Interno-external hemorrhoids with severe anemia
3.4.6 Painful Mass in the Anal Region
When thrombosis of the prolapsed haemorrhoid occurs, patient may present with a painful mass with sudden onset (Fig. 3.2). Rise in tissue tension within and outside the anal canal is responsible for pain and edema. The condition can be diagnosed by inspection alone. If surgery is not performed, the natural history of thrombosed hemorrhoid is one of slow resolution. The edema and inflammatory swelling reduce in course of 4–5 days, and complete resolution occurs in 4–6 weeks leaving behind a skin tag.
3.5 Clinical Examination
A detailed history is very important in the diagnosis of hemorrhoids. The color and the character of the anorectal bleeding and the relief obtained from reduction of the prolapsed mass into the anal canal lead to the diagnosis. The presence of hemorrhoid does not exclude other causes of bleeding. Third-degree hemorrhoid is a prolapsing mass, the outer part of which is covered with skin, the inner portion with red or purplish anal mucosa, and the junction between these two areas being marked by a linear furrow (Fig. 3.3). In long-standing cases, the lining epithelium often undergoes metaplasia to a squamous type. When this change has occurred, the covering epithelium is seen as a pale, white pannus extending from mucocutaneous junction over the mucosal surface.
Prolapsed thrombosed external hemorrhoids
3.5.1 Digital Rectal Examination
Usually, uncomplicated hemorrhoids are not palpable. Large hemorrhoids can be felt as soft elevation of the mucosa of the anal canal just above the dentate line. Piles are felt when thrombosed.
3.5.2 Endoscopic Examination
Proctoscopy permits accurate diagnosis of the hemorrhoids as well as the degree of prolapse. Sigmoidoscopy is essential to exclude any pathology beyond the reach of the proctoscope.
One should always keep in mind other anorectal pathological conditions may present with similar symptoms. They include rectal prolapse (partial or complete), polyps, and carcinoma.
Colonoscopy or air contrast barium enema is indicated when no source of bleeding is evident on anorectal examination, presence of occult blood in stool, atypical bleeding for hemorrhoids, and when patient is at high risk for developing colonic neoplasms.
The treatment of hemorrhoids is based on the degree of prolapse, severity and nature of symptoms, expertise of the surgeon, and the facilities available. The treatment options include dietary modification, medical treatment, office procedures for early and less symptomatic hemorrhoids, and operative intervention for third- and fourth-degree hemorrhoids.
3.6.1 Dietary and Lifestyle Modification
Increased fiber and water intake reduced straining at stools, and local hygiene is an integral part in the management of all degrees of hemorrhoids. Patient should be advised to take diet rich in fiber (20–35 g/day). Fiber supplementation (psyllium, methylcellulose, calcium polycarbophil) has been shown to improve overall symptoms and bleeding (Alonso-Coello et al. 2006). Fiber supplement is usually recommended for patients who are noncompliant for taking sufficient fiber in diet. Psyllium with water adds moisture to stools and thereby reduces constipation.
Lifestyle modifications play an important role to improve symptoms in these patients. Neglecting the first urge to defecate, spending prolonged time at toilet, and straining are common defecation errors which need to be corrected.
3.6.2 Medical Treatment
In spite of lack of rigorous evidence in the literature, doctors continue to use topical and systemic agents to relieve symptoms in patients with hemorrhoids. Most effective symptomatic relief can be obtained by warm (40 °C) sitz baths for not more than 15 mins or use of ice packs for limited period. Topical ointments or creams containing corticosteroid, local anesthetics, antiseptics, decongestants, etc. have been shown to give symptomatic relief. Micronized purified flavonoid fractions act by enhancing venous tone. Topical glyceryl trinitrate has been reported effective in strangulated internal hemorrhoids by decreasing internal sphincter tone (Patti et al. 2006). Prolonged use of topical agents should be avoided as they can cause local allergic effects and sensitization of skin. Although topical agents improve the symptoms, it is unlikely they will eliminate or cause the disease.
Calcium dobesilate can be used locally as well as systemically in the dose of 500 mg twice a day. It decreases capillary permeability, platelet aggregation, and blood viscosity. It also increases transportation of lymph. Calcium dobesilate has been found to be safe, fast acting, and efficient in treating acute symptoms of hemorrhoidal diseases.
3.6.3 Office Procedures
126.96.36.199 Injection Sclerotherapy
The technique was pioneered by Mitchell of Clinton, Agbo SP, in 1871. He kept it secret and sold to quacks just before his death. These quacks would roam in the USA and were known as traveling “Piles Doctor.” Eventually, Andrews of Chicago got the secret from one of the quacks and gave it to the medical profession in 1879.
