Crohn's Disease May Not Be a Contraindication to Hemorrhoidectomy

By Will Boggs MD

November 12, 2019

NEW YORK (Reuters Health) - Excisional hemorrhoidectomy may be a viable treatment option in patients with Crohn's disease who have failed nonoperative hemorrhoidal therapy, according to a retrospective study.

Excisional hemorrhoidectomy is the gold standard for advanced medically refractory hemorrhoids, but most physicians avoid it in patients with Crohn's disease due to reports of an increased risk of complications. One review found a 17.1% complication rate in patients with Crohn's disease versus 5.5% in patients with ulcerative colitis.

Dr. Amy L. Lightner of Cleveland Clinic, in Ohio, and colleagues sought to assess whether excisional hemorrhoidectomy in patients with Crohn's disease is safe and effective for the management of internal and/or external hemorrhoids.

From medical records, they identified 36 patients (median age, 49 years) who underwent both medical therapy and excisional hemorrhoidectomy between 1995 and 2019.

Two-thirds of the patients had other perianal disease at the time of hemorrhoidectomy.

During a median follow-up of 31.5 months after hemorrhoidectomy, four patients developed long-term complications potentially related to the hemorrhoidectomy: one developed an anal stricture, one a nonhealing wound, one a perianal abscess/fistula and one had intermittent bleeding due to recurrent hemorrhoidal disease treated with injection sclerotherapy.

None of the patients required proctectomy or fecal diversion as a result of their hemorrhoidal disease or excisional hemorrhoidectomy, the team reports in Inflammatory Bowel Diseases, October 21.

"This suggests that excisional hemorrhoidectomy for symptomatic hemorrhoidal disease may now be safer in Crohn's disease patients due to improved luminal disease control with more widespread use of biologics," the researchers note. "However, it is important to keep in mind that these conclusions are limited by the small number of patients included."

"Although this is a large series of excisional hemorrhoidectomy in Crohn's disease, patient numbers remain small and preclude the ability to draw definitive conclusions about outcomes with varying medical regimens, influence of skin tags, perianal fistulizing disease or anal canal disease, and patients who have intestinal diversion at the time of operative intervention," they conclude. "For this reason, we still recommend exuding caution when performing perianal surgery in Crohn's disease or referring to an inflammatory bowel disease center when unsure of the pathology or optimal management."

Dr. Kellie L. Mathis of Mayo Clinic, in Rochester, Minnesota, who recently evaluated the safety of interventional management of hemorrhoids or anal skin tags in patients with inflammatory bowel disease, told Reuters Health by email, "Crohn's disease is not a contraindication to surgical management of hemorrhoids. Highly selected Crohn's patients with pain and suffering related to hemorrhoidal disease may be considered for hemorrhoidectomy."

"Patients should have good medical management of their Crohn's disease with no active proctitis before considering hemorrhoidectomy," said Dr. Mathis, who was not involved in the study. "Additionally, traditional nonoperative management strategies should be exhausted before surgical intervention is considered."

Dr. Lightner did not respond to a request for comments.

SOURCE: https://bit.ly/33ozkyi

Inflamm Bowel Dis 2019.

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