Haemorroidal disease How common?

The most frequently observed anal pathologyOverall prevalence 80% populationNo difference in prevalence between men and womenWomen are slightly more symptomatic than men80% of all patients attending colorectal clinic present with symptoms of piles

Anal Cushions

Constant positionR anterior (11 o’clock)R posterior (7 o’clock)L lateral (3 o’clock)

Rich intercommunicating blood supply from superior, middle and inferior rectal arteries

Etiology of haemorrhoidsThomson“Vascular Cushion Theory”Anatomical support of muscularis submucosae weakens (degeneration, disintegration)Aging (deterioration after the third decades)Straining effortHormonal influenceGenetic predisposition

Haemorroidal diseaseHaemorroidal disease

ClassificationInternal haemorrhoidsArise above the dentate lineMicroscopically covered by transitional or columnar epitheliumExternal haemorrhoidsAppear at perianumSituated below dentate lineMicroscopically covered by modified skin epithelium (no skin appendages)Skin tagsResidue from previous external haemorrhoids

Classification

First degreeNo prolapseSecond degreeSpontaneously reducibleThird degreeProlapse requiring manual replacementFourth degreePermanent prolapse

First degree pilesFirst degree piles

Second degree pilesSecond degree piles

Third degree pilesThird degree piles

Fourth degree pilesFourth degree piles

Symptoms

BleedingProlapseBurning or pressure sensationPain (not a prominent symptom except at the time of thrombosis)Pruritis

Bleeding

Bright red (AV shunts)Mucosal erosionEpisodicMay or May Not associates with motionDrip or Squirt into toilet bowlStaining tissue paperSevere anaemia (uncommon)

Prolapse

Usually not associates with pain in the early stageMay be unaware of the protruding anal cushionsSpontaneous reductionManual reduction

Burning sensation

Engorgement with bloodSwellingIncrease pressure sensationTemporarySubsides over few daysSustained Thrombosis Pain

ComplicationsComplications

strangulationstrangulation

TreatmentTreatment

Non-surgical treatmentDietary adviseRecommend high fiber diet with sufficient fluid intakeModify defecatory habit– Straining has never been proved to have a causative

role in piles– Excessive straining precipitates symptoms or worsens

existing ones– Avoid constipation

Non-surgical treatmentTopical treatment (cream / suppository)– antiseptic– local anaesthetic– steroids (atrophy of anoderm, eczema) – Nonsteriodal– Vasoactive– anti-thrombotic

Oral drug – phlebotropic drugDaflon (micronized purified flavonoid fraction)

Surgery

Milligan and Morgan: Open technique (UK)Ferguson and Heaton: Closed technique (USA)Whitehead (circumferential) haemorrhoidectomyParks (submucosal) haemorrhoidectomy

Open haemorrhoidectomyDescribed by two surgeons in St Marks Hospital in 1935E.T.C. MilliganC. Naughton MorganFulfilled three criteria1. Acceptable post-op pain2. Low risk3. Low recurrence rateInitiated modern surgical treatment for haemorrhoids

HaemorroidectomyHaemorroidectomy

Closed haemorrhoidectomyDescribed in 1959 byFerguson and HeatonProponents believed that primary wound closure decreases post-op painNo difference shown in terms of pain, complication rate, hospital stay and post-op recovery

Wolfe et al 1979 Dis Colon RectumRoe et al 1987 Br J Surg

Submucosal haemorrhoidectomy

Described in 1952 by Sir Alan ParksNot been widely adopted (even in UK)Technically demanding and time consumingPreserve anal mucosa during haemorrhoidectomy in order toMinimize post-op painMinimize stenosisMinimize faecal continence disturbance

Whitehead haemorrhoidectomy

Introduced in 1882 by Walter WhiteheadContraindicationsSmall haemorrhoidsExcess scar from previous operationChronic diarrheaIncontinenceThin and tight anoderm

