الفهرس 
Aim of the workOnly 14 pages are availabe for public view
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Abstract
UPDATED MANAGEMENT OF HEMORRHOIDS
Essay
Submitted for partial fulfillment of master Degree in
General surgery
By
Islam Asem Mahmoud Abd El-khalik
M.B.B.Ch.
Supervised by
Prof. Dr. MOHAMMAD EMAD SALEH
Professor of General surgery
Faculty of Medicine
Ain Shams University
DR. MOHAMMAD MAHFOUZ MOHAMMAD
Assistant Professor of General surgery
Faculty of Medicine
Ain Shams University
Faculty of Medicine
Ain Shams University
2015
ACKNOWLEDGEMENTS
All Praise is due to ALLAH
I wish to express my deepest gratitude to all those who assisted me to complete this
work.
First and foremost, my thanks are directed to Prof. Dr. Mohammad Emad Saleh
,Professor of General surgery Faculty of Medicine Ain Shams University, for his
unlimited help and continuous insistence on perfection, without his constant
supervision, this essay could not have achieved its present form.
Great thanks and appreciation to Dr. Mohammad Mahfouz Mohammad ,Assistant
Professor of General surgery Faculty of Medicine Ain Shams University, for his
unlimited help, support and encouragement he gave, and for his effective
participation and meticulous revision of every step during this work.
I wish to thank every person who has contributed assistance during preparation of
this work.
Finally, I appreciate the most help of my family and my wife. They always gave me
the feeling of hope, love and encouragement.
Islam Asem Mahmoud
2015
Table of Contents
Page
Introduction 1
Aim of the work 3
- Anatomy of anal canal
- Anatomy of hemorrhoids
- Surgical pathology of hemorrhoids
- Management of hemorrhoids
4
11
15
30
Summary 84
Conclusion 86
References 87
Arabic summary
List of Figures
Page
Figure 1. Surgical anal canal. 6
Figure 2. Anal canal. 8
Figure 3. Anal cushion showing Treitz’s muscle derived from
the conjoined longitudinal muscle of the anal canal.
14
Figure 4. Photograph of grade 3 hemorrhoid with prolapse
(left) and after manual reduction (right).
16
Figure 5. Traditional Gabriel needle and syringe 36
Figure 6. Injection of sclerosing solution at appropriate site for
internal hemorrhoid.
37
Figure 7. originally Barron ligator. 39
Figure 8. McGivney hemorrhoidal ligator 39
Figure 9. McGown one hand suction ligator. 40
Figure 10. rubber ring ligation, the hemorrhoid is grasped and
firmly tethered, the tissue is drawn into the drum, and
the two rubber rings are released.
41
Figure 11. rubber bands cutter. 42
Figure 12. O’Regan disposable banding system. 43
Figure 13. ShortShots multi band ligator. 43
Figure 14. infrared photocoagulation. 50
Figure 15. Bipolar diathermy. 52
Figure 16. postoperative view of Milligan Morgan
hemorrhoidectomy.
59
Figure 17. Modified Ferguson excisional hemorrhoidectomy. A
Double elliptical incision made in mucosa and
anoderm around hemorrhoidal bundle with a scalpel.
B The hemorrhoid dissection is carefully continued
cephalad by dissecting the sphincter away from the
hemorrhoid. C After dissection of the hemorrhoid to
its pedicle, it is either clamped, secured, or excised.
The pedicle is suture ligated. D The wound is closed
with a running stitch. Excessive traction on the suture
is avoided to prevent forming dog ears or displacing
the anoderm caudally.
62
Figure 18. ligasure sealing system. 64
Figure 19. PPH procedural set. 66
Figure 20. Stapled anoplasty (procedure for prolapse and
hemorrhoids). A Retracting anoscope and dilator
inserted. B Monofilament pursestring suture (eight
bites) placed using operating anoscope
approximately 3–4 cm above anal verge. C Stapler
inserted through pursestring. Pursestring suture tied
and ends of suture manipulated through stapler. D
Retracting on suture pulls anorectal mucosa into
stapler. E Stapler closed and fired. F Completed
procedure.
71
Figure 21. a Disposable proctoscope with the Doppler
transducer on the tip. b The proctoscope connects to
the Doppler device and produces easily recognizable
acoustic signals.
73
Figure 22. THD device description (SRA: superior rectal
artery).
78
Figure 23. Needle rotation inside the device: the needle holder
tip is inserted in the pivot and the needle rotates to
surround the artery.
79
Figure 24. Location of the terminal branches of the superior
rectal artery.
79
Figure 25. Anopexy with running suture (SRA: superior rectal
artery.
80
List of Abbreviations
ASCRS American Society of Colo-Rectal Surgeons
CCR Corpus Cavernosum Recti
DG-HAL Doppler-Guided Haemorrhoidal Artery Ligation
ECG Electrocardiogram
FDA Food and Drug Administration
Fig Figure
HAL Haemorrhoidal Artery Ligation
PPH Procedure for Prolapse and Haemorrhoids
SRA Superior rectal artery
SH Stapled hemorrhoidopexy
THD Transanal Haemorrhoidal Dearterialization
1
Introduction
Hemorrhoids are a very common anorectal condition defined
as the symptomatic enlargement and distal displacement of the
normal anal cushions. They affect millions of people around the
world and represent a major medical and socioeconomic
problem
(1)
.
Hemorrhoids are a series of 3 cushions in the anal canal,
located in the left lateral, right anterior and right posterior
positions. A sinusoidal pattern of arteriovenous communication
is formed within the cushions, which explains why
hemorrhoidal bleeding is arterial, rather than venous in nature
(2)
.
The exact pathophysiology of hemorrhoidal development is
poorly understood. Today, the theory of sliding anal canal lining
is widely accepted
(2)
. This proposes that hemorrhoids develop
when the supporting tissues of the anal cushions disintegrate or
deteriorate
(3)
.
Hemorrhoids are generally classified on the basis of their
location and degree of prolapse. Internal hemorrhoids , external
hemorrhoids and Mixed (interno-external) hemorrhoids. For
practical purposes, internal hemorrhoids are further graded
based on their appearance and degree of prolapse, known as
Goligher’s classification: First-degree hemorrhoids (grade Ι),
Second-degree hemorrhoids (grade II), Third-degree
hemorrhoids (grade Ш) and Fourth-degree hemorrhoids (grade
IV)
(4)
.
2
Therapeutic treatment of hemorrhoids ranges from dietary and
lifestyle modification to radical surgery, depending on degree
and severity of symptoms
(5, 6).
Medical treatment include Oral flavonoids
(7)
, Oral calcium
dobesilate
(8)
and Topical treatment (contain various ingredients
such as local anesthesia, corticosteroids, antibiotics and antiinflammatory drugs
(9)
.
A number of effective nonsurgical approaches are available
for patients with hemorrhoids as Sclerotherapy
(6),
Rubber band
ligation
(10)
, Infrared coagulation
(11)
, Radiofrequency ablation
(12)
and Cryotherapy
(13)
.
An operation is indicated when non-operative approaches have
failed or complications have occurred. Excisional
hemorrhoidectomy is the most effective treatment for
hemorrhoids with the lowest rate of recurrence compared to
other modalities
(14)
.Plication involves oversewing of
hemorrhoidal mass and tying a knot at the uppermost vascular
pedicle
(5)
. Doppler-guided hemorrhoidal artery ligation a new
technique based on doppler-guided ligation of the terminal
branches of the superior hemorrhoidal artery was introduced in
1995 as an alternative to hemorrhoidectomy
(15)
. Stapled
hemorrhoidopexy (SH) has been introduced since 1998
(16)
.
3
Aim of the work
Spotlight on updated management of hemorrhoids and recent
nonsurgical and surgical procedures used nowadays.
4
Anatomy
Anal Canal Structure, Anus, and Anal Verge
The anal canal is anatomically peculiar and has a complex
physiology, which accounts for its crucial role in continence and,
in addition, its susceptibility to a variety of diseases. The anus or
anal orifice is an anteroposterior cutaneous slit, that along with the
anal canal remains virtually closed at rest, as a result of tonic
circumferential contraction of the sphincters and the presence of
anal cushions. The edge of the anal orifice, the anal verge or
margin (anocutaneous line of Hilton), marks the lowermost edge of
the anal canal and is sometimes the level of reference for
measurements taken during sigmoidoscopy. Others favor the
dentate line as a landmark because it is more precise. The
difference between the anal verge and the dentate line is usually 1–
2 cm. The epithelium distal to the anal verge acquires hair follicles,
glands, including apocrine glands, and other features of normal
skin, and is the source of perianal hidradenitis suppurativa,
inflammation of the apocrine glands
(17)
.
Anatomic Versus Surgical Anal Canal:
Two definitions are found describing the anal canal. The
“anatomic or “embryologic” anal canal is only 2.0 cm long,
5
extending from the anal verge to the dentate line, the level that
corresponds to the proctodeal membrane.
The “surgical” or “functional” anal canal is longer,
extending for approximately 4.0 cm (in men) from the anal verge
to the anorectal ring (levator ani). This “long anal canal” concept
was first introduced by Milligan and Morgan in 1934 and has been
considered, despite not being proximally marked by any apparent
epithelial or developmental boundary, useful both as a physiologic
and surgical parameter
(18)
.
The anorectal ring is at the level of the distal end of the
ampullary part of the rectum and forms the anorectal angle, and the
beginning of a region of higher intraluminal pressure. The
anorectal ring is the name given by Milligan and Morgan to the
muscular ring which encircles the anorectal junction, and is
composed of the upper border of the internal and external
sphincters and puborectalis. It is claimed that this ring is
responsible for anal continence and that its complete division
results in incontinenence
(19)
.
6
.
Figure 1. Surgical anal canal
(17)
Epithelium of the Anal Canal:
The lining of the anal canal consists of an upper mucosal
(endoderm) and a lower cutaneous (ectoderm) segment . The
dentate (pectinate) line is the “saw-toothed” junction between these
two distinct origins of venous and lymphatic drainage, nerve
supply, and epithelial lining
(20)
.
Above this level, the intestine is innervated by the
sympathetic and parasympathetic systems, with venous, arterial,
and lymphatic drainage to and from the hypogastric vessels. Distal
to the dentate line, the anal canal is innerv ated by the somatic
nervous system, with blood supply and drainage from the inferior
hemorrhoidal system. These differences are important when the
classification and treatment of hemorrhoids are considered. The
7
pectinate or dentate line corresponds to a line of anal valves that
represent remnants of the proctodeal membrane
(17)
.
Above each valve, there is a little pocket known as an anal
sinus or crypt. These crypts are connected to a variable number of
glands, in average 6 (range,3–12)
(21)
.
The anal glands first described by Chiari in 1878 are more
concentrated in the posterior quadrants. More than one gland may
open into the same crypt, whereas half the crypts have no
communication. The anal gland ducts, in an outward and
downward route, enter the submucosa; two-thirds enter the internal
anal sphincter, and half of them terminate in the intersphincteric
plane
(22)
.
Cephalad to the dentate line, 8–14 longitudinal folds, known as
the rectal columns (columns of Morgagni), have their bases
connected in pairs to each valve at the dentate line. At the lower
end of the columns are the anal papillae.
The mucosa in the area of the columns consists of several
layers of cuboidal cells and has a deep purple color because of the
underlying internal hemorrhoidal plexus. This 0.5- to 1.0-cm strip
of mucosa above the dentate line is known as the anal transition or
cloacogenic zone. Cephalad to this area, the epithelium changes to
8
a single layer of columnar cells and macroscopically acquire the
characteristic pink color of the rectal mucosa
(23)
.
The cutaneous part of the anal canal consists of modified
squamous epithelium that is thin, smooth, pale, stretched, and
devoid of hair follicles and sweat glands. The terms pecten and
pectin band have been used to define this segment
(24)
. However, as
pointed out by Goligher, the round band of fibrous tissue called
pecten band, which is divided in the case of anal fissure
(pectenotomy), probably represents the spastic internal anal
sphincter
(25)
.
Figure 2. Anal canal
(17)
.
9
Arterial Supply of the Rectum and Anal Canal:
The superior hemorrhoidal artery is the continuation of the
inferior mesenteric artery, once it crosses the left iliac vessels. The
artery descends in the sigmoid mesocolon to the level of S-3 and
then to the posterior aspect of the rectum. In 80% of cases, it
bifurcates into right, usually wider, and left terminal branches;
multiple branches are present in 17%.
(26)
. These divisions,once
within the submucosa of the rectum, run straight downward to
supply the lower rectum and the anal canal. Approximately five
branches reach the level of the rectal columns, and condense in
capillary plexuses, mostly at the right posterior, right anterior, and
left lateral positions, corresponding to the location of the major
internal hemorrhoidal groups. The superior and inferior
hemorrhoidal arteries represent the major blood supply to the
anorectum. In addition, it is also supplied by the internal iliac
arteries
(27)
.
The contribution of the middle hemorrhoidal artery varies
with the size of the superior hemorrhoidal artery; this may explain
its controversial anatomy. Some authors report absence of the
middle hemorrhoidal artery in 40% to 88%
(28, 29)
whereas others
identify it in 94% to 100% of specimens
(26).
It originates more
10
frequently from the anterior division of the internal iliac or the
pudendal arteries, and reaches the rectum.
The middle hemorrhoidal artery reaches the lower third of the
rectum anterolaterally, close to the level of the pelvic floor and
deep to the levator fascia. It therefore does not run in the lateral
ligaments, which are inclined posterolaterally
(30)
. The middle
hemorrhoidal artery is more prone to be injured during low anterior
resection, when anterolateral dissection of the rectum is performed
close to the pelvic floor and the prostate and seminal vesicles or
upper part of the vagina are being separated
(31)
.
The anorectum has a profuse intramural anastomotic network,
which probably accounts for the fact that division of both superior
and middle hemorrhoidal arteries does not result in necrosis of the
rectum. The paired inferior hemorrhoidal arteries are branches of
the internal pudendal artery, which in turn is a branch of the
internal iliac artery. The inferior hemorrhoidal artery arises within
the pudendal canal and is throughout its course entirely
extrapelvic. It traverses the obturator fascia, the ischiorectal fossa,
and the external anal sphincter to reach the submucosa of the anal
canal, ultimately ascending in this plane
(17)
.
11
Venous drainage of the rectum and anal canal:
The anorectum also drains, via middle and inferior
hemorrhoidal veins, to the internal iliac vein and then to the
inferior vena cava. Although it is still a controversial subject, the
presence of communications among these three venous systems
may explain the lack of correlation between portal hypertension
and hemorrhoids
(32)
.
The paired inferior and middle hemorrhoidal veins and the
single superior hemorrhoidal vein originate from three anorectal
arteriovenous plexuses. The external hemorrhoidal plexus, situated
subcutaneously around the anal canal below the dentate line,
constitutes when dilated the external hemorrhoids. The internal
hemorrhoidal plexus is situated submucosally, around the upper
anal canal and above the dentate line. The internal hemorrhoids
originate from this plexus. The perirectal or perimuscular rectal
plexus drains to the middle and inferior hemorrhoidal veins
(27)
.
Anatomy of hemorrhoids:
Hemorrhoids are cushions of specialized, highly vascular
tissue found within the anal canal in the submucosal space. The
term “hemorrhoidal disease” should be reserved for those vascular
cushions that are abnormal and cause symptoms in patients
(17)
.
12
These cushions of thickened submucosa contain blood
vessels, elastic tissue, connective tissue, and smooth muscle
(33)
.
The anal submucosal smooth muscle (Treitz‟s muscle) originates
from the conjoined longitudinal muscle .These smooth muscle
fibers then pass through the internal sphincter and anchor
themselves into the submucosa. Thereby contributing to the bulk of
the hemorrhoids and suspending the vascular cushions at the same
time
(34)
.
Some of the vascular structures within the cushion when
examined microscopically lack a muscular wall. The lack of a
muscular wall characterizes these vascular structures more as
sinusoids and not veins. Studies have shown that hemorrhoidal
bleeding is arterial and not venous because hemorrhage from
disrupted hemorrhoids occurs from presinusoidal arterioles that
communicate with the sinusoids in this region. This is supported
by the bright red appearance and the arterial pH of the blood
(33)
.
The venous plexus and sinusoids below the dentate line which
constitute the external hemorrhoidal plexus drain primarily via the
inferior rectal veins into the pudendal veins which are branches of
the internal iliac veins. Venous drainage also occurs to a lesser
extent via the middle rectal veins to the internal iliac veins. This
overlying tissue is somatically innervated and is therefore sensitive
to touch, pain, stretch, and temperature. The subepithelial vessels
13
and sinuses above the dentate line which constitute the internal
hemorrhoid plexus are drained by way of the middle rectal veins to
the internal iliacs
(17)
.
The vascular cushions within the anal canal contribute to anal
continence and function as a compressible lining that protects the
underlying anal sphincters. Additionally, the cushions are critical
in providing complete closure of the anus, further aiding in
continence. As an individual coughs, strains, or sneezes, these
fibrovascular cushions engorge and maintain closure of the anal
canal to prevent leakage of stool in the presence of increased
intrarectal pressure. These cushions account for approximately
15%–20% of the anal resting pressure.( Additionally, this tissue
likely supplies important sensory information that enables
individuals to discriminate between liquid, solid, and gas, further
aiding in continence
(35)
.
14
Figure 3. Anal cushion showing Treitz‟s muscle derived from the conjoined longitudinal muscle
of the anal canal
(17)
.
It is essential to consider that while undertaking any treatment
for hemorrhoidal disease the fibrovascular cushions are a part of
normal anorectal anatomy and are important in the continence
mechanism. Therefore, surgical removal may result in varying
degrees of incontinence particularly in individuals with marginal
preoperative control
(17)
.
There are three main vascular cushions that are found
anatomically in health as well as in disease. The cushions are
located in the left lateral, right anterior and right posterior positions
of the anus. This specific configuration has been shown in cadaver
studies to be present only 19% of the time
(33)
.
15
Most individuals have additional smaller accessory cushions
present in between the main cushions. This anatomic configuration
apparently bears no relationship to the terminal branching of the
superior rectal artery. The position of hemorrhoids within the anal
canal, however, remains remarkably consistent. The configuration
of these cushions is quite constant and borne out by the fact that
the same configuration can be found in children, the fetus, and
even in the embryo
(33)
.
The topographic location of pathology around the anus should
be described in anatomic terms (anterior, posterior, right lateral,
left lateral, etc.) and not by the numbers on the face of a clock. In
this way, regardless of whether the patient is in a prone, supine, or
lateral position, the pathology can always be accurately located
(17)
.
Surgical pathology of Hemorrhoids
Classification of hemorrhoids:
Internal Hemorrhoids: Redundant portions of mucous membrane
of anal canal above the dentate line, lined by columnar epithelium.
External Hemorrhoids: Certain swellings at anal verge and canal
below dentate line, skin covered.
16
This classification refers only to the site of origin as after a while,
the internal hemorrhoids become enlarged and therefore appears
externally
(36)
.
Most colorectal surgeons use the grading system published in
1985 by Banov and Others
(37)
:
First degree: Symptomatic enlarged masses of hemorrhoidal
tissue which do not prolapse out of the anal canal.
Second degree: Masses that prolapse and reduce
spontaneously.
Third degree: Masses which prolapse and need to be
manually reduce
Fourth degree: Permanently prolapsed.
Figure 4. Photograph of grade 3 hemorrhoid with prolapse (left) and after manual
reduction(right)
(38)
17
Etiologic factors:
Etiologic factors thought to be contributory to the pathologic
changes in the vascular cushions include constipation, prolonged
straining, irregular bowel habits, diarrhea, pregnancy, heredity,
erect posture, absence of valves within the hemorrhoidal sinusoids,
increased intraabdominal pressure with obstruction of venous
return, aging (deterioration of anal supporting tissues) and internal
sphincter abnormalities
(17)
.
Patients with hemorrhoid disease have been shown to have
increased anal resting pressures when compared with controls
(1)
.
This increased resting pressure returns to normal after
hemorrhoidectomy, but it is unclear whether the hemorrhoids are
the cause of this increase
(39)
.
Theories of hemorrhoidogenesis:
1. Sliding anal cushion theory:
Thomson in 1975
(33)
concluded that a sliding downward of the
anal lining is responsible for the development of hemorrhoids.
Repeated stretching of the anal supporting tissues (submucosal
Treitz‟s muscle and elastic connective tissue framework) which
normally functions to anchor and suspend the anal canal lining
causes fragmentation of the supporting tissues and subsequent
prolapse of the vascular cushions.
18
Furthermore, straining and irregular bowel habits may be
associated with engorgement of the vascular cushions making their
displacement more likely. This theory is further supported by
histologic studies that have shown deterioration of the anal
supporting tissues by the third decade of life
(40)
.
2. Venous obstruction theory:
The principle cause of haemorrhoidal disease seems to
be congestion and hypertrophy of the internal anal cushions. The
cushions congest because they fail to empty rapidly during the act
of defecation. When the cushions are congested, they are more
likely to bleed and to become edematous. The edema causes
swelling and stretching of the tissues and finally hypertrophies.
Failure of the cushions to empty rapidly is an often
postulated but never proven hypothesis to explain the cause of
haemorrhoidal disease. An anatomical vascular pathway of venous
drainage through the rectal musculature has been demonstrated and
is suggested that a fecal mass impacted in the rectum may
compress these veins. Furthermore, the act of straining constricts
the intermuscular veins by raising the intra-abdominal pressure and
so impedes the rapid emptying of the cushions
(41)
.
19
3. Vascular hyperplasia theory:
This theory considers piles to result from a sort of vascular
tissue hyperplasia or to be haemangiomatous in nature. This
theory originates from the observed similarity between the tissues
of piles and cavernous tissue
(1)
.
Arteriovenous communications are demonstrated in the anal
submucosa, which are corpus cavernosum recti. Stelzner and
Others in 1962
(42)
had suggested that piles might results from
hyperplasia of the corpus cavernosum recti. This theory explains
bright red colour of the bleeding and the fact that bleeding of piles
is said to be their earliest manifestations.