Sclerotherapy is indicated for first- and second-degree hemorrhoids but contraindicated in thrombosed, prolapsed, ulcerated, infected, and gangrenous hemorrhoids. The agents used for sclerotherapy are 50 % phenol in vegetable oil, quinine, sodium morrhuate, sodium tetradecyl sulfate, and hypertonic saline. 5ml of solution is injected into the interstitial tissue of submucosa (unlike varicose where sclerosant is injected into the vein). Total of 12–15 ml of solution can be used. The injection is given with a Gabriel syringe through proctoscope at the base of the hemorrhoid mass just below the anorectal ring (Fig. 3.4). The sclerotherapy causes inflammatory reactions, fibrosis, scarring, and fixation of mucosa to muscularis propria thereby shrinkage and reduction of the pile mass.
The Gabriel syringe has two lateral rings on the barrel and a ring at the end of the piston for a secured grip. The needle is straight or slightly angulated with a shoulder on it about 2 cm from sharp end of the needle. The solution should flow freely. Resistance means wrong placement of needle. The amount of fluid to be given depends on the laxity of mucosa. Following injection, red mucosa turns purple. After an hour or so, the fluid granulates down and may cause some soreness. First injection is most effective. Subsequent injections can be given after 1–2 years if symptoms reappear. Repeat sclerotherapy is difficult because of previous fibrosis. Injected area feels like an indurated mass for 2–3 weeks, after which it gradually subsides. Complication of sclerotherapy includes pain, hemorrhage, local sepsis, necrosis, ulceration, portal pyemia, prostatitis, hematuria, and erectile dysfunction (Guy and Soew-Choen 2003). Pain is due to sclerosant tracking down or injection given low down on sensitive area. That is why patient is kept on bed for few hours with foot end elevated. Bleeding can be stopped by pressure with proctoscope or finger. Sclerotherapy can be given in patients on anticoagulation. Senapati and Nicholls (1988) have shown that fiber supplementation may be as effective as injection sclerotherapy.
188.8.131.52 Rubber Band Ligation
It is a simple, inexpensive, and one of the most widely used outpatient procedure for bleeding and prolapsed first-, second-, and third-degree internal hemorrhoids. The procedure was first described in 1963 by Baron. The band results in ischemic necrosis of the tissue which sloughs in a weeks’ time leaving an ulcer which heals by fibrosis resulting in fixation of tissue to the underlying sphincter. Banding should be avoided in patients on anticoagulants.
Different types of ligators are available in the market. The conventional Baron’s hemorrhoidal ligator consists of 11-mm wide hollow drum (Fig. 3.5a, b). The rubber band is placed over the drum by a loading cone. A second drum moves over it to push the rubber band into position. The two drums are mounted on a handle fitted with a trigger device. The hemorrhoidal mass is drawn into the hollow drum by a specially designed hollow forceps or Allis forceps. It must be made sure that the rubber band grips the pedicle at least 2 cm above the sensitive area, dentate line to avoid pain. The trigger is pulled, the outer drum slides over the inner one and pushes the rubber band to grip the pedicle of the pile mass. The forceps is released and the ligator is removed.
(a, b) Hemorrhoidal band ligator
In a modified technique, a McGown suction ligator is used whereby hemorrhoidal mass is drawn into ligating barrel by suction thereby avoiding the use of second hand or an assistant. Being smaller in size, it bands lesser tissue than other ligators.
O’Regan invented a disposable syringe like ligator to simplify the procedure for the patient as well as surgeon.
Multiple hemorrhoidal masses can be ligated in a single stage with no significant increase in morbidity (Poon et al. 1986). Some surgeons prefer to do it in multiple sittings after seeing the response to first ligators. The procedure can be repeated after 4–8 weeks.
About 60–70 % patients respond to single session of band ligation with significant symptomatic relief, although repeat treatment may be required at a later date. A meta-analysis of first trials comparing treatment options for grade I to III hemorrhoids found better response and better long-term efficacy with hemorrhoidectomy than banding, but there were lesser complications in those patients who underwent banding treatment. Compared to injection sclerotherapy, banding showed better response to similar complication rate (MacRae and McLeod 1995; Shanmugam et al. 2005).
Pain is the most common complication which occurs in 5–60 % of patients. Cataract blade is used to cut the rubber band to relieve pain. Delayed pain in the form of sensation of full mass may occur after 24–48 h and is due to edema over the band which extends down to dentate line. It is treated by complete bed rest and anti-inflammatory drugs.