Obsolete rarely done

ComplicationsEarly– Urinary retention (within 24-48 hrs)– Reactional haemorrhage

Intermediate– Faecal impaction– Haemorrhage (7-16 days post-op)

Late complications– Anal stricture– Incontinence– Ectropion– Anal tags– Rectal stricture– Fissure / ulcer– Fistula– Pseudopolyps– Recurrence

Injection Sclerotherapy1869 John Morgan 5% Phenol in almond oilMechanism– Inject a solution that will cause fibrosis– Causing a low grade & long-standing inflammatory

reaction– Binds down the mucosa and scleroses the

submucosal tissues– Thus shrinking the haemorrhoids

Retricted to smaller haemorrhoids(1st or early 2nd degree) in which bleeding is the predominant symptomSclerotherapy to achieve prolapse associates with high incidence of failure

Rubber band ligationInitially performed in 19th centuryNot popular till reintroduction in 1958 by BlaisdellFurther modified by Barron in 1963Nowadays still the most widely practiced office procedure for symptomatic piles despite the development of other modalitiesMechanism– Local obliteration of submucosal vessels– Ischaemic necrosis– Ulceration (7-10 days post banding)– Fixation of mucosa by fibrosis

(the area healed by 3-4 weeks)

Haemorrhoidal artery ligation

Haemorrhoidal anatomy

“Hypervascularisation of the anorectum contributes to the growth of haemorrhoids rather than being a consequence” Aigner et

al 2006

DGHAL/HALO

DGHAL/HALO

YearAuthorN=“Overall” success

Complications

1995Morinaga et al)5-12 months(

11687%None

2001Sohn et al?)12 months(

6090%Fissure (1.7%), perianal thrombosis (6.7%)

2002Arnold et al)1-2 months(

10586%Fissure (1.9%), perianal thrombosis (2.8%), infection (0.9%)

2003Shelygin et al)12 months(

10282.6%?none

2004Bursics et al (12 months, RCT)

3093%None

2006Greenberg et al)12 months(

10094%None

Ligation Anopexy

Thermal Methods

Thermal methods been used for hundreds of years ranging from heating to freezingInfraredLaserDiathermyCryotherapyRecently Harmonic Scalpel and ligasure

Infrared ThermocoagulationMechanism– Infrared radiation penetrates the tissue to a

predetermined depth– Instantly converted into heat (slightly above 100 0C)

protein denaturationResults– Safe and well-tolerated– Almost immediate return to normal activity– Less post-treatment discomfort– Inferior to rubber band ligation– Higher rate of recurrence (54% vs 27%)– Need multiple treatments

Bipolar diathermy and DC electrocoagulation

Principle is similar to infrared coagulationTissue destruction by heatOut-patient procedure without anaesthesiaSafe and well-tolerated20% pain24% rectal ulcerationMore tedious to perform

Diathermy haemorrhoidectomy

CryotherapyFirst used in the latter half of 1960sApplication of liquid nitrogen cryo-probeRapid freezing (temp down to –60 to –120 0C)Frozen tissue becomes a white solid massCircumferential limit of freezing may be clear cut but the depth of freezing is not apparentNot widely acceptedMost patients considered “unpleasant”Results– More than 2/3 suffer from recurrent symptoms within 10 yrs of

cryotherapy treatment– Much worse than results of standard haemorrhoidectomy

Laser haemorrhoidectomy

No differences between laser and conventional haemorrhoidectomy with regards to effectiveness and complicationsMajor drawbacksExpensive equipment and maintenance costAdditional precaution to protect staffHigh recurrence rate

Haemorrhoidectomy

Surgical excision is one of the oldest treatments for pilesMost effective and long-term cure<5% recurrence rateSeveral described techniquesNone has been shown to be the best

Stapled haemorrhoidopexy

Originated in Italy by Dr Antonio Longo in 1993Fully developed and released in 1997More than 1000000 operations been doneMechanism– Not really haemorrhoidectomy– Better described as prolapsectomy or anopexy

Reduction and fixation of the prolapse– Same principle as RBL and sclerotherapy