Reporter : R1 姜冠宇

Background• Hemorrhoid - “Anal cushions”

• Submucosal A-V malformation• Connective tissue• Muscle of Treitz

• Mechanism: • Straining

• Treatment:• Sclerosing and shrinkage• 5% phenol almond oil (PAO), for grade 1 to 2 hemorrhoids

Aluminum potassium sulfate and tannic acid (ALTA) • Interrupted Blood flow Shrinkage of the hemorrhoids• Persistent fibrosis Adhesion to the muscular layer

------------------------------------------------------------------------------• More significant inflammation and fibrosis• More lasting effects• Effective for the treatment of grade 3 to 4 hemorrhoids• Similar to those of a radical hemorrhoidectomy

INDICATIONS / Contraindications• Indication:

• Only for internal hemorrhoids

• Contraindication: 1.Hemorrhoids in an acute stage

• External thrombosed hemorrhoids • Strangulated hemorrhoids

1.Fissures, fistulae and polyps

2.Large hemorrhoids that require more than 40 mL of ALTA

11Surgical treatments

4-step injection

① Submucosa, superior pole.

② Submucosa, central part

③ Mucous lamina propria, central part

④ Submucosa, inferior pole.

COMBINED MODALITY THERAPY-hybrid hemorrhoidectomy

• Type A, accessory file• Type B, big sized file

• Lower ligation • Less stricture

• Type C, complete injection

Low ligation

Complications of aluminum potassium sulfate and tannic acid (ALTA) injectionComplication Cause

Hard indruation Excessive dose administration

Insufficient massage

Rectal ulcer, hemorrhoid necrosis Injection too shallow

insufficient massage

Rectal stricture Excessive dose administration in step 1

Anal pain Injection or infiltration of ALTA solution into the dentate line, anal canal or skin

Rectal necrosis Insertion to the muscular layer

Prostatitis, epididymitis, testitis Penetration into the prostate

PERFORMANCE OF ALTA INJECTION• Result for prolapsed internal hemorrhoid grade 3 & 4: No significant difference• Postop 1 year, the recurrence rate: ALTA 16% (12/73 cases) > Surgery 2% (2/81 cases)

• Vagovagal nerve stimulation reflex~• Recurrence rate was high during insufficient ALTA injection

• Bradycardia• Lower abdominal pain• Hypotension

Since then, ALTA + lidocaine was introduced • ~ Kunimoto et al

CONCLUSION• Outcomes of ALTA treatment

• Almost the same as hemorrhoidectomy• But with almost no pain.

• Mixed hemorrhoids Combined modality therapy • Less postoperative pain• Fewer complications• Shortened period of wound healing• Faster return to normal life