Hemorrhoidectomy and Excision of Skin Tags in IBD: Harbinger of Doom or Simply a Disease Running Its Course?

Background Controversy in performing hemorrhoidectomy and anal skin tag excision in patients with IBD stems from dated reports of nonhealing wounds resulting in proctectomy. Objective This study aimed to determine the safety of interventional management of hemorrhoids or anal skin tags in patients with Crohn's disease or ulcerative colitis. Design This study is a retrospective review of patient records from 2000 to 2017. Setting The patient records were retrieved from a multistate health system. Patients Adult patients with IBD undergoing interventional management of hemorrhoids or skin tags were included. Main outcome measure The primary outcome measured was the long-term requirement of proctectomy. Results Ninety-seven patients (n = 49 Crohn's disease, 48 ulcerative colitis) underwent interventional management of hemorrhoids or anal skin tags (n =35 rubber band ligation, 27 anal skin tag excision, 21 hemorrhoidectomy, 14 excision/incision of thrombosed hemorrhoid). Thirty-day complications were observed in 5 patients (n = 4 urinary retention, 1 perianal abscess). Five patients with Crohn's disease eventually required proctectomy at a median of 7 years after skin tag excision (range, 6 months to 10 years), but none were secondary to impaired wound healing. Two patients with ulcerative colitis who had previously undergone IPAA were subsequently diagnosed with Crohn's disease of the pouch after skin tag excision. No other long-term complications were seen in patients with ulcerative colitis. Limitations The study's retrospective design does not allow identification of patients with IBD who underwent only medical management of their hemorrhoids. There is also selection bias in which patients were selected for interventional management of their disease. Conclusions The requirement for proctectomy after hemorrhoidectomy/skin tag excision appears to be secondary to the natural disease course of perianal Crohn's disease rather than perianal intervention. Selective hemorrhoidectomy and skin tag excision in patients with well-controlled luminal disease should be considered. See Video Abstract at http://links.lww.com/DCR/B55. HEMORROIDECTOMIA ASOCIADA A LA EXCISION DE PLICOMAS EN CASOS DE ENFERMEDAD INFLAMATORIA INTESTINAL: ?ANUNCIO DE FATALIDAD O SIMPLEMENTE EVOLUCION NATURAL DE LA ENFERMEDAD?: Esta controvertida la realizacion de una hemorroidectomia asociada a la excision de plicomas ano-cutaneos en pacientes con enfermedad inflamatoria intestinal, asi lo han demostrado informes detallados sobre la no cicatrisacion de las heridas conllevando a una proctectomia.Determinar los margenes de seguridad en casos de tratamiento instrumental de hemorroides asociadas a la excision de plicomas ano-cutaneos en pacientes portadores de colitis ulcerosa o enfermedad de Crohn.Revision retrospectiva de historias clinicas de pacientes entre 2000 y 2017.Servicio Multiestatal de Salud.Adultos con enfermedad inflamatoria intestinal sometidos a tratamiento instrumental de hemorroides asociado a la excision de plicomas ano-cutaneos.Requisitos a largo plazo para una proctectomia.Noventa y siete pacientes (49 con enfermedad de Crohn, 48 con colitis ulcerosa) se sometieron a un tratamiento instrumental de hemorroides asociada a la excision de plicomas ano-cutaneos (35 ligadura con bandas elasticas, 27 excision de plicomas ano-cutaneos, 21 hemorroidectomias, 14 excisiones / incisiones de hemorroides trombosadas) Se observaron complicaciones a los 30 dias en cinco pacientes (4 con retencion urinaria, 1 absceso perianal). Cinco pacientes con enfermedad de Crohn requirieron proctectomia en una media de 7 anos despues de la excision de los plicomas ano-cutaneos (rango, 6 meses a 10 anos), pero ninguno fue secundario a la mala cicatrizacion de la herida. Dos pacientes con colitis ulcerosa que previamente se habian sometido a una anastomosis colo-anal protegia por ilestomia fueron diagnosticados posteriormente con enfermedad de Crohn localizada en la ostomia despues de la excision de plicomas ano-cutaneos. No se observaron complicaciones a largo plazo en pacientes con colitis ulcerosa.El diseno retrospectivo del estudio no permite la identificacion de pacientes con enfermedad inflamatoria intestinal que se sometieron unicamente al tratamiento medico de las hemorroides. Tambien existe un sesgo de seleccion de pacientes escogidos para tratamiento instrumental de la enfermedad hemorroidaria.El requisito de proctectomia despues de la hemorroidectomia / excision de plicomas anocutaneos parece ser secundario al curso de la enfermedad natural de la enfermedad de Crohn perianal en el sitio de la intervencion perianal. Se debe considerar la hemorroidectomia selectiva y la excision de plicomas ano-cutaneos solo en pacientes con enfermedad endoluminal controlada. Vea el video del resumen en http://links.lww.com/DCR/B55.