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TREATING HAEMORRHOIDS
An Experience and An Opinion
Bhanu R Shah
Hon. Surgeon, Bhatia General Hospital, Mumbai 400 007.
Haemorrhoidal disease is the commonest and oldest malady that afflicts mankind. The controversies that exist about its nature and the best method of its treatment only indicates that we are still not sure as to what are haemorrhoids, why do they occur, and what is the best method to treat them. Common impression is that no treatment is totally satisfactory and most methods have some unacceptable morbidity and annoying failures. It seems that the last word has not been spoken yet.Haemorrhoids have been given many names : engorged submucous varicosities or arteriovenous communications, mucosal capillary malformations, mucosal slides and even erectile tissue or a sliding mucosal hernia.[1] The only agreement has been is 'an increased venous pressure causing a rupture of piles' and increased resistance in anal sphincter and straining at defaecation as the prime accused.
After examining over 25,000 patients and operating on about 12,000 patients I feel that almost everybody is right. It is just that there are many variations of haemorrhoidal disease but 'tight anus' is a common aetiological factor. This means that if we satisfactorily correct tight anus and treat the variants of haemorrhoidal disease by selecting an adequate procedure, almost like selective surgery for different types of piles; we would reach an acceptable philosophy of treatment of haemorrhoids.
The modalities of treating haemorrhoids, over last 3000 years have remained more or less same with scientific refinements which appear to be 'changes'. All present methods have roots deep down in the past.
Ointments made from herbs and oils, cauterising piles with red hot irons, tying ligatures of threads, ice packs, leeches, hot baths, applying caustics and rectal bouginage were all used by our ancestors during last 3000 years.
During the 19th century, ligature and sclerosants remained standard methods. Ligature was extended to ligature and excision during evolution of surgical methods, in early 20th century. Besides destroying piles, attention was focussed to sphincter, towards middle of 20th century and various types of sphincterotomies were evolved. Haemorrhoidectomy remained a more acceptable method over last century.
With several technical innovations i.e. closed, open, and submucous. What seemed significant advance during these years was the addition of attention to sphincters by dilatation, stretching and sphincterotomies.
How does a surgeon choose a particular method to treat piles? The thoughts that dominate his mind are basically good long term result, less morbidity, less complications, ease of method, equipment availability, types of patients available, his own perceptions of what are haemorrhoids and learning from past as well as present contemporary colleagues and the teaching imparted to him during the formative years.
During my training years in England 1956-63, haemorrhoidectomy, largely open, was a predominant method. To me it appeared 'too much' because a lot of skin and lot of mucosa had to be removed and these were innocent tissues. Post operative care, bleeding and pain were a bit toomuch. Submucous haemorrhoidectomy was a refinement at that time but It appeared bloody, time consuming and prone to breakdown and secondary haemorrhage.
Cryosurgery looked attractive as a non-surgical method done without anaesthesia. But most people seemed to use nitrous oxide machines which give only - 85oc would appear inadequate but liquid nitrogen (-180oC) machines were expensive and difficult to maintain. Major drawbacks appeared to be liquefaction of frozen tissue and subsequent liquid discharge for several weeks. The scatter of freezing, on application of probes can be unpredictable and damage to underlying muscle and later scarring and anorectal tightness of an already tight anus was a hazard to contend with. Post operative bleeding can occur more frequently because of long lasting liquefaction process.
Rubber bands looked like sophisticated modification of old ligature techniques. But I fail to understand how it can go around a haemorrhoid which is at the best like a cushion - flattish and not like a dangling polyp at whose root you can tie a rubber band and hope it to slough away. I feel, all it does is to catch a bite of mucosa and go around its base. The inflammatory reaction that follows the strangulation of bitten mucosa could cause thrombosis of submucosal vessels and some degree of success may have been achieved. But by all logic it appears to be a very inadequate effort to destroy a flat intercommunicating venous plexus ring. Slough and secondary haemorrhage were always a possibility.
Infrared application appeared also very much like cryo in principle and had nothing more to offer in terms of effectiveness.
That left me with some basic considerations around which I had to make my choice for the method to treat haemorrhoids.
