear : Normal form, cerumen (-), tympani membrane intac

Nose : Normal form, no deviation on septum, epitaction, -/-

Mouth : Normal

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Neck

Enlargement of lymph nodes (-)

Trachea in the middle

No mass

Thorax

Lungs – pulmonary

Inspection : The right and left of his chest shape is

symmetrical

Palpation : His right and left fremitus tactile and

vocal is symmetrical, crepitus (-), tenderness (-), rebound

tenderness (-)

Percussion : The sound of percussion are resonant in both of

his lung fields

Auscultation : The sound of his lung is vecular and bronchial

in the entire of lung field, ronkhi -/-, wheezing -/-

Heart

Inspection : Ictus cordis is not visible

Palpation : Ictus cortis palpable on the left of midclavicula

on ICS line 5

Percussion : Upper limit ICS 3 linea parasternalis sinistra.

Right limit ICS 4 linea sternalis dextra. Left limit ICS 5 linea

midclavicula sinistra

Auscultation : Heart sound I – II pure regular, mumur (-),

gallops (-)

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Abdomen

Inspection : Flat abdomen shape, supple, not visible skin disorders

Palpation : Tenderness (-), rebound tenderness (-)

Percussion : There was a whole field tympanic abdomen

Auscultation : Bowel (+) Normal

Ekstremity

Superior : Warm akral, edema -/-, CTR <2”

Inferior : Warm akral, edema -/-, CTR <2”

Genitalia : There was a lump on the rectal

D. INVESTIGATIONS

Laboratory Examination

Complete Blood

Leukocytes : 9,64 10e3/uL

Red Blood Cell : 5,27 10e6/uL

Hb : 14,8 g/dL

HCT : 46,4 %

Platelets : 369 10e3/uL

BT : 1’30”

CT : 4’

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E. DIAGNOSIS OF WORK

Prolaps hemorrhoid

F. DIFFERENTIAL DIAGNOSIS

G. MANAGEMENT PLAN

Non-medical:

Hemorrhoidectomy

Medical:

Cefixime 2x1

Cefazolin 2x1

Ketorolac 2x1

H. PROGNOSIS

Quo ad vitam : Ad Bonam

Quo ad functionam : Ad Bonam

Quo ad sanationam : Ad Bonam

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LITERATURE REVIEW

Background

Hemorrhoids are swollen blood vessels in the lower rectum. They are among

the most common causes of anal pathology, and subsequently are blamed for virtually

any anorectal complaint by patients and medical professionals alike. Confusion often

arises because the term "hemorrhoid" has been used to refer to both normal anatomic

structures and pathologic structures. In the context of this article, "hemorrhoids"

refers to the pathologic presentation of hemorrhoidal venous cushions.

Hemorrhoidal venous cushions are normal structures of the anorectum and are

universally present unless a previous intervention has taken place. Because of their

rich vascular supply, highly sensitive location, and tendency to engorge and prolapse,

hemorrhoidal venous cushions are common causes of anal pathology. Symptoms can

range from mildly bothersome, such as pruritus, to quite concerning, such as rectal

bleeding.

Although hemorrhoids are a common condition diagnosed in clinical practice,

many patients are too embarrassed to ever seek treatment. Consequently, the true

prevalence of pathologic hemorrhoids is not known. In addition, although

hemorrhoids are responsible for a large portion of anorectal complaints, it is important

to rule out more serious conditions, such as other causes of gastrointestinal (GI)

bleeding, before reflexively attributing symptoms to hemorrhoids.

In a study of 198 physicians from different specialties, Grucela et al found the rate of

correct identification for 7 common, benign anal pathologic conditions (including anal

abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external

hemorrhoid; condyloma acuminata; and full-thickness rectal prolapse) was greatest

for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions. 

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Anatomy

Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg,

arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz

muscle), and connective tissue lined by the normal epithelium of the anal canal.

Hemorrhoids are present in utero and persist through normal adult life. Evidence

indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is

supported by the bright red color and arterial pH of the blood.