Anatomical abnormalties detected in haemorrhoids:- The subepithelial space:-Varicose dilatation of the anal canal veins was accepted
dramatically until recently, supported histologically by mural
degeneration of the vascular spaces
(43)
.
Stelzner and Others in 1962
(42)
recognized that these vascular
spaces were normal and discarded the varicose veins
concept,proposing instead hyperplasia of corpus cavernosum recti.
20
Thomson in 1975
(33)
found venous dilatations in eight of ten
infants and showed that, apart from occasional thrombosed vessels,
the histology of haemorrhoidectomy specimnens did not differ
from that normal cadavers.
Haemorrhoids leads to disorderd fragmented subepithelial
connective tissue. There is hypertrophy of subepithelial smooth
muscle of the anal cushions and commonly squamous metaplasia
of prolapsing haemorrhoids
(44)
.
Miles in 1919
(45)
described a thickened fibrous layer, the
pectin band.This is probably the free edge of internal sphincter.
Shafik in 1984
(46)
has described submucosal collagen band;
the anorectal band in all symptomatic patients that he claimed is a
developmental anomaly the division of which treats haemorrhoids.
Anal sphincter musculature:
Haqqani and Hancock in 1978
(47)
observed fibrosis of
internal anal sphincter in symptomatic patients with haemorrhoids
more often than in cadavers without known haemorrhoidal
disease,but its amounts was unreleated to anal manometry,
haemorrhoid size or duration.
Teramoto and Others in 1981
(48)
examined external anal
sphincter biopsies taken at hemorrhoidectomy. They found muscle
hypertrophy, which they deducted from increased fiber diameter,
21
an increased tendency to central nucleation of muscle fibers and
more type I oxydatively metabolizing fibers(consistent with greater
tonic activity) in the patients.
Functional abnormalities in haemorrhoids:
Anal pressure:
Despite different techniques, most investigations recorded a
high maximum resting pressure in patients with haemrrohides.
Symptoms and pressure may be related: prolapsing haemorrhoids
are associated with lower resting pressure than non-prolapsing
haemorrhoides
(1)
.
Gibbons and Others 1988
(49)
measured anal pressure with
probes of three different diameters to determine whether
haemorroidal bulk or internal sphincter activity accounted for
increased resting pressure. Each probe demonstrated increased
resting and maximum contraction pressure in patients with
haemorrhoids: residual pressure during rectal distention did not
differ from that in controls. The contributions from muscle tone,
tissue elasticity and vascular pressure were indistinguishable.
Rectoanal inhibition:
Some studies show normal inhibition
(39)
, others showed
increased resting pressure but normal residual pressure during
22
distention, and thus a larger change
(49)
, while other studies have
shown the opposite, with a smaller change in pressure, particularly
in the distal anal canal of patients with non-prolapsing
hemorrhoids
(4)
.
Ultraslow waves:
They are defined as fluctuations of the resting anal pressure
greater than 25cm water occurring at less than two cycles per
minute. Ultraslow waves are commoner with haemorrhoids, being
associated with higher resting pressure
(50)
.
Electrophysiology:
External sphincter EMG recorded continuously with
ambulatory manometry has revealed increased activity with
haemorrhoids
(51)
.
Anal and rectal sensations:
Anal electrosensitivity and temperature sensation are reduced
in patients with haemorrhoids. The greatest change being in the
proximal and mid anal canal, perhaps contributing to decreased
continence. Rectal sensation to balloon distention is not different
from that in controls
(1)
.
Symptoms:
1. Bleeding: It is usually the first symptom to occur as a slight
streak of blood on the motion or toilet paper; it is not mixed with
23
the stool it occurs especially when the patient is constipating. This
occurs with early stages of hemorrhoids. Later on the patient may
find that there is a steady drip of blood for few seconds after the
motion has been passed. At later stages when the piles have
become much larger bleeding may occur apart from defecation and
at any time when the hemorrhoids become prolapsed and
congested and this is the cause of hypochromic anemia. The blood
is bright red, arterial in origin, and seems to arise from capillaries
in the lamina propria rather than venous dilation
(52,53,54)
2. Prolapse: prolapse of hemorrhoids is a later development as a
rule it occurs initially during defecation the hemorrhoid appears at
the anal orifice. At the maximum expulsive effort, true prolapse of
internal hemorrhoid due to sliding of the anal mucosa caused by
weakness of the pelvic floor muscles. The internal hemorrhoids
will be seen with the external hemorrhoids as one mass at the
mucocautaneous junction which lies in the perianal skin region this
type is termed (permanently prolapsed hemorrhoid) the prolapse
occurs mostly in old debilitating patients with weak pelvic floor
and weakness of the perianal muscle
(1)
.
3. Thrombosis: (strangulated hemorrhoids): This is almost
always a complication of large prolapsing 2nd or 3rd degree
hemorrhoids and this is because it is nipped by the sphincter
muscles whilst in the prolapsed position, so that congestion and
24
thrombosis result. As a consequence the piles become hard, tender
and usually irreducible. At the same time considerable ede ma
develop in the adjacent perianal skin and subcutaneous tissues,
forming a large swelling external to the piles. It is painful
condition and the pain may be increased by simultaneous
thrombosis of external hemorrhoidal plexus
(55)
.
4. Discharge: A mucoid discharge from the rectum can occurs in
any case with prolapsing piles but is most sever in patient with
piles that are in a permanent prolapsed condition. The soiling of
the under clothing with mucous and sometime fecal matter occurs
then becomes a troublesome symptom
(56)
.
5. Anal irritation: irritation of the peri-anal skin, due to its
becoming moist and sodden from discharge, is an almost invariable
accompaniment of large 3rd degree hemorrhoids, and may also
occurs in older cases with a less sever degree prolapse.
6. Secondary anemia: The repeated bleeding from hemorrhoids
can cause secondary anemia. The patient may complain from
breathlessness on excursion, dizziness on standing, lethargy and
pallor
(57)
. Kluber and Wolef in 2000 found that the incidence of
anemia attributed to hemorrhoids was 0.5 per 100,000 people per
year
(56)
.
7. Thrombosis of external hemorrhoids or perianal hematoma:
thrombosis occurs in the veins of the external hemorrhoidal plexus.
25
This occurs as a result of rupture of one of the veins of external
hemorrhoidal plexus during straining at defecation with escape of
blood to the subcutaneous tissue where it clots and form a painful
swelling. This condition, also known as subpectineal
thrombosis
(58)
.
8. Anal skin tags: They are common may be single or multiple
and may vary from a slight excrescence of the skin to grossly
projecting tags.
Two types of skin tags are present:
1) Idiopathic skin tags: It may possible presented as result of
resolved hematoma. But in many cases there is nothing in patient
history suggesting such thrombotic events has ever occurred.
Idiopathic skin tags are soft and pliable and are covered by normal
skin.
2) Secondary skin tags: It is present as result of anal fissure or
purities ani, in this case the skin tags are associated with
edematous and infected skin rugae and the anal canal and peri anal
skin show typical changes of pruritis ani
(57)
.
Assessment of hemorrhoidal disease patients
The following scheme is suggested for assessment of such cases.
1-History:
A) Bleeding:
26
This is the most common complaint and usually the earliest in
development of disease. This is invariably bright red and is often
first noticed on the lavatory paper, particularly after passing a non
blood stained hard stool. The type of bleeding in hemorrhoidal
disease is different form that produced by rectal neoplasm or
ulcerative proctitis but may be similar to that experienced by
patients with fissure in ano or even when there is perianal
dermatitis with severely macerated skin. Hemorrhoidal disease can
generally be distinguished from these last two conditions by the
absence of pain or pruritis
(59)
.
Later in the development of the disease the bright red bleeding
may become profuse, drippling into the pain like a tap or spattering
the sides like a jet to mark the end of the act of defecation. This
profuse bleeding occurs when the cushion are prolapsed +
and congested by the sphincter
(56)
.
B) Pain:
Although, hemorrhoidal disease dose not associated with pain, the
patient should be asked if gets pain during or post-defecation for
the presence of concomitant and fissure
(56)
.
C) Continence:
Dose the patient incontinent to feces and or flatus? What is the
pattern of incontinence whether diurnal or nocturnal, severity,
urgency and lack of warning
(60)
.
27
D) Bowel habits:
Constipation or diarrhea, frequency, use of aperients and their
dosage and duration of straining at defecation
(61)
E) Prolapse:
Dose any flesh come outside the anus? Is it persistent or only
during defecation? Dose it reduce spontaneously or manually?
How far dose it projects. Is it associated with bleeding, discharge
or proctitis
(56)
F) Previous illness and operation:
Especially dysentery, diarrhea, anal and rectal surgery,
laminectomy, trauma, to the cord and sacral root injury, obstetric
and gynecological trauma in female
(62)
.
2-Examination:
The genus pectoral (knee shoulder) position is optimum as it offers
an adequate view of the rectum on proctoscope. Yet it is an
uncomfortable embarrassing position especially for females. Sim‟s
left lateral position is easy and satisfactory for anorectal
examination. Adequate light with a flexible mobility is highly
recommended. A suitable lubricant should be at hand
(59)
.
A- Inspection:
It is an important step in anal examination. A sentinel pile at lower
edge of a fissure, fecal soiling around anal verge, gaping of the
28
anus at rest or on traction, absence of corrugation, perineal descent
on straining, prolapse, contraction of gluteal muscle and external
sphincter should not be missed
(62)
. Inspection is also important in
the diagnosis of aconcomitant anal fissure
(59)
.
B- Palpation:
Is conducted only after the patient is completely relaxed and
confident in the procedure, as fear or psychological distress will
render the procedure tedious. If the surgeon finds it difficult to
introduce his finger, he has to delay his trial while maintaining
steady pressure on the sphincter till it relaxes. Warning the patient
about the expected discomfort and false sensation of distention will
help to allay any difficulties
(63)
.
The peri anal region is palpated for abscesses, fistulous tracks,
residual inflammation and scars of previous operation and should
readily differentiate between thrombosed hemorrhoids, tumor or an
abscess
(59)
.
Quality of the external sphincter tone is assessed; length of the anal
canal is estimated by asking the patient to contract his anal
musculature and palpating his puborectalis. Intersphincteric groove
at the lower part of the anal canal is palpated. Ano-rectal angle is
palpated for fixity within the perineum, angulations and motility to
and fro and sideway. Tenderness is interpreted over a fissure
bearing area. The finger is pushed deeper into the rectum palpating
29
its wall for tumors, papillomata or excoriations. Nature of stool in
its lumen should be reported
(64)
. Para rectal structures, e.g. the
prostate, seminal vesicle, sacrum and coccyx should be
examined
(64)
.
3- Instrumentation:
Proctoscopy:
This will demonstrate the presence of internal vascular cushions
and may show them to be bleeding. The differentiation of causes of
rectal or anal bleeding is the most important objective of the
assessment. We make no apology for repeating the observation that
it is not enough simply to demonstrate that a patient with rectal
bleeding has congested internal anal cushions on anoscopoy. It
dose not mean that these have been the cause of bleeding, not even
if they are seen to bleed with the trauma of the examination. Other
causes of bright red rectal bleeding must be excluded
(65)
.
Sigmoidoscopy:
This will demonstrate the normality of the rectal mucosa and to
exclude inflammatory bowel disease. It should also exclude
solitary rectal ulcer, mucosal polyps or carcinoma of the rectum
(66)
.
Bright red rectal bleeding can come from sigmoid neoplasm so the
assessment of rectal bleeding includes sigmoidoscopy to 60 cm,
which will require the flexible instrument. Full sigmoidoscopy is
mandatory whenever there is blood mixed with the stool. In some
30
patients with bright red blood on the toilet paper only, or a normal
non-bloody stool, it may permissible to confine examination of the
rectum providing the symptom is cured by treatment
(67)
.
If there is any doubt what so ever concerning the diagnosis
the rest of the colon will need investigating, preferable by
colonoscopy or by barium enema if colonoscopy is not readily
available
(59)
.
MANAGEMENT OF HEMORRHOIDS
Treatment regimen for hemorrhoids date back thousands of
years
(68)
. Numerous therapeutics modalities have been used to
manage hemorrhoids, but many of these treatments would have
had doubtful efficacy
(69)
, and modern treatment are merely
sophisticated modification of these historical methods
(70)
.
A good understanding of the pathophysiology of hemorrhoids
helps one to select the most appropriate technique for treatment.
Traditionally the management of hemorrhoids has been based on
the degree of prolapse of the vascular anal cushions, severity and
type of symptoms. Most of available options for treatment of
hemorrhoids are performed as outpatient procedures
(54)
.
There are many lines of treatment of hemorrhoids as the following:
A. Conservative treatment:
1- Diet and stool bulking agent:
31
Dietary modification is a mainstay for any therapy for
hemorrhoidal disease. If the patient is constipated or straining, a
diet high in fiber (usually at least 20-30 g/day) is recommended,
striving for soft stool that is easy to pass. This reduces the
requirement to strain with bowel movement and lessens the chance
of hemorrhoidal injury
(71,72)
.
Dietary fiber is more appropriately referred to as a stool normalizer
rather than a stool softener. It is uncommon for dietary fiber to
cause complication, and allergic reactions to the active or inactive
ingredient are exceptionally rare. The most common clinical
difficulty is non- compliance due to problems with taste or
symptoms of bloating and cramping abdominal pain
(73)
.
2- Oral medication:
In Europe and Asia, oral vasotopic drugs are used for treating
hemorrhoids. These treatments were first described in the
treatment of varicose veins, venous ulcers, and edema. Purified
flavonoid fraction is a botanical extract from citrus. It exerts its
effects on both diseased and intact vasculature, increasing vascular
tone, lymphatic drainage, and capillary resistance; it is also
assumed to have anti-inflammatory effects and promote wound
healing. Lately, several randomized controlled studies evaluated
the use of oral micronized, purified flavonoid fraction in the
treatment of hemorrhoidal bleeding
(74)
.
32
In all of the studies, bleeding was relieved rapidly, and no
complications were reported. In another recent randomized
controlled trial, postoperative use of micronized, purified flavonoid
fraction, in combination with short-term routine antibiotic and antiinflammatory therapy, reduced both the duration and extent of
postoperative symptoms and wound bleeding after
hemorrhoidectomy, compared with antibiotic and antiinflammatory treatment alone
(75)
.
Currently, the Food and Drug Administration (FDA) does not
approve the use of micronized, purified flavonoid fraction in the
United States
(76)
.
3- Topical treatment
The use of over-the-counter medications is omnipresent in the
treatment of hemorrhoids and includes pads, topical ointments,
creams, gels, lotions, and suppositories. These preparations may
contain various ingredients such as local anesthetics,
corticosteroids, vasoconstrictors, antiseptics, keratolytics,
protectants (such as mineral oils, cocoa butter), astringents
(ingredients that cause coagulation, such as witch hazel), and other
ingredients
(77)
.
33
Topical application of corticosteroids may ameliorate local
perianal inflammation, but longterm use of high-potency
corticosteroid creams should be avoided, because it can cause
permanent damage and thinning of the perianal skin. Most of these
products help the patient maintain personal hygiene, and may
alleviate symptoms of pruritus and discomfort. There are no
prospective randomized trials suggesting that they reduce bleeding
or prolapse
(78)
.
Nonsurgical treatment
These interventions include rubber-band ligation,
sclerotherapy, infrared coagulation, bipolar diathermy and directcurrent electrotherapy, cryotherapy, laser therapy, and more. These
procedures are usually office-based procedures done during the
patient‟s first visit. They offer treatment for hemorrhoidal disease
without the need for anesthesia or preparation of the
patient
(77)
.Some physicians advocate a mild bowel preparation
(such as an enema or a mild oral cathartic) before these procedures.
The presence of fecal material in the rectum is not considered a
contraindication to these procedures, although liquid stool might
make the procedure technically more difficult.
When treating mixed hemorrhoids, it is important to remember
that they have a component of the anoderm (which is richly
34
innervated with pain fibers) and that some form of anesthesia is
required
(77)
.
1- Sclerotherapy
This procedure was first described 2 centuries ago as
treatment for hemorrhoidal disease. Currently, it is recommended
as a treatment option for patients with symptomatic nonprolapsing
grades I to II hemorrhoidal disease;
(76)
occasionally, a large
hemorrhoid can be successfully treated with sclerotherapy.
Sclerotherapy is frequently done without anesthesia; the
anoscope or proctoscope is passed through the anal canal into the
rectal ampulla and then withdrawn until the mucosa “prolapses”
over the opening of the scope. After the hemorrhoidal tissue is
identified, the submucosa at the base of the hemorrhoid is injected
with 5 mL of 5% phenol oil, vegetable oil, quinine, and urea
hydrochloride or hypertonic salt solution. Injection of the
sclerosant solution directly into the hemorrhoidal vein should be
avoided because it can cause immediate transient precordial and
upper abdominal pain
(79)
.
The injection of an irritant sclerosant produces edema,
inflammatory reaction with proliferation of fibroblasts, and
intravascular thrombosis; this reaction creates submucosal fibrosis
and scarring, which prevents or minimizes the extent of the
35
mucosal prolapse and potentially reduces the hemorrhoidal tissue
itself. After the procedure, the patient should receive appropri ate
dietary education and take stool softeners, bulking agents, sitz
baths, and mild analgesics
(77)
.
Although sclerotherapy can be done safely within a few
minutes,
(80)
the physician needs to be particularly cautious when
injecting in this area because of the proximity of the rectum to the
periprostatic parasympathetic nerves. Accidentally injuring the
periprostatic parasympathetic nerves can cause erectile dysfunction
after sclerotherapy
(81)
.
Hepatic complications after sclerotherapy for hemorrhoidal
disease were also described
(82)
. Local infection and abscess
formation are rare but may occur. Burning sensation and
discomfort are often experienced by patients undergoing multiple
injections. Advanced-grade internal hemorrhoids with evidence of
inflammation, infection, or ulceration sho uld not be treated with
sclerotherapy.
Concomitant anal diseases such as fistulas, tumors, anal
fissures, and skin tags are a contraindication to treatment with
sclerotherapy. Sclerotheraphy is not a treatment option for external
hemorrhoidal disease, and might result in scarring and stricture if
applied to external hemorrhoids
(77)
.
36
Antibiotic prophylaxis is indicated for patients with
predisposing valvular disease or immunodeficiency because of the
possibility of bacteremia after sclerotherapy
(83)
. If the patient is
asymptomatic after sclerotherapy, a follow up visit is not required.
Numerous studies have been conducted to evaluate and
compare different treatment modalities for hemorrhoidal disease;
the results have been inconsistent, although sclerothe rapy seems to
be a less effective option
(14)
.
Figure 5. Traditional Gabriel needle and syringe
(84)
.
37
Figure 6. Injection of sclerosing solution at appropriate site for internal hemorrhoid
(84)
.
2- Rubber-band ligation
Historical notes
Using of rubber bands ligation as an office procedure for internal
hemorrhoids was originally started by Blaisdell, 1958
(85)
. He used
silk for his ligature and designed a special instrument for this
ligating method. Modification of Blaisdell‟s instrument was done
by Barron who also used rubber bands for ligation instead of
silk
(86)
.
Principle of rubber bands ligation:
The principle of the methods is local obliteration of the hemorrhoid
vessels, resulting in necrosis and ulceration, followed by scarring
and fixation of the mucosa
(87)
.
38
Indications:
This treatment is most commonly described for first, second, and
third degree hemorrhoids
(88, 14, 89)
.
Advantages:
Rubber band ligation is the most effective outpatient procedure for
hemorrhoids, providing a cure in 80% of patients with first to third
degree hemorrhoids
(87)
.
Disadvantages:
It is operator skill-dependant; it can cause sever pain if the bands
are placed too low and it may cause difficulty or complete inability
in voiding urine
(90)
.
A theoretical disadvantage of rubber ring ligation is that no
pathologic specimen is obtained. Invasive carcinoma or other
tumor occasionally has been reported in an excised hemorrhoid
specimen (perhaps in less than 1% of cases)
(54)
.
Cataldo and MacKeigan in 1992
(91)
reviewing 21,257
hemorrhoidectomy specimens, found only one case of unexpected
anal cancer. Based on this fact they recommended that histological
examination of hemorrhoidal nodules should be a test for selected
cases only rather than a routine one
(92)
. The standard of care no
longer requires submission of a pathologic specimen even when a
surgical hemorrhoidectomy was performed. If there is any doubt or
39
concern about the presence of a lesion or the possibility of
underlying malignancy, biopsy should be performed
(54)
.
Instruments used for rubber bands ligation:
Original Barron hemorrhoid ligator is shown (fig.7).
Figure7: originally Barron ligator
(54)
McGivney ligator has much more secure shift, which may be
rotated in a 360-degree arc to facilitate placement (fig.8)
Figure 8: McGivney hemorrhoidal ligator
(54)
All non-suction instruments have the relative disadvantage of
requiring two persons to perform the procedure: one to maintain
the anoscope or retractor in position and the other to hold the
ligator and grasping forceps. Alternatively, the physician may use
40
a suction hemorrhoidal ligator such as Lurz-Goltner or the
MacGown ligator. These instruments draw the hemorrhoid into the
cup through suction and therefore don‟t require a grasping forceps.
Because the Lurz-Goltner ligator is a side application device,
maneuvering the ligator onto the piles is quite easy. An end suction
instrument, such as McGown ligator, is also very simple to use, but
it requires slightly more manipulation to fit it onto the
hemorrhoids. Conversely, the disadvantage of the side suction
ligator is that mechanical problems often prevent the instrument
from working optimally
(54)
.
Figure 9: McGown one hand suction ligator
(54)
Treatment with suction ligator seems to be associated with less
patient discomfort, but this is perhaps because the drum
incorporates a smaller volume of tissue. This factor, of course, is a
potential disadvantage, because the open-barrel device can permit
41
incorporation of very large hemorrhoids and even redundant rectal
mucosa
(93)
. (Figure 10) shows an anal canal in which ligator and
alligator forceps have been inserted. The alligator forceps securely
grab the tissue, but more importantly they facilitate visualization of
the site to be treated. However, most surgeons are familiar with
and use Allis forceps. This short instrument is less than ideal
because one‟s hand is often in the way, but the angled Allis forceps
help somewhat in ameliorating this difficulty
(54)
.
Figure 10: rubber ring ligation, the hemorrhoid is grasped and firmly tethered, the tissue
is drawn into the drum, and the two rubber rings are released
(54)
.
The patient rarely experiences pain so sever that removal of the
ring is necessary, but if required, this can be done by interposing
the end of a conventional suture removal scissor or the application
42
of the crochet hook. George McGown has designed for this sole
purpose. Other methods for removing the ring such as cutting with
scalpel tend to precipitate bleeding. Removal of the rubber rings
can be accomplished by accomplished with minimal trauma within
a few minutes after application. However, if the patient returns at a
later time because of pain, the associated odema precludes the
possibility of save removal. Adequate analgesic medication,
therefore, is the preferred option. This presupposes that sepsis is
not the cause.
(54)
.
Figure 11: rubber bands cutter
(54)
.
A newer modification of a rubber band ligator has been developed,
that of disposable instrument, the O‟Regan system fig (12).This
device is selfcontained syringe-like instrument that eliminates the
need for wall suction and tubing. As with the reusable instrument,
it requires only one person, but clearly the primary advantage is
that of disposability. In an era of concern for reprocessing costs,
occupational health issues, and the risks of crosscontamination,
this alternative has real merit
(54)
.
43
Figure 12: O‟Regan disposable banding system
(54)
Another innovation that facilitates the performance of multiple
ligations in one sitting is a multiple-banding instrument, the short
shot hemorrhoidal multi-band ligator fig. (13). this is a suction
ligating device that permits up to four banding with one
instrument
(55)
.
Figure 13: ShortShots multi band ligator (54)
44
Anesthesia:
No anesthesia is required, but the rubber ring must be placed on an
insensitive area, usually at or just above the dentate line
(54)
.
Preparation:
A small cleansing enema is given
(54)
.
Technique:
The procedure is performed through the proctoscope, which is
inserted and placed about 1-2 cm. above the dentate line. The
hemorrhoid cushion is allowed to prolapse into the scope, after that
it is grasped by forceps or “suction” into the ligature instrument,
and the rubber band is applied to the base of hemorrhoid. It is
important that the patient experience no pain when the cushion is
grasped; if pain is experience, the ligature has been planned too
low and has to be placed in a more prox imal position. When the
physician is sure that there is no discomfort, a tight rubber ring
with an inner diameter about 1 mm, is applied over the neck of
hemorrhoid. If the patient complains of pain, it must be assumed
that the band has been placed too low; the band should then be cut
and a new band replaced at higher level
(87)
.
Suction band ligation is superior to forceps ligation for the
treatment of second and third degree hemorrhoids in terms of pain
tolerance, amount of analgesia consumed and intra-procedure
bleeding
(93)
. Barron recommended ligature of only one cushion at
45
a time
(86)
. However, up to three hemorrhoids can be banded at the
same time. Multiple ligation of bleeding internal hemorrhoids in
one session can stop bleeding better than single ligation with no
more complications.
Elastic band ligation by using flexible endoscopes was first
introduced for treatment of esophageal varices by Stiegmann and
others in 1989
(94)
, Trowers and others in 1989
(95)
showed that this
technique also is feasible and safe for the treatment of
hemorrhoids. The video-endoscope with the attached reusable
multiband ligator was inserted, and the dentate line was identified.
The largest hemorrhoids were suctioned into the ligation cap. Up
to 5 elastic bands can be mounted onto the multiband ligator. An
excellent result was obtained in 80% of the patients
(89)
.
Care following treatment
Bowel actions should be maintained without the patient straining.
Appropriate dietary instruction, bulk agent, or stool softener should
be considered. The individual should be forewarned that some
bleeding may be noted initially and again when the rubber ring is
dislodged
(54)
.
Complication:
Complications are occasionally seen after rubber ring ligation and
may include the following:
1-pain
46
A moderate sense of discomfort or pain in the rectum can be
anticipated for few days following the procedure, but complaints
are usually minimal and can be often be relived by sitz baths and
mild analgesics
(54)
. There was a significant reduction in pain at 60
minutes and 6 hours after the procedure in the rubber band ligation
plus local anesthetic injection patients compared with the rubber
band ligation only group, but there was no reduction in pain when
local anesthetic was used compared with rubber band ligation only
on days 1, 2, 3 and 4 days after ligation. On day 10 after banding,
there was no difference between the two groups
(96)
. Immediate
sever or progressive pain is an indicated of the misplaced rubber
band ligation, which is too close to the dentate line and require
immediate removal. One of the difficulties is the removal of the
rubber band, which is usually rapid and firmly fixed by oedema of
the strangulated mucosa
(97)
.
2- Sepsis
The origin of this complication is unclear, but some have
suggested that many of these individuals may actually be in an
immunocompromized state or physician failed to recognized a
septic process as the cause of the patient‟s so-called “hemorrhoid”
complaints
(98)
. The triad of sever pain, fever and urinary retention
should always be considered as suggestive of pelvic sepsis.
Finding on physical examination may include fever, perineal
47
oedema, scrotal oedema, perineal ulceration, cellulites, or frank
gangrene. Rectal examination usually demonstrates a boggy,
oedematous anal canal that is extremely tender
(99)
.
Treatment requires massive antibiotic therapy, vigorous
debridement, and possibly hyperbaric oxygen treatment.
Suggestion for prevention has included using prebanding enemas,
prophylactic antibiotics and even meticulous sterile technique
(100)
.
3- Haemorrhage
Early hemorrhage or passage of blood with the first bowel
movement is common after this procedure. Patient should be
instructed accordingly in order to avoid undue apprehension.
Seldom, bleeding is sever immediately after the procedure and a
simple fleet enema generally empties the rectum and solves the
problem
(62)
.
Late hemorrhage (1 to 2 weeks after treatment) following rubber
ring ligation occurs approximately 1% of patient. This may be
attributed to sepsis in the pedicle or to early cutting through of the
tissue
(54)
. Significant bleeding, as determined by the presence of
clots or by the passage of blood without stool, requires urgent
assessment, even emergency management. Anoscopoy
examination is mandatory. If the patient is patient is unstable,
hypertension or tachycardia, hospitalization is required, blood
transfusion may be necessary. If the facilities are unsatisfactory for
48
adequate visualization and suturing, packing the anus with gauze
and with a haemostatic agent such as Gelfoam may be effective on
temporary basis. The use of Foley‟s catheter with 30 mL balloon
has also been suggested as a useful means for tamponading the
bleeding. It is because of the risk of late hemorrhage the rubber
band ligation is absolutely contraindicated for individuals who are
taking anticoagulants. An excisional option, sclerotherapy, infrared
coagulation, or one of the other alternatives may be considered
(98)
.
4- Thrombosis
With ligation of internal hemorrhoids, the risk for subsequent
thrombosis of corresponding external hemorrhoids is 2% to 3% if
thrombosis occurs; sitz baths and stool softener are recommended.
Occasionally, excision of thrombosed hemorrhoid is requiring
(54)
.
5- Ulceration
The rubber rings cause tissue necrosis, and they generally fall off
in 2 to 5 days, leaving an ulcerated area. On rare occasions, a large
ulcer, sometime associated with a fissure, may be a troublesome
complication. Treatment consists of sitz baths and perhaps a
topical cortisone preparation, but if fissure persists, internal anal
sphincterotomy should be considered
(54)
.
6- Slippage
The rubber ring can slip or break at any time, but this usually
happened after the initial bowel movement. Breakage may be
49
caused by a defective rubber ring, hens, and the reason to use two;
or as a consequence of tension produced by a large bulking of
tissue that has been ligated. The use of mildlaxative, bulking agent
or stool softener can help prevent the passage of a hard stool and
avoid dislodgement of the rings. If necessary, a repeat ligation of
the same ligation of the same pile site can be reasonably performed
3 to 4 weeks after initial procedure
(97)
.
7- Anal fissure
Starting about a week after banding signifies the development of a
fissure. The lesion occurs in much the same way as that which
some times following excision of external thrombosed
hemorrhoids. It results from the ulceration that follows the
sloughing of tissue, and it spreads to the lower anal canal.
Conservative treatment is prescribed initially and is followed by
sphincterotomy if the fissure is not healed. The lesion occurs in
less than 1% of the patient
(62)
.
3- Infra Red Photocoagulation:-The use of infrared photocoagulation for treatment of hemorrhoids
was first discovered by Neiger in1979. Infrared light penetrate the
tissue and is converted to heat, which causes tissue destruction.
Infrared photocoagulation is simple device with quartz halogen
lamp and a light-conduction handle. 1.5s pulses of infrared
50
radiation generate a tissue temperature of 100C, and produce
accuracy definite necrosis 3mm and 3mm in diameter
(101)
.
Figure 14: infrared photocoagulation
(101)
.
Varying the optical wavelength of the coagulator or the contact
time varies the depth of penetration into the tissues. The infrared
coagulator gun is set to between 1.0 to1.5s. Through the
proctoscope the base of hemorrhoids is identified in the same way
as for sclerotherapy. Three areas of coagulation are recommended
at the base of hemorrhoid in a triangular shape. Photocoagulation
creates a constant depth of necrosis. This area (seen as a white spot
after the procedure) forms an ulcer, and ultimately an area of
mucosal tethering, with associated shrinkage of the hemorrhoidal
mass. Results for nonprolapsing hemorrhoids appear to show that
this is a superior technique to injection sclerotherapy. Certainly it
51
is less technique dependant and avoids the complication of
misplaced injections
(102)
.
It is smoke free and odor free in contrast to diathermy, and can be
performed by one person
(103)
. The main use of photocoagulation is
for grade one and two hemorrhoids and repetitive treatment is
often required
(104)
.
4- Bipolar Diathermy (Bipolar electro coagulation):-Bipolar electrocoagulation (Bicap) works by the local application
of heat through a specialized probe and produces a white coagulum
that only 3mm depth and some smoke, will be seen during using
disposable plastic (non conducting) proctoscopy, the tip of the
probe is directed to the hemorrhoid after ensuring that this area is
above the dentate line
(105)
.
Similar to photocoagulation, it can be performed by a single
operator without the need for assistant
(69)
.
It is indicated for treatment of first and second degree hemorrhoids
and repeated treatment may be required
(106)
.
Routinely the three hemorrhoids sites are treated in the same
sitting. There is no need for any preparation or enema and can
return to home immediately, as this procedure is out patient
procedure
(93)
, and it is effective as photocoagulation
(105)
.
52
Figure 15: Bipolar diathermy
(105)
.
5- Galvanic Generator and probe (Unipolar
electrocoagulation):-The galvanic generator and probe differ conceptually from infrared
photocoagulation and bipolar diathermy. A low voltage current is
passed between the probe and earth plate on the patient. This
treatment take 10 minutes per each pile to be completed and only
one pile be treated in every visit
(105)
.
The technique used is to apply the earth pad electrode to the patient
and then touch the base of hemorrhoid with t he probe tips, and
increase the current setting to 2 milliamp, the probe tip should be
advanced 5 mm in hemorrhoids, the current is increased to 16
milliamp, and the probe tip is held still for the duration of the
treatment (10 minutes).
53
If the patient can not tolerate this current, the current is reduced. If
the current is not switched off or if the probe tip is displaced
accidentally during the treatment the patient may feel shock
(103)
.
It is indicated in for treatment of first and second degree
hemorrhoids and repeated treatment may be required
(106)
.
Randall and others in 1999 reported similar efficacy and
complication rates between bipolar and unipolar electrocoagulation
techniques
(105)
.
6-Cryotherapy
The principle of cryotherapy is based on cellular destruction
through rapid freezing followed by tissue swelling, which followed
by delayed thrombosis and infarction during a 24 hours period
(103)
.
Cryotherapy is performed with a liquid nitrogen (-196ºC)or nitrous
oxide probe (-60º to 80ºC).
In non-randomized trial, MacLeod in 1983 reported that it is more
effective than banding and sclerotherapy, although he treat only
one hemorrhoid per patient at a time, require multiple sites per
patient
(106)
. This procedure is associated with perfuse foul smelling,
discharge and irritation. In addition to pain and slow healing, the
inappropriate use of cryotherapy can cause necrosis of internal anal
sphincter resulting anal stenosis and incontinence therefore,
54
because this procedure dose not offer any advantage compared
with other forms of treating hemorrhoids and is associated with
high morbidity, it is now generally believed that cryotherapy
showed be eliminated from therapeutics lines in the management
of hemorrhoidal disease
(59)
.
surgical treatment
surgical treatment should be offered to patients in whom office
procedures were unsuccessful, patients who are not capable of
tolerating office procedures, patients with large external
hemorrhoidal disease, and patients with grades III to IV mixed
(internal-external) hemorrhoidal disease
(102)
.
Preoperative preparation usually includes one or two
disposable phosphate enemas (CB Fleet Co, Inc) on the morning of
the operation. Prophylactic antibiotics are necessary for patients
who are at high risk, in accordance with the recommendation of the
American Heart Association
(108)
.
There are numerous surgical methods of hemorrhoidectomy
aiming to decrease postoperative pain and hemorrhage
(109)
. The
conventional procedure includes excision of the external and
internal components of the hemorrhoidal tissue, using various
55
techniques, with or without closure of the anorectal mucosa or the
anoderm.
Different instruments are available to perform excision of the
hemorrhoidal tissue, including electrocautery, scissors, scalpel,
laser, bipolar scissors, linear staplers, LigaSure, or Harmonic
Scalpel
(109,110)
. These instruments can be combined with a variety
of surgical procedures.
In 1995, Dr Antonio Longo presented another surgical
procedure that clearly and demonstrably reduced postoperative
pain. This novel operative technique for hemorrhoidal disease is
actually performed in the distal rectal mucosa and submucosa
away from the modified squamous epithelium of the distal anal
canal, which is richly innervated with somatic pain fibers. In
Longo‟s procedure, neither the anal mucosa nor the hemorrhoidal
tissue is removed, so the procedure is not a hemorrho idectomy.
The procedure was termed procedure for prolapse and hemorrhoids
(PPH), hemorrhoidopexy, or stapled anopexy
(111)
.
A modified circular stapler is used to remove a ring of distal
rectal mucosa and submucosa, with simultaneous fixation of the
redundant tissue to the rectal wall. Because of the distance from
the somatic fibers in the distal anal canal, it is presumed that this
procedure is associated with less postoperative pain
(112)
.
56
All of these techniques require special training, because the
complications can be devastating and can result in hemorrhage,
incontinence, anal stenosis, fistula, and fatal septic complications
including Fournier‟s gangrene Each technique will be individually
addressed.
Common Complications of Hemorrhoids Treatment
1) Pain
2) Urinary retention
3) Hemorrhage
4) Constipation
5) Fissure
6) Abscess
7) Skin tag
8) Pseudopolyp
9) Anal stricture
10) Fistula, rectovaginal fistula
(77)
11) Sepsis
12) Rectal perforation
13) Incontinence
57
Open hemorrhoidectomy (Milligan-Morgan):
The operation can be performed in the lithotomy or prone jack
knife position, under spinal or general anesthesia. In the lithotomy
position the patient is placed with the feet in stirrups, and the anal
canal is gently dilated
(113)
.
A proctoscope is inserted to identify the site of the three principal
hemorrhoids. A weak adrenaline solution (1:200.000) in saline is
infiltrated around the skin adjacent to each primary hemorrhoid,
and further injection is made in the lower part of the
intersphincteric space and in the submucosal plane under the
hemorrhoid
(113)
.
Tissue forceps are then applied to each pile and to the skin adjacent
to the hemorrhoid. Start with the 7 O‟clock hemorrhoid, followed
by 3 O‟clock hemorrhoid, and finish with 11 O‟clock hemorrhoid,
so that the operation field is not obscured by bleeding. The tissue
forceps holding the hemorrhoid and its adjacent sk in is grasped in
the left hand
(113)
. A V-shape incision is made in the surrounding
perianal skin with scissor. The cut is deepened toward the anal
canal to reveal the lower fiber of the internal sphincter. The
sphincter is gently swept away with tissue forceps from the
hemorrhoid. The scissors are then used to excise the hemorrhoidal
tissue within the anal canal, which leaves the apex of the
58
hemorrhoid with its arterial supply and venous drainage intact for
ligature.
The pedicle of each hemorrhoid is then enclosed in an arterial clip,
and the pedicle is transfixed using nonabsorbable suture material.
Hemostasis is then secured from the bed of the hemorrhoid by
using of cautery. The ligature is left long so that if any farther
bleeding occurs, the pedicle can be easily identified and delivered
into the operative field. Each hemorrhoid is dealt with in the same
manner; however, well established skin bridges between each Vshaped segment of excised skin must remain. At the end of
operation, an anal speculum is inserted to be absolutely certain that
there is complete hemostasis. Guze dressings are then applied to
each hemorrhoidal area
(113)
.
59
Figure 16: postoperative view of Milligan Morgan hemorrhoidectomy
(113)
Postoperative complication of open hemorrhoidectomy:
The complication that are of most concern after hemorrhoidectomy
are sever pain, urinary retention, bleeding, soft fecal impaction and
itching, later complications include urinary tract infection,
secondary bleeding, wound infection, fissure, incontinence and
anal stenosis
(114)
.
The most common fear of hemorrhoidectomy patients is the pain.
There are many ways that can at least minimize it. The methods to
reduce postoperative pain include use of limited incision, suturing
60
the vascular pedicle without any incision, performing a
concomitant lateral internal sphincterotomy, use of metronidazol,
using anal sphincter relaxants, warm sitz baths, injecting local
anesthetics, sing anxiolytics, and parasympathomimetics. All these
strategies, however, have had mixed results and therefore cannot
be recommended for routine use
(115)
.
Ferguson’s (closed) hemorrhoidectomy
This procedure was developed in 1952, in the United States,
by Ferguson. Currently, like any other surgical treatment for
hemorrhoids, it is usually done in an outpatient setting (23 hours or
less hospital stay).
According to surgeon, anesthesiologist, and patient
preference, anesthesia can be general, caudal, or spinal. Local
anesthesia, in which the anal submucosa is infiltrated with a local
anesthetic combined with low-dose epinephrine, is usually also
applied. This technique minimizes bleeding but does not affect the
patient‟s blood pressure or heart rate, and allows creation of a
plane between the hemorrhoidal tissue and the underlying internal
sphincter, making the surgical excision easier and safer to
perform
(78)
.
61
The conventional Ferguson‟s hemorrhoidectomy is
performed with a scalpel, scissors, or electrocautery, although
excision of the hemorrhoidal tissue can be achieved with any
(electronic or other) cutting instrument. There are numerous
publications about these techniques, and the results are inconsistent
about which method causes fewer complications and less pain
(17)
.
After the hemorrhoidal pedicle has been mobilized, an
absorbable suture is usually placed at the pedicle site. After the
hemorrhoidal bundle is excised, with any internal or external
components of the disease, the mucosal wound and skin are
completely closed with a continuous suture. Wounds are cleaned
and checked for appropriate hemostasis, and antiseptic ointment
and a small dressing are Often applied; no packing is necessary
(77)
.
Postoperative care includes prolonged sitz baths
(approximately 20 minutes Or more) several times a day. Topical
creams or lotions may be applied, although the use of ointments
should be avoided. Mild nonnarcotic analgesics are usually
recommended to avoid constipation. Diet modifications rich with
fiber and high fluid intake, bulking agents, or stool softeners are
strongly recommended. Preferably, the patient will void after the
procedure or before discharge. The patient should be instructed to
report any complaints of urinary retention. The patient should also
be notified that often after the first bowel movement, the sutures
62
loosen. The followup visit is usually scheduled 3 or 4 weeks after
the procedure if no complications develop in the interim
(78)
.
Figure 17.Modified Ferguson excisional hemorrhoidectomy. A Double elliptical incision
made in mucosa and anoderm around hemorrhoidal bundle with a scalpel. B The
hemorrhoid dissection is carefully continued cephalad by dissecting the sphincter away
from the hemorrhoid. C After dissection of the hemorrhoid to its pedicle, it is either
clamped, secured, or excised. The pedicle is suture ligated. D The wound is closed with a
running stitch. Excessive traction on the suture is avoided to prevent forming dog ears or
displacing the anoderm caudally
(17)
.
Complication after closed hemorrhoidectomy:
The introduction of the closed hemorrhoidectomy by ferguson as
opposed to the open technique by Milligan -Morgan did not
eliminate the risk of delayed bleeding. Obviously, both the
63
classical open and closed hemorrhoidectomy techniques are far
from optimal: both operations seem to be followed by protracted
convalescence period, postoperative anal stenosis and significant
prevalence of complications although the fear of infection caused
by primary closure of hemorrhoidectomy incision is
unfounded
(116)
.
Harmonic and LigaSure hemorrhoidectomy
Excision of the hemorrhoidal tissue can be achieved with
numerous techniques. The Harmonic Scalpel (Ethicon EndoSurgery) uses ultrasonic waves that allow cutting and coagulation
of hemorrhoidal tissue at lower temperatures in a specific point,
with reduced lateral thermal effect. The Harmonic Scalpel
generates less smoke compared with lasers and other
electrosurgical instruments
(77)
.
When using electrocautery, coagulation is achieved at
temperatures higher than 150°C, resulting in formation of eschar
that covers and seals the bleeding area.
In one prospective study that compared Harmonic Scalpel
hemorrhoidectomy with traditional closed hemorrhoidectomy,
Harmonic Scalpel hemorrhoidectomy did not show any advantage
in postoperative pain, fecal incontinence, operative time, quality of
64
life, or other complications compared with trad itional closed
hemorrhoidectomy
(117)
.
The LigaSure vessel sealing system (Valleylab, Tyco Health
Care Group) for sutureless hemorrhoidectomy is a technique that
uses a bipolar electrothermal device. The procedure offers surgical
treatment with shorter operative time and less postoperative
pain
(118)
.
Figure 18: ligasure sealing system
(118)
Theoretically, the ligasure system is an ideal instrument for
hemorrhoidectomy, as it enables effective, excision of hemorrhoids
with minimal tissue trauma, the limited tissue injury also reduce
wound sepsis, facilitate wound healing and decrease postoperative
pain
(119)
.
Advantages:
65
(1) Decrease post operative pain as ligasure vessel sealing system
delivers optimal electrocautery energy across the diathermy jaws,
which ensure complete coagulation with minimal thermal spread
and limited tissue charring, which is in contrast to that produced
when using the existing electrocautery instruments.
(2) Early hospital discharge
(3) reduction in the intaoperative blood loss
(4) reduction of operative time
(5) no foreign material is left behind and no dislodges clips
(120)
.
Indication:
It indicated mainly in the third and fourth degree
hemorrhoids
(118,120)
.
The procedure for prolapse and hemorrhoids PPH (Longo’s
procedure):
This procedure has numerous terms: mechanical
hemorrhoidectomy with a circular stapler
(112)
, stapler
hemorrhoidectomy,circular stapler hemorrhoidopexy, stapled
circumferential mucosectomy
(121)
procedure for prolapsing
hemorrhoids (PPH), stapled anopexy, among others. The terms
PPH and hemorrhoidopexy most accurately describe this
technique.
66
Figure 19: PPH procedural set(
121)
Shortly after Longo introduced the technique in 1995,
numerous reports, mainly from Asia and Europe, were published
documenting less operative time, less postoperative pain, faster
recovery, and earlier return to daily activities. In 2001, an
international task force convened to assess the efficacy and safety
of this procedure and to create general guidelines for surgeons who
plan to practice this technique
(122)
.
The procedure was named stapled hemorrhoidopexy. The
committee stated that to perform this procedure, it is fundamental
that the surgeon be familiar with anorectal anatomy and
experienced in anorectal surgery, has adequate experience with
circular stapling devices, and was formally trained by attending an
official course. The device for PPH is manufactured by Ethicon
Endo-Surgery, Inc.
The procedure can be done with mild sedation, local, regional,
or general anesthesia
(123)
. In the United States, the procedure is
done in an outpatient setting. During the procedure, a
67
circumferential pursestring suture is placed approximately 2 cm
proximal to the dentate line. The stapler is introduced transanally
and the suture is tied around the shaft. On closing and firing the
stapler, a circumferential band of excessive rectal mucosa and
submucosa proximal to the hemorrhoidal tissue is excised, and the
defect in the mucosa is simultaneously closed by the stapler while
fixing the mucosa to the underlying rectal wall
(77)
.
This procedure also interrupts the blood supply of the
superior hemorrhoidal artery proximal to the hemorrhoidal tissue.
So it treats the mucosal prolapse, with concurrent disruption of the
blood supply to the hemorrhoidal tissue
(111)
.
In 2002 Zmora and Others using a porcine model, performed
a study to assess whether PPH can be safely performed twice.The
investigators performed two PPH procedures in one session,
leaving a ring of approximately 1 cm of mucosa between the two
staple lines
(124)
.
The anal canal was examined 1 month later. The
investigators documented that there was no evidence of anal
stenosis, no significant difference in degree of fibrosis, and the
mean mucosal blood flow between the two staple lines did not
differ significantly from the flow measured proximally and
distally. Their findings suggested that a synchronous or a
68
subsequent PPH is feasible. A controlled experience involving
human subjects is required to further validate these findings
(124)
.
Indications for PPH include :
Grade III hemorrhoidal disease and Uncomplicated grade IV
hemorrhoidal disease that are reducible at operation or after
manipulation in the operating room (because the hemorrhoidal
tissue is not excised during the procedure), and patients in whom
other treatments failed
(122)
.
But while performing conventional hemorrhoidectomy, a
simultaneous treatment of other perianal conditions, such as anal
fissure, skin tags, hypertrophied anal papillae, and acute
thrombosis can easily be accomplished.
PPH does not involve incisions in the anoderm, so does not
treat any external components of the disease or other perianal
conditions. The surgeon must inform the patient that these
conditions will not be treated by PPH, unless additional incisions
are made to deliberately treat them
(77)
.
Contraindications for PPH include: Anal abscess or
gangrene, because the operation does not remove the source of
sepsis. Anal stenosis is also considered a contraindication, because
the procedure requires insertion of a circular anal dilator
(77)
.
69
Full-thickness rectal prolapse is also considered a
contraindication, because it is not adequately treated with PPH.
Use of the circular anal dilator during the procedure and the
inadvertent removal of smooth muscle while removing excessive
mucosa was speculated to lead to impairment of bowel control,
although studies suggest that PPH does not significantly affect the
continence score, quality of life, or mean anal resting
pressure
(125,126)
.
Patients with preexisting sphincter injury and those with anal
incontinence should be offered other treatment modalities.
Although one of the advantages of PPH is the reduction of
postoperative pain, pain may result from thrombosis of the residual
hemorrhoidal tissue. Other possible explanations for postoperative
pain include a staple line that is too close to the anal verge, which
may result in partial excision of sensitive anoderm, or
inappropriate placement of the purse-string suture that may result
in incorporation of rectal muscle and nerves
(17)
.
Bleeding after the procedure may occur at the staple line.
This complication can take place during the procedure, and
hemostasis can easily be achieved by oversewing the bleeding
point. Postoperative bleeding can be managed by submucosal
injection of epinephrine during proctoscopy. If injection fails, if
the bleeding source is undetected, or if the proctoscopy causes
70
discomfort to the patient, examination under anesthesia is
indicated. Acute urinary retention may also occur as a
complication of PPH, and should be managed as described for
conventional hemorrhoidectomy
(17)
.
Other rare postoperative serious complications after PPH that
have been reported include: rectal perforation, anastomotic
dehiscence, retroperitoneal sepsis, retropneumoperitoneum, rectal
stricture, rectal obstruction, rectovaginal fistula, and even
mortality
(127,128,129,130)
.
The risk for rectovaginal fistula can be minimized by
assessing the thickness of the rectovaginal septum before applying
the purse-string; care should be taken not to place the suture too
deep, and the vagina must be examined before firing the stapler.
Incorrect placement of the purse-string suture may also result in
complete rectal obstruction.
71
Figure 20.Stapled anoplasty (procedure for prolapse and hemorrhoids). A Retracting
anoscope and dilator inserted. B Monofilament pursestring suture (eight bites) placed
using operating anoscope approximately 3–4 cm above anal verge. C Stapler inserted
through pursestring. Pursestring suture tied and ends of suture manipulated through
stapler. D Retracting on suture pulls anorectal mucosa into stapler. E Stapler closed and
fired. F Completed procedure
(17)
.
Doppler-Guided hemorrhoidal artery ligation (Transanal
Hemorrhoidal Dearterialization)
Currently the most common excision-ligation procedures are the
„open hemorrhoidectomy,‟ described in 1937 by Milligan, Morgan,
Jones, and Officer
(131)
and the closed variant of the latter, the
72
Ferguson operation, described in 1959
(132)
. These procedures are
usually performed as inpatient treatments, and they are generally
burdened by severe postoperative pain.
For this reason less invasive outpatient treatments have been
developed, such as rubber band ligation
(86)
, infrared coagulation
(133)
and sclerotherapy
(134)
. The first one, in particular, became very
popular for its good results and low complication rate in seconddegree symptomatic piles
(135)
.
The main disadvantages of these outpatient procedures are
the necessity of several treatments and the high recurrence rate
(depending upon the hemorrhoidal stage)
(136,137,138)
.
The surgical management of hemorrhoids has changed over
the last decade. The technique of stapled hemorrhoidopexy,
introduced by Longo
(139)
, is a less painful alternative to traditional
surgery. In 1995 Morinaga described a new technique for the
surgical treatment of hemorrhoids: this technique consists of
ligation of the terminal branches of the superior rectal artery in
order to eliminate the hemorrhoidal symptoms.
He utilized a proctoscope coupled with a Doppler probe to
locate and ligate those arteries, reporting good results for this
technique
(140)
.
73
Figure 21. a Disposable proctoscope with the Doppler transducer on the tip. b The
proctoscope connects to the Doppler device and produces easily recognizable acoustic
signals
(140)
.
Rationale
The hemorrhoidal cushions consist of plexuses of large
venous spaces, arterio-venous communications between the
terminal branches of the superior rectal arteries and the superior,
74
middle, and inferior rectal vein
(33,40,141)
. These structures have been
named by Stelzner as corpus cavernosum recti (CCR)
(42)
. The
blood supply to the CCR is provided by the terminal branches of
the superior rectal artery; it is a functional blood supply th at fills
this cavernous network
(142,143,144,145,146)
.
This structure plays an important role in continence by acting
as a conformable plug, in order to ensure the complete closure of
the anal canal. This mechanism contributes up to 15–20% of
resting anal pressure
(147)
.
Even though the pathogenesis of hemorrhoids is not
completely explained
(148)
, there are two major theories that do not
exclude each other: the sliding down theory and the vascular
theory.
The first assumes that prolapsed hemorrhoids are caused by a
pathological slippage of the normal anal lining, caused by the
deterioration of supportive connective tissue and increased by the
straining during defecation
(34,1,40)
. The second, the „vascular
hyperplasia theory,‟supposes that an abnormal behaviour of the
arteriovenous shunt is responsible for the hypertension of
hemorrhoidal plexuses, their consequent dilatation, and therefore
their prolapse and bleeding
(145,50)
.
75
In reality the etiopathogenesis of the hemorrhoidal disease is
multifactorial and either of the two theories alone is not sufficient
to explain all its aspects. Several studies have demonstrated high
resting anal pressure in patients. It is presumed that this high
pressure is caused by increased activity of the internal anal
sphincter
(42)
or the external anal sphincter
(50)
, or by increased
vascular pressure within the anal cushions
(142,145)
.
The deterioration with age of the supportive connective tissue
causes a lack of support of the blood vessels within the
hemorrhoidal plexuses
(33,40)
. that facilitates the hypertension of the
anal cushions. This leads to increased straining during defecation
that impairs the venous drainage and facilitates a further increase
of cushion pressure with a stress on the connective supportive
mesh, finally resulting in intermittent or permanent prolapse
(148)
The ideal surgical technique for hemorrhoidal disease should
consider and have efficacy on both mechanisms, with regard to
anatomy and physiology. The excision techniques are very
effective because they remove the whole hemorrhoidal plexuses,
ligating the vascular pedicles. This approach is far from being
physiological, considering the importance of the anal cushions for
continence and the sensitivity of the terminal rectal mucosa
(147)
.
76
However, the most negative outcome after traditional
hemorrhoidectomy is the long-lasting intense postoperative pain.
Technique:
Transanal hemorrhoidal dearterialization is a nonexcisional
surgical method that consists of localization of the terminal
branches of the superior rectal artery using a Doppler, and the
consequent surgical ligation of those branches.
In order to perform this technique, in 1999, Khubchandani and
others devised; with the collaboration of Tagariello a new
instrument named THD, a specifically designed proctoscope with a
slot into which can fit an apposite Doppler probe. Distally to the
Doppler probe there is an operative window that allows the
application of the stitches to the rectal mucosa. The tip of the
needle holder is inserted inside a pivot in the proctoscope that
allows the needle to have always the same precise trajectory.
The proctoscope is illuminated by a light cable inserted
through its handle. The Doppler is used to localize the terminal
branches of the superior rectal artery 1–2 cm above the the internal
cushions. After complete insertion into the patient‟s anus, the
proctoscope is gently rotated around the rectal circumference in
order to locate an audible pulsating arterial signal that confirms
that the Doppler transducer is directly above the artery
(77)
.
77
There are six terminal branches of the superior rectal artery,
consistently located at odd hour positions (1, 3, 5, 7, 9, and 11
o‟clock;. This topography has never been described as a constant,
but in clinical practice it is the norm. In several hundred cases of
THD performed, have always been able to locate these branches in
the positions described above
(149)
.
After their localization, the arteries are ligated approximately
3 cm above the dentate line with absorbable 2.0 suture mounting a
5/8 short round needle, with a „„figure-of-eight‟‟ stitch. The knot is
tied outside the proctoscope and laid down using a knot pusher.
Confirmation of the vessel ligation is performed by repeat Doppler
measurements. The reduction or complete absence of the Doppler
signal provides evidence of vessel occlusion
(140)
.
This results in decongestion of the hemorrhoidal tissue and
alleviation of symptoms. The decreased tension allows for the
regeneration of the connective tissue within the cushions. This
facilitates the shrinkage of the piles and the reduction of
prolapse
(140)
.
In 2002 was a modification to the technique described by
Morinaga in order to more effectively treat prolapsed hemorrhoids.
After the arterial location with the Doppler, a running suture with
3–5 stitches is applied on the prolapsed piles (original technique),
78
in order to surround the prolapsed cushion, being careful that the
most distal stitch lies above the dentate line; then the knot is tied at
the level of the most cranial stitch in order to lift the prolapse and
to occlude the eventual perforating arterial branches.
The final outcome of this procedure is a mucosal folding with
a fixation to the deeper layers of the rectal wall by the resulting
fibrosis. In this way it is possible to obtain a good mucusal pexy
and to treat hemorrhoids of third degree with a voluminous
prolapse. This technique is to be applied only on those cushions
that are prolapsed, and not to be repeated routinely for all six
positions described above
(77)
.
Figure 22. THD device description
(77)
(SRA: superior rectal artery).
79
Figure23. Needle rotation inside the device: the needle holder tip is inserted in the pivot
and the needle rotates to surround the artery
(77)
.
Figure 24. Location of the terminal branches of the superior rectal artery
(77)
80
Figure 25. Anopexy with running suture (SRA: superior rectal artery
(77)
Treatment of thrombosed hemorrhoids :
1- Thrombosed external hemorrhoids
Thrombosis often manifests as acute discomfort and the
presence of a painful mass. In patients with recurrent episodes of
thrombosis, avoidance of straining and constipation combined with
increasing the amount of dietary fiber and fluid intake may serve
as a prophylactic measure. Thrombosis is often encountered after
heavy lifting, prolonged sitting, excessive straining at stool, or,
conversely, diarrhea.
Conservative treatment includes sitz baths, mild analgesics,
and stool softeners to relieve the symptoms. The thrombus will
slowly be absorbed during the course of several weeks, the pain
81
usually will subside after 2 or 3 days, and the mass will resolve
within 7 to 10 days
(78)
.
In a prospective, randomized trial, Perrotti and associates
(150)
demonstrated that topical application of nifedipine combined with
lidocaine ointment is a safe option in the conservative treatment of
thrombosed external hemorrhoids.
Surgical excision can be performed safely as an outpatient
procedure under local anesthesia, with a low recurrence and
complication rate
(151)
. Before surgical intervention, the extent of
the hemorrhoidal disease should be assessed and other anal
pathology should be excluded, especially thrombosed internal
hemorrhoids.
Excision within 48 to 72 hours of onset of symptoms often
results in rapid relief from symptoms. The patient should be aware
of the natural course of the disease and realize that after 72 hours,
the discomfort of surgical excision often exceeds the pain of the
thrombosed hemorrhoid. So, excision should be recommended,
especially for patients with severe pain, or if ulceration or rupture
occur within 72 hours of onset of symptoms
(77)
.
Incision and simple removal of the clot should be avoided;
although it causes the pain to subside, it often results in recurrent
hemorrhage into the subcutaneous tissue and clot reorganization.
82
Usually, an elliptical incision is made into the skin overlying the
thrombosed hemorrhoid, preferably radial to the sphincter.
Bleeding often accompanies the incision and may be controlled
with pressure or electrocautery. The wound can be left open or
primarily closed. In patients with bulky hemorrhoidal disease,
severe pain with hypersensitivity, or anxiety, the procedure can be
done under general anesthesia
(77)
.
If a mass or an unusual tissue is encountered during the
procedure, a histopathologic analysis is warranted
(152)
.
Postoperative care should include pressure to control
bleeding. This goal may be achieved with a pressure dressing,
which the patient should not remove until a few hours after the
procedure. Late bleeding is occasionally seen, especially when the
wound is left open and epinephrine is used in combination with the
local anesthetic. Sitz baths, topical anesthetic cream, and mild
analgesics are recommended for the first 7 to 10 days after the
procedure
(77)
.
Complications are usually minor and may include bleeding
that becomes evident after the influence of the epinephrine wears
off, or with the passage of a hard stool. Local infections are
uncommon, probably because of the rich vascular network in the
83
anal area; nevertheless, prophylactic antibiotics are prescribed by
some physicians
(77)
.
Skin tags and scarring can also occur, but, if desired, can be
electively addressed at a subsequent date
(152)
.
2- Thrombosed internal hemorrhoids
Prolapse of internal hemorrhoids may cause stasis and result
in thrombosis. This complication is less common than are
thrombosed external hemorrhoids and is less painful, but because
of the location of the internal hemorrhoids, operative intervention
is more complicated and is rarely indicated.
Sitz baths, analgesics, topical anesthetics and stool softeners
are recommended.
If surgery is indicated, excisional hemorrhoidectomy is
recommended
(59)
.
84
Summary
Hemorrhoids are a very common anorectal condition defined as
the symptomatic enlargement and distal displacement of the
normal anal cushions. They affect millions of people around the
world, and represent a major medical and socioeconomic problem.
Hemorrhoids are a series of 3 cushions in the anal canal, located in
the left lateral, right anterior, and right posterior positions.
The theory of sliding anal canal proposes that hemorrhoids develop
when the supporting tissues of the anal cushions disintegrate or
deteriorate.
Therapeutic treatment of hemorrhoids ranges from dietary and
lifestyle modification to radical surgery, depending on degree and
severity of symptoms
Medical treatment include Oral flavonoids, Oral calcium dobesilate
and Topical treatment.
A number of effective nonsurgical approaches are available for
patients with hemorrhoids as Sclerotherapy, Rubber band ligation,
Infrared coagulation, Radiofrequency ablation and Cryotherapy.
Excisional hemorrhoidectomy is the most effective treatment for
hemorrhoids with the lowest rate of recurrence compared to other
modalities Plication involves oversewing of hemorrhoidal mass
and tying a knot at the uppermost vascular pedicle. Doppler-guided
85
hemorrhoidal artery ligation a new technique based on dopplerguided ligation of the terminal branches of the superior
hemorrhoidal artery was introduced in 1995 as an alternative to
hemorrhoidectomy Stapled hemorrhoidopexy (SH) has been
introduced since 1998.
86
Conclusion
Excisional hemorrhoidectomy Still is the most effective treatment for
hemorrhoids with the lowest rate of recurrence compared to other
modalities.
There are several promising modalities that were introduced as an
alternative to hemorrhoidectomy as Doppler-guided hemorrhoidal artery
ligation and Stapled hemorrhoidopexy.
78
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ملاتعلا ءاحنأ عيمج تف سانلا نم نييلاملا تلع رثؤز اينإ .أشنملا نع اديعب تيجرشلا هدسًلاا
.تيداصتقاً تيعامتجاً تيبط تلكشم لثمزً
ريساوبلا نم ةلسلس يه ثلاث دئاسو رشلا ةانق يف ج ننم نميلأا بناجلا يف و رسيلأا بناجلا يف عقتو ،
فلخلاو ماملأا .
ةيرظن قلاننا ةنناطب ةاننق جرنشلا ت رنتق رينساوبلا نأ رونطتت ت امدننع روهدنتتو نكف ةجنسنلأا ةنمعادلا
لل دئاسو ةيجرشلا .
جلاع ريساوبلا وارتي نم يئاذغلا ماظنلا ليدعت و ةنيرذج ةنيارجل ةانييلا طنمن نلع ادانمتعا د ةنجر
ضارعلأا ةدشو .
يئاودلا جلاعلا لمشي ديونوفلافلا تابكرم ةيومفلا و تلايسبود مويسلاكلا ةيومفلا يعضوملا جلاعلاو .
رفوتي جهنلا نم اددع ةييارجلا ريغلا ةلاعفلا ضرمل ريساوبلا طيرشلاب طبرلاو ةيبلصتلا ةجلاعملا لثم
طاطملا ي و ريثختلا ءارميلا تيت ةعشلأاب ديربتلاب جلاعلاو ةيويدارلا تاددرتلاب ثاثتجقاو .
روننسابلا لاننصئتسا يننيارجلا ةنننراقم اننهعوجرل لدننعم ننندأ عننم ريننساوبلل ةننيلاعف رننثكلأا جلاننعلا وننه
رننخقا رطلاننب . وننلعلا نننعلا يننف ةدننقع طننبرو ريننساوبلا ةننلتك ةننكايي ءارننجحا اذننه لمننشيو طبرننلا
شا ةيجوتب روسابلا نايرشلا طبر . ذغملا رلبودلا ةع ةنيفرطلا فورنفلا طنبر نلع دنمتعت ةدنيدج ةنينقت
مانع ينف تمدنق رلبود ةعشا ةيجوتب ولعلا روسابلا نايرشلا نم 5991 رونسابلا لانصئتسق ليدنبك .
ريساوبلا تيبثت سيبدتلاب (SH) لخدأ ت ماع 5991 .
ريساوبلا جلاعل ةثيدحلا قرطلا
ر هلاس هيديهمت همدقم نم
بيبطلا / ملاسإ دومحم مصاع لاخلا دبع ق
سويرولاكب بطلا و ةحارجلا
ةئطوت لوصحلل ىلع ةجرد ريتسجاملا ةماعلا ةحارجلا يف
تحت فارشإ
حلاص دامع دمحم / روتكد ذاتسأ
ةماعلا ةحارجلا ذاتسأ
بطلا ةيلك
سمش نيع ةعماج
روتكد / وفحم دمحم ظ دمحم
ةحارجلا دعاسم ذاتسأ ةماعلا
بطلا ةيلك
سمش نيع ةعماج
بطلا ةيلك
سمش نيع ةعماج
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