Basic considerations
1.Attention to the sphincters was necessary for good long term results in treatment of haemorrhoids.
2.Conservative treatment by high residue diet, regular bowel habits, ointments, reducing mental tension etc managed piles for sometime but did not cure them.
3.Intrarectal pressure studies had concluded that in haemorrhoids, the aetiogenesis was a tight anal canal leading to constipation and piles.[2]
4.Internal piles bleed when a critical pressure level is reached and at other times they don't. Anal canal resistance and the strain of defaecation (hard stool) or sluggish rectal movements would be deciding factors.
5.External piles are external systemic veins and even though they are communicating with internal haemorrhoids, can disappear if they get thrombosed.
6.Fissures, external tags, hypertrophied papillae even polypoid, are often accompaniments and do need attention for full symptomatic relief.
7.Preservation of lower rectal mucosa and sensitive anoderm would reduce possibilities of a tight anus and ensure smooth functioning of the defaecation reflex. They are innocent tissues, which do not warrant removal.
With these thoughts, following studies impressed me and helped to choose my method.
1.St. Mark's Hospital, a major institution treating anorectal diseases, treated 75% haemorrhoids by injection treatment and chose only 25% for haemorrhoidectomy of various kinds.[2]
2.Goligher sclerosed all piles and got 75% cure rate by simple injections.[3]
3.Peter Lord, by his maximal dilation of anus performed by inserting fingers starting with one finger and reaching eight fingers, achieved success rate of 75%. It was more successful if piles were already thrombosed by prolapsing and strangulating themselves.[4]
While Lord was happier in 3rd and 4th degree haemorrhoids Goligher found sclerosants better in 1st and 2nd degree haemorrhoids, I thought of combining these 2 methods (with some modifications) which looked complimentary to each other for all degrees of haemorrhoids and doing so, could get a cure rate much better and morbidity much lesser than either of these methods or possibly all other methods. This is an experience of over 12000 operations, spread over 30 years.
I am using 'stretching and sclerosants', a day care method, almost exclusively for all varieties of piles with occasional addition of 'reduction of mucosa' for prolapsing haemorrhoids. During this experience, many things were sorted out, i.e. how much to stretch, what and how much to inject and to achieve a balance of safety and adequacy, streamline the type of anaesthesia; postoperative care and prevent and manage any complications.
Anaesthesia
Almost all variety of haemorrhoids selected for surgery are operated as ambulatory cases - under Propofol induction and local anaesthesia - using no muscle relaxants and no intubation with addition of small quantities of ketamine hydrochloride or gas oxygen or halothane as required. Local anaesthesia is given by infiltration around anus and inferior haemorrhoidal (ischiorectal fossae) blocks. Lithotomy position is always used.
Stretching
Stretching is carried out with fingers of both hands - index and middle fingers of right hand posteriorly and the thumb or same fingers of left hand anteriorly and stretching the posterior and anterior loops of sphincteric (int. and ext.) tissue of the anal tube against each other. Sustained stretching is done with slowly increasing the force until 'all tight ridges' of the musculature gave way and the anal canal feels smoothly ironed out. This was the most convenient and effective way. The 'ironing out' is an unfailing feeling and is the only guideline for adequacy among the variations in length, strength and thickness and tightness of the anus. The stretching would often tear the anal skin at one or few places but is of no consequence.
Occasionally bleeding points may have to be spray cauterized. The stretched anus is packed for 2-3 minutes. It is useful for haemostasis and holding it open for a while.
This procedure is not dilatation but 'stretching' with some force and some feeling of adequacy. From MDA (Maximal dilatation of the anus) as suggested by Peter Lord; this is a change to ASA (adequate stretching of anus). It is that much different and I feel it has reduced recurrence to nominal because it lasts. It is neither maximal nor inadequate but 'just enough'. It is to be practiced and perfected. Effort is worthwhile, it covers the attention to sphincter theory in treatment of haemorrhoids.
Open or subcutaneous sphincterotomy is most likely to be inadequate as one is scared to divide a lot of sphincter. Besides it will cut all fibres - good and bad at one point damaging sphincter strength. Stretching would be a deliberate 'highly selective closed sphincterotomy', tearing out rigid fibres and saving elastic fibres which would stretch but not break. Stretching also ruptures the plexus and a haematoma is formed which is useful for sclerosis and subsequent adhesion of mucosa to muscle causing devascularisation of submucous space.
Transient sphincter dysfunction due to bruising may occur but gets better with time. If occasionally stretching is overdone perineal muscle exercises would put it right - occasional tear of the anus can be stitched and it would heal even if left alone. There are no disheartening problems.
Various studies have found the pressure changes that last and are beneficial to the defaecation reflex and process of evacuation and help in the prevention of recurrence.[5]
Sclerosants
Sclerosis is done after removing the 2 minute pack put in after stretching. I use the old fashioned 5% phenol in almond oil because it has worked and there are no problems. No body knows who invented this but it has lasted over a 100 years. Even almond oil alone was found to have sclerosant effects, combined with 5% phenol, it causes enough inflammation without necrosis. Phenol is good sclerosant. It has been found good in the treatment of oesophageal varices.
An oblique ended, short, wide proctoscope, which would allow only one pile on view at a time. Careful submucous injections in the middle of the pile are carried out in all piles. The solution spreads in the submucous area of the pile but does not spread all over the circumference because of septa between the piles. Basically at 3,7 and 11 o'clock position but may have to be injected in between. The pile area gets swollen to a translucent, tense, shining ring. The puncture holes may be cauterized to stop any bleeding or leak from the hole otherwise; pressure of an anal swab pack for a couple of minutes is enough to stop leak or bleeding. Pack is not left in. Gabriel top on regular 10 ml. syringe and a 30o bend at 1" on No. 18 spinal 4" short bevel needle is useful to make the process easy. Commercially available needles have a very thin lumen and oil does not flow easily. Mucosa is lifted with the angled needle and short bevel and the fluid injected. Average pile needs approx. 3-5 ml but a total of 20 ml is also safe and necessary in large prolapsing piles.
With a prophylactic antibiotic and preoperative evacuation of bowels; abscesses or sloughing just does not occur. Very occasionally the thrombotic nodules last longer and are palpable for sometime. Proteolytic enzymes and anti-inflammatory agents are helpful in such situations. Occasional bleeding is easily controlled with oral ethamsylate.
Additional features
Hypertrophied papillae are cauterized. Some feeding vessel communications (at ano rectal junction can be cauterized. External tags can be excised or cauterized as necessary. External piles are not to worry about as the sclerosants trickles along the commuting veins and they also get thrombosed and disappear after some time.
Occasionally if a large prolapsing pile or piles keep coming out it can be removed over a clamp (artery forceps) removing the excess mucosa and suturing over it with chronic catgut almost like an anastomosis.
It is easy and there is no harm doing it on ambulatory basis. Post-operative antibiotics are quite helpful if large quantities are injected, or such reductions are carried out. It is safest way to add 'haemorrhoidectomy' of one or more piles on 'stretching and sclerosant' procedure.
Fissure in ano often accompanies piles and is adequately treated with stretching which frees the adherent edges from the underlying muscle and rarely needs freshening. The muscle is also freed and with tight fibres torn, functions better. Pain goes away because of relaxed and free muscle. Fissures heal quickly. Mucosal prolapse in elderly people with lax anus is not treated as piles. Genuine primary haemorrhoids (occasionally even with portal hypertension or inflammatory colon disease) can all be treated with this combination day care. Patients with this local and minimal general anaesthesia can be discharged within an hour after a lot refreshing drink.
Postoperatively antibiotics, analgesics, bulk laxatives, local anaesthetic ointments are prescribed as required for a few days.
Complications are rare and minimal and can be treated conservatively; hospitalisation for complication would be a rare event. Nominal bleeding settles on its own or with haemostatics i.e. ethamsylate.
Occasional complaints of minor imperfections of control need more reassurance than treatment. Perineal exercise would solve most problems. The abscesses, sloughing and secondary haemorrhages, fibrosis, granuloma and incontinence just do not occur with maximum care during stretching and sclerosis.
Occasional urinary difficulty is treated with urecholine and not catheterisation.
I did follow up first, thousand of them for 5 years. Then, large volume was difficult to follow up but feedback was almost complete and never had to really regret for what I had done.
It has been one of the most pleasing experience in my surgical career, spanning over 37 years.
When it comes to understanding how this method works and how it clears much confusion about the aetiology and treatment of piles, I would like to say this after looking back, thinking and theorising a vast experience.
Haemorrhoidal plexus appears to be just an abrupt transition from arterial system to venous system at the end of an organ and that is why even venous blood is red in colour and flows like a jet; such a high pressure plexiform venous system, which does not have valves, when aggravated by straining and anal resistance would appear to be dilating into haemorrhoids. In this experience a tight anus was found unfailingly in all cases and straining due to tightness appears to be an important factor in converting this vascular abnormality into disease.
Chronic injury and infection in the anal glands which penetrate the sphincter musculature could be the most likely cause of fibrosis of some of its fasciculi and ultimately a tight anus. Like throat, anus also has enough bacteria to cause a chronic infection. The so called circumferential pecten bands are probably fibrosed fasciculi of the anal sphincters and are felt as circular ridges while stretching.
Stretching is not just a dilatation or a pectenotomy but is a deliberate and 'highly selective anal sphincterotomy' performed with fingers and not a knife. It has the benefit of tearing only rigid fibres and saving the elastic ones, which would stretch but not break or tear. So the bad fibres are torn and the good ones saved. This makes it a very selective sphincterotomy unlike any other form of sphincter cutting operation and hence it is more effective and safer. I see no possibility of patients being made permanently incontinent with surgeons fingers while their scalpel occasionally can.
Besides tearing the tough fibres, stretching also tears the poorly supported dilated veins of the haemorrhoidal plexus. I have almost always noticed piles looking larger after stretching. This submucous haematoma could be a good sclerosant and possibly no effort should be made to possibly prevent it by anal pack. Addition to it of sufficient quantities of chemical sclerosant would ensure the involvement of whole submucous plexus in the process of mechanical - inflammatory destruction and subsequent devascularisation of submucous space as well as any mucosal vascular abnormality.
This is achieved without any destruction of innocent mucosa and anoderm and so without the complication like mucosal discharge haemorrhage or stenosis. It also treats the haemorrhoids as a venous plexus and not as 3,7 and 11 o'clock bulges. With the lasting nature of stretching it treats the cause as well as the effect.
Infact this combination method appears to be the only surgical method which is comprehensive as well as having a sound anatomical as well as a physiological basis.
This I believe gives it an edge over other methods.
A word about 'Laser'
It has been categorically concluded by Senagore A and others that there are no patient care advantages associated with the use of Nd : YAG laser for excision haemorrhoidectomy compared to scalpel excision. As new technology becomes available therapeutic efficiency and cost benefit ratio has to be considered, before deciding to employ this technology for patient care".[6]
Leff EL using CO2 laser also concluded that "No difference were seen between laser and non laser haemorrhoidectomy. Patients were monitored for post-operative pain, wound healing and complications.[7]
Sir AJH Rains somewhere said "when it comes to assessing the value of operative surgery, everything depends upon the result." Results have come and this brand of ambulatory proctology has come to stay.
REFERENCES
1.Thomson WHF. The nature of haemorrhoids. British Journal of Surgery 1975; 62 : 542.
2.Brain D. Hancock. How do surgeons treat hemorrhoids? Annals of the RCs Eng 1982; 64 : 400-4.
3.Goligher JC. Surgery of the anus rectum and colon, Baliere, Tindal and Cassel. 1967.
4.Lord PH. A new regime for the treatment of hemorrhoids. Proceedings of the Royal Society of Medicine. 1968; 61 : 935.
5.Hancock BD. Measurement of anal pressure and motility. Gut 1976; 17 : 645-51.
6.Senagore A, Mazier WP, Luchtefeld MA, Mackeigan JM, Wengret T. Lasers in anorectal surgery. Dis Colon Rectum Nov. 1993; 36 (11) : 1042-9.
7.Leff EI. Hemorrhoidectomy laser vs nonlaser : outpatient surgical experience. Dis Colon Rectum Aug. 1992; 35 (8) : 743-6.
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