Hemorrhoids are classified by their anatomic origin within the anal canal and by their

position relative to the dentate line; thus, they are categorized into internal and

external hemorrhoids (see the following image).

Image 1 : Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.

External hemorrhoids develop from ectoderm and are covered by squamous

epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and

lined with the columnar epithelium of anal mucosa. Similarly, external hemorrhoids

are innervated by cutaneous nerves that supply the perianal area. These nerves include

the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by

somatic sensory nerves and therefore cannot cause pain. At the level of the dentate

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line, internal hemorrhoids are anchored to the underlying muscle by the mucosal

suspensory ligament.

Hemorrhoidal venous cushions are a normal part of the human anorectum and

arise from subepithelial connective tissue within the anal canal. Internal hemorrhoids

have 3 main cushions, which are situated in the left lateral, right posterior (most

common), and right anterior areas of the anal canal. However, this combination is

found in only 19% of patients; hemorrhoids can be found at any position within the

rectum. Minor tufts can be found between the major cushions.

Present in utero, these cushions surround and support distal anastomoses

between the superior rectal arteries and the superior, middle, and inferior rectal veins.

They also contain a subepithelial smooth muscle layer, contributing to the bulk of the

cushions. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting

anal pressure and provides important sensory information, enabling the differentiation

between solid, liquid, and gas.

External hemorrhoidal veins are found circumferentially under the anoderm;

they can cause trouble anywhere around the circumference of the anus.

Venous drainage of hemorrhoidal tissue mirrors embryologic origin. Internal

hemorrhoids drain through the superior rectal vein into the portal system. External

hemorrhoids drain through the inferior rectal vein into the inferior vena cava. Rich

anastomoses exist between these 2 and the middle rectal vein, connecting the portal

and systemic circulations.

Mixed hemorrhoids are confluent internal and external hemorrhoids.

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Epidemiology

Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4%

in the general population. In the United States, up to one third of the 10 million people

with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions

per year.

The number of hemorrhoidectomies performed in US hospitals is declining. A

peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate

declined to 37 hemorrhoidectomies per 100,000 people in 1987. Outpatient and office

treatment of hemorrhoids account for some of this decline.

There is no known sex predilection, although men are more likely to seek

treatment. However, pregnancy causes physiologic changes that predispose women to

developing symptomatic hemorrhoids. In older adults. The prevalence of hemorrhoids

increases with age, with a peak in persons aged 45-65 years.

Etiology

The term hemorrhoid is usually related to the symptoms caused by

hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal

columns exist in utero. When these vascular cushions produce symptoms, they are

referred to as hemorrhoids. Hemorrhoids generally cause symptoms when they

become enlarged, inflamed, thrombosed, or prolapsed.

Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling

of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses.

This leads to stretching of the suspensory muscles and eventual prolapse of rectal

tissue through the anal canal. The engorged anal mucosa is easily traumatized, leading

to rectal bleeding that is typically bright red due to high blood oxygen content within

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the arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge

(triggering pruritus) and predisposes to incarceration and strangulation.

Although many patients and clinicians believe that hemorrhoids are caused by chronic

constipation, prolonged sitting, and vigorous straining, little evidence to support a

causative link exists. Some of these potential etiologies are briefly discussed below.

Decreased venous return

Most authors agree that low-fiber diets cause small-caliber stools, which result

in straining during defecation. This increased pressure causes engorgement of the

hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally

high tension of the internal sphincter muscle can also cause hemorrhoidal problems,

presumably by means of the same mechanism, which is thought to be decreased

venous return. Prolonged sitting on a toilet (eg, while reading) is believed to cause a

relative venous return problem in the perianal area (a tourniquet effect), resulting in

enlarged hemorrhoids. Aging causes weakening of the support structures, which

facilitates prolapse. Weakening of support structures can occur as early as the third

decade of life.

Straining and constipation

Straining and constipation have long been thought of as culprits in the

formation of hemorrhoids. This may or may not be true. Patients who report

hemorrhoids have a canal resting tone that is higher than normal. Of interest, the

resting tone is lower after hemorrhoidectomy than it is before the procedure. This

change in resting tone is the mechanism of action of Lord dilatation, a surgical

procedure for anorectal complaints that is most commonly performed in the United

Kingdom.