Bleeding may be primary or secondary after 5–10 days following banding which is due to sloughing of the pile mass. Passage of blood with the first bowel moment is common. Patient needs complete bed rest and reassurance. Perianal and pelvic sepsis has been reported (Guy and Soew-Choen 2003; O’Hara 1980) in patient present with anal pain, fever, difficult urination, and defecation. Rarely, liver abscess and necrotizing infection have been reported (Chau et al. 2007). These patients need hospitalization and treatment with intravenous fluids, antibiotics, drainage of pus, and debridement.
The principle is based on cellular destruction by rapid freezing followed by rapid thawing. The freezing temperature is achieved with nitrous oxide at −60 to −80 °C, or liquid nitrogen at −60 to −190 °C can treat hemorrhoids by necrosing the vascular cushion due to thrombosis of microcirculation (Smith et al. 1979). The procedure is time consuming and associated with profuse 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 in anal stenosis and incontinence. Therefore, it is no longer recommended for treatment of internal hemorrhoids.
184.108.40.206 Infrared Coagulation (IRC)
The infrared radiation is generated by a tungsten Halogen lamp. A gold-plated reflector and specially made polymer tubing facilitate the process (Fig. 3.6).
Infrared coagulation equipment
First described by Natti and popularized by Neiger in 1979, the infrared light penetrates the tissue to a level of approximately 3 mm in the submucosa in the form of heat energy of 100 °C. This heat process is an actual burn, leading to tissue destruction and eventually to scarring. It causes not only the disappearance of vascular tissue but also the tethering of the hemorrhoids, resulting in no further bleeding or prolapse. It works best for bleeding small first- and second-degree hemorrhoids. The site of application is similar to the area advised for sclerosing agent or rubber band application. Three or four coagulations can be performed at the base of each haemorrhoid and it takes about 30 s for each piles. All the three hemorrhoids can be treated in one session. Repeat application may be needed in some patients after 2 months. There can be some mucous discharge and a sensation of fullness and discomfort until complete healing occurs. An ulcerated area develops over the applied site after 4–5 days which usually heals in 4 weeks’ time.
A meta-analysis of five trials comparing different technique showed similar results 12 months after treatment for IRC, RBL, and injection sclerotherapy. However, IRC was associated with fewer and less severe complications. They suggested that IRC may be an optional alternative method of treatment.
Transient discomfort during application of the probe is common. If pain persists, it is because the site chosen is too close to the dentate line. Bleeding after infrared coagulation may occur in the 6–8th post-application day and can be managed by bed rest and other conservative methods.
220.127.116.11 Bipolar Diathermy or Coagulation (BICAP OR LigaSure)
This technique was designed to produce tissue destruction, ulceration, and fibrosis by the local application of heat. This effect is obtained by bipolar diathermy, an electric current to generate a coagulation of tissue at the end of cautery tip. Heat does not penetrate as deeply as monopolar coagulation. A 2-s pulse is applied to each hemorrhoid in a suitable location in the same manner as infrared coagulation. It can be repeated as many times as required. This technique has been used in first- to third-degree hemorrhoids with high success rate.
18.104.22.168 Direct Current Therapy
In this technique, direct current is applied through an anoscope to the apex of the hemorrhoid. It is not so effective for large pile masses and as such has not become popular.
22.214.171.124 Anal Dilatation or Stretch (Lord’s Procedure)
The proponents of this method were of the opinion that stretching improves the venous return thereby causes reduction in pile masses and some symptomatic relief. But because of high rates of incontinence due to sphincter damage, it has almost been given up.
3.6.4 Surgical Treatment
Any surgical treatment of anorectum should be undertaken seriously with special care, proper judgment, and careful execution. The anal canal deserves as much respect as urethra or common bile duct. Surgical treatment is indicated for patients who do not respond to conservative or office procedures, patients with large external hemorrhoids, grade III to IV interno-external hemorrhoids, thrombosed, strangulated and gangrenous hemorrhoids, and concomitant conditions like fistula or fissure. Some patients with even lower grades of disease may show preference for surgical treatment. If properly executed, recurrence is uncommon. Though surgery is the most effective treatment for hemorrhoids especially grade III, it is indicated only in about 5–10 % of patients.
Numerous surgical options are available. In conventional procedures, hemorrhoidal tissue is excised and either left open to heal by secondary intention (Milligan Morgan hemorrhoidectomy) or closed primarily (Ferguson’s hemorrhoidectomy). Various modifications have come up using different instruments for excision like electrocautery, bipolar sessions, laser LigaSure, harmonic scalpel, circular stapler and Doppler-guided hemorrhoidal artery ligator (DGHAL) alone or in combination with resection (RAR).