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Pregnancy

Pregnancy clearly predisposes women to symptoms from hemorrhoids,

although the etiology is unknown. Notably, most patients revert to their previously

asymptomatic state after delivery. The relationship between pregnancy and

hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.

Portal hypertension and anorectal varices

Portal hypertension has often been mentioned in conjunction with

hemorrhoids. However, hemorrhoidal symptoms do not occur more frequently in

patients with portal hypertension than in those without it, and massive bleeding from

hemorrhoids in these patients is unusual. Bleeding is very often complicated by

coagulopathy. If bleeding is found, direct suture ligation of the offending column is

suggested.

Anorectal varices are common in patients with portal hypertension. Varices occur in

the midrectum, at connections between the portal system and the middle and inferior

rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they

rarely bleed. Treatment is usually directed at the underlying portal hypertension.

Emergent control of bleeding can be obtained with suture ligation. Portosystemic

shunts and transjugular intrahepatic portosystemic shunts (TIPS) have been used to

control hypertension and thus, the bleeding.

Other risk factors

Other risk factors historically associated with the development of hemorrhoids include

the following:

Lack of erect posture

Familial tendency

Higher socioeconomic status

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Chronic diarrhea

Colon malignancy

Hepatic disease

Obesity

Elevated anal resting pressure

Spinal cord injury

Loss of rectal muscle tone

Rectal surgery

Episiotomy

Anal intercourse

Inflammatory bowel disease, including ulcerative colitis, and Crohn disease

Pathophysiology of symptoms of internal hemorrhoids

Internal hemorrhoids cannot cause cutaneous pain, because they are above the

dentate line and are not innervated by cutaneous nerves. However, they can bleed,

prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal

skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal

pain by prolapsing and causing spasm of the sphincter complex around the

hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are

exposed. This muscle discomfort is relieved with reduction.

Internal hemorrhoids can also cause acute pain when incarcerated and strangulated.

Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis

may cause more deep discomfort. When these catastrophic events occur, the sphincter

spasm often causes concomitant external thrombosis. External thrombosis causes

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acute cutaneous pain. This constellation of symptoms is referred to as acute

hemorrhoidal crisis and usually requires emergent treatment.

Internal hemorrhoids most commonly cause painless bleeding with bowel movements.

The covering epithelium is damaged by the hard bowel movement, and the underlying

veins bleed. With spasm of the sphincter complex elevating pressure, the internal

hemorrhoidal veins can spurt.

Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This

mucus with microscopic stool contents can cause a localized dermatitis, which is

called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the

offending elements reach the perianal tissue. Hemorrhoids are not the primary

offenders.

Pathophysiology of symptoms of external hemorrhoids

External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of

the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually

related to a specific event, such as physical exertion, straining with constipation, a

bout of diarrhea, or a change in diet. These are acute, painful events.

Pain results from rapid distention of innervated skin by the clot and

surrounding edema. The pain lasts 7-14 days and resolves with resolution of the

thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin

tags. External thromboses occasionally erode the overlying skin and cause bleeding.

Recurrence occurs approximately 40-50% of the time, at the same site (because the

underlying damaged vein remains there). Simply removing the blood clot and leaving

the weakened vein in place, rather than excising the offending vein with the clot, will

predispose the patient to recurrence.

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External hemorrhoids can also cause hygiene difficulties, with the excess,

redundant skin left after an acute thrombosis (skin tags) being accountable for these

problems. External hemorrhoidal veins found under the perianal skin obviously

cannot cause hygiene problems; however, excess skin in the perianal area can

mechanically interfere with cleansing.

Symptoms

An adequate history should include the onset and duration of symptoms. In

addition to characterizing any pain, bleeding, protrusion, or change in bowel habits,

special attention should be placed on the patient's coagulation history and immune

status.

Rectal bleeding is the most common presenting symptom. The blood is usually

bright red and may drip, squirt into the toilet bowl, or appear as streaks on the toilet

paper. The physician should inquire about the quantity, color, and timing of any rectal

bleeding. Darker blood or blood mixed with stool should raise suspicion of a more

proximal cause of bleeding.

A patient with a thrombosed external hemorrhoid may present with complaints

of an acutely painful mass at the rectum (see the image below). Pain truly caused by

hemorrhoids usually arises only with acute thrombus formation. This pain peaks at

48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-

onset anal pain in the absence of a thrombosed hemorrhoid should prompt

investigation for an alternate cause, such as an intersphincteric abscess or anal fissure.

As many as 20% of patients with hemorrhoids will have concomitant anal fissures.

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Image 2 : Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.Image courtesy of MedicineNet, Inc

The presence, timing, and reducibility of prolapse, when present, will help

classify the grade of internal hemorrhoids and guide the therapeutic approach (see

Grading of Internal Hemorrhoids). Grade I internal hemorrhoids are usually

asymptomatic but, at times, may cause minimal bleeding. Grades II, III, or IV internal

hemorrhoids usually present with painless bleeding but also may present with

complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.

Diagnosis

In addition to the general physical examination, physicians should also perform

visual inspection of the rectum, digital rectal examination, and anoscopy or

proctosigmoidoscopy when appropriate.

The preferred position for the digital rectal examination is the left lateral decubitus

with the patient's knees flexed toward the chest. Topical anesthetics (eg, 20%

benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by

examination.

Inspect and examine the entire perianal area. Warn the patient before any

probing or poking. Because patient apprehension is great before any anal

examination, go to great lengths to reassure the patient. Gentle spreading of the

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buttocks allows easy visualization of most of the anoderm; this includes the distal anal

canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without

internal probing. Note the location and size of skin tags and the presence of

thromboses. Normal corrugation of the anoderm and a normal anal wink with

stimulation confirms intact sensation.

The following are external findings that are important to note:

Redundant tissue

Skin tags from old thrombosed external hemorrhoids

Fissures

Fistulas

Signs of infection or abscess formation

Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

Digital examination of the anal canal can identify any indurated or ulcerated

areas. Also assess for any masses, tenderness, mucoid discharge or blood, and rectal

tone. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft

vascular structures, they are usually not palpable unless thrombosed.

Current guidelines from most gastrointestinal and surgical societies advocate

anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding.

Colonoscopy should be considered in the evaluation of any rectal bleeding that is not

typical of hemorrhoids such as in the presence of strong risk factors for colonic

malignancy or in the setting of rectal bleeding with a negative anorectal examination.

To see further into the anal canal (into the lower colon, or sigmoid), sigmoidoscopy

may be used, or the entire colon may be viewed withcolonoscopy. For both

procedures, a lighted, flexible viewing tube is inserted into the rectum. A barium X-

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ray can also show the outline of the entire colon's interior. First, a barium enema is

given, then X-rays are taken of the lower gastrointestinal tract.

Management

Internal hemorrhoids

Internal hemorrhoids do not have cutaneous innervation and can therefore be

destroyed without anesthetic, and the treatment may be surgical or nonsurgical.

Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and

to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works

well for symptoms that persist despite the use of conservative therapy. Most

nonsurgical procedures currently available are performed in the clinic or ambulatory

setting.

The following is a quick summary of treatment for internal hemorrhoids by grade:

Grade I hemorrhoids are treated with conservative medical therapy and avoidance of

nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods

Grade II or III hemorrhoids are initially treated with nonsurgical procedures

Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical

hemorrhoidectomy

Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue

requires prompt surgical consultation

Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an

excellent alternative for treating internal hemorrhoids that have not been amenable to

conservative or nonoperative approaches. Short- and medium-term results are

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excellent. Patients with minimal external tags and large internal hemorrhoids are

easily treated with procedure for prolapsing hemorrhoids and skin tag excision.

In a meta-analysis of randomized, controlled trials, however, Chen et al concluded

that the recurrence rate of prolapsing hemorrhoids was higher with stapled

hemorrhoidectomy than with LigaSure hemorrhoidectomy.[18] Operative resection is

sometimes required to control the symptoms of internal hemorrhoids.

External hemorrhoids

External hemorrhoid symptoms are generally divided into problems with acute

thrombosis and hygiene/skin tag complaints. The former respond well to office

excision (not enucleation), whereas operative resection is reserved for the latter.

Remember that therapy is directed solely at the symptoms, not at aesthetics.

When performed well, operative hemorrhoidectomy should have a 2-5%

recurrence rate. Nonoperative techniques, such as rubber band ligation, produce

recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually

be addressed with further nonoperative treatments.[19] Long-term results from

procedure for prolapsing hemorrhoids are unavailable at this time

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Surgical hemorrhoidectomy

Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids

and in particular is indicated in the following situations:

Conservative or nonsurgical treatment fails (persistent bleeding or chronic

symptoms)

Grade III and IV hemorrhoids with severe symptoms

Presence of concomitant anorectal conditions (eg, anal fissure or fistula, hygiene

trouble caused by large skin tags, a history of multiple external thromboses, or

internal hemorrhoid trouble) requiring surgery

Patient preference

About 5-10% of people with hemorrhoids eventually require surgical

hemorrhoidectomy. Proper anesthetic care (especially if local anesthesia with

supplementary IV sedation), attention to perioperative fluid restriction, and careful

postoperative instructions can ease the patient's recovery.

Postoperative pain remains the major complication, with most patients requiring 2-4

weeks before returning to normal activities. Other possible complications include

urinary retention, anal stenosis, and incontinence.

Prevention and Control

• Run healthy lifestyle

• Regular exercise

• Eat fibrous food

• Avoid too much sitting

• Do not smoke, drugs, etc

• Avoid sexual intercourse is not fair

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• Drinking enough water

• Do not scratch excessively anal

Prognosis

With appropiate therapy, all symptomatic hemorrhoids can be

made asymptomatic. Conservative approach should be attempted first in all case.

Hemorrhoidectomy generally gives good result. After all patient should be taught to

avoid eating food with fiber obstipation in order to prevent recurrence of the

symptoms of hemorroids.

Most hemorrhoids resolve spontaneously or with conservative medical therapy

alone. However, complications can include thrombosis, secondary infection,

ulceration, abscess, and incontinence. The recurrence rate with nonsurgical techniques

is 10-50% over a 5-year period, whereas that of surgical hemorrhoidectomy is less

than 5%. Regarding complications from surgery, well-trained surgeons should

experience complications in fewer than 5% of cases. Complications include stenosis,

bleeding, infection, recurrence, nonhealing wounds, and fistula formation.

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REFFERENCE

1. Chen HL, Woo XB, Cui J, et al. Ligasure versus stapled hemorrhoidectomy in the

treatment of hemorrhoids: a meta-analysis of randomized control trials. Surg

Laparosc Endosc Percutan Tech. 2014 Aug. 24(4):285-9.

2. El Nakeeb AM, Fikry AA, Omar WH, et al. Rubber band ligation for 750 cases of

symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008

Nov 14. 14(42):6525-30.

3. Hollingshead JR, Phillips RK. Haemorrhoids: modern diagnosis and

treatment. Postgrad Med J. 2016 Jan. 92 (1083):4-8. 

4. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is

associated with a higher long-term recurrence rate of internal hemorrhoids

compared with conventional excisional hemorrhoid surgery. Dis Colon

Rectum. 2007 Sep. 50(9):1297-305.

5. Picchio M, Palimento D, Calì B, Corelli S, Spaziani E. Long-term outcome of

stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids. Dis Colon

Rectum. 2008 Jul. 51(7):1107-12.

6. Raahave D, Jepsen LV, Pedersen IK. Primary and repeated stapled

hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years. Dis

Colon Rectum. 2008 Mar. 51(3):334-41.

7. Yudhautama, Herry S dr. Diagnosis and Management Hemorroid (Convensional

Hemorroidectomy or Surgical Stappler or Laser Surgery).

http://herryyudha.blogspot.co.id/2012/03/diagnosis-and-management-

haemorhoid.html. Diakses pada 19 Mei 2016 pukul 21.00