126.96.36.199 Open Hemorrhoidectomy: Milligan Morgan
The choice of anesthesia and patient positioning are individualized and generally depend on patient’s condition and surgeon’s preference. Nowadays, any surgeons perform open hemorrhoidectomy as a day-care procedure.
Open hemorrhoidectomy was the procedure commonly performed throughout the world up to 1960. Milligan et al. popularized the open technique. Since the procedure was relatively simple, it was adapted at one time throughout the world. This technique is popular in the UK and Europe.
The haemorrhoid complex is everted by applying artery forceps to reach the level of the anorectal ring (Fig. 3.7a–d). A V shaped incision is made in the anal and perianal skin. The point of V should lie 1–1.5 cm from the anal verge. As the dissection proceeds upward, the mucosa is divided on each side of the hemorrhoidal mass to converge toward the apex of the pedicle in order to avoid a broad bulky mucosal pedicle. Care should be taken not to injure the internal anal sphincter during dissection. The apex of the pedicle is transfixed with 1/0 Vicryl suture with round body needle. While incising the perianal skin and anal mucosa, leave sufficient islands of anoderm between the excised segments to prevent anal stenosis. After completion of the operation, the perianal wound should look like a clover or three pear-shaped wounds. Open hemorrhoidectomy is an option when the wound cannot be completely closed or in the presence of gangrene or circumferential hemorrhoids. Though the results are excellent, it is more painful in the postoperative period, takes a little longer time to heal, and incidence of postoperative stenosis is relatively high.
(a–d) Steps of open hemorrhoidectomy
188.8.131.52 Closed Hemorrhoidectomy (Ferguson)
Ferguson and Heaton reported closed hemorrhoidectomy technique in 1959. Over the years, this technique was widely accepted and practiced and is more popular in the USA. Closed hemorrhoidectomy has three principle objectives: (1) to remove as much vascular tissue as possible without sacrificing anoderm, (2) to minimize postoperative serous discharge by prompt healing, and (3) to prevent stenosis that may complicate healing of large raw wounds.
After positioning the patient, decision should be made which hemorrhoid should be removed first. Generally, the best defined, least complex hemorrhoid and that seems to be main offender should be tackled first. Tissue distortion should be avoided all the time. The larger the hemorrhoids are, the longer the incision. It should be with a ratio of 3:1 (length to breadth). The technique of excision is similar to that of open technique. After excision of long triangular segment of hemorrhoidal tissue to the level of the anorectal ring, sufficient undermining of the wound edges is accomplished to facilitate the removal of accessory hemorrhoidal tissue and tension-free closure of the wound. Starting from the pedicle, a running suture with 2/0 Vicryl is used for wound closure (Fig. 3.8a, b). No internal anal dressing is necessary. The advantages of closed hemorrhoidectomy are less postoperative discomfort, minimal inpatient stay, practically no outpatient care, and no need for subsequent dilatation. Occasionally, the surgery is done by making a linear incision in the region of the hemorrhoidal mass, undermining flaps carefully, followed by excision of hemorrhoidal tissue without removing anoderm or skin. The wound can then be closed with sutures thereby reducing the risk of postoperative stenosis. A prospective randomized trail comparing open with closed hemorrhoidectomy in patients with grade III or IV hemorrhoids demonstrated less postoperative pain in close hemorrhoidectomy group (You et al. 2005). Though another study by HO et al. (1997) concluded that closed hemorrhoidectomy was associated with faster healing, there was no difference in postoperative pain and complication.
(a, b) Primary closure after excisional hemorrhoidectomy
184.108.40.206 White Head (Submucosal) Hemorrhoidectomy
The procedure is repeated for other hemorrhoidal mass. The operation is technically difficult, bloody with high rate of postoperative stricture, loss of normal sensation, and development of ectropion. The ectropion is so common that it is called as “white head deformity.” Some surgeons, however, claimed good results after modifying the technique (Whitehead 1882; Wolff and Culp 1988).
The submucosal hemorrhoidectomy of Sir Allen Park (1956) gave good results in his hands. According to him, because no anoderm or skin was removed, the wound heals fast with less induration, scaring, and stenosis.
220.127.116.11 Laser Hemorrhoidectomy
Both carbon dioxide (CO2) and Neodymium-Yttrium-Aluminum-Garnet (Nd: YAG) laser have been used for surgical management of hemorrhoids. Either instrument can be used to excise or evaporate the tissue. When used as a cutting instrument, the technique is exactly the same as that for a blade. The duration of wound healing after laser technique is almost equal to any other technique, but there is higher risk of stenosis (Wang et al. 1991).
18.104.22.168 LigaSure Hemorrhoidectomy
LigaSure (LigaSure TM, Valleylab, Covidien) is a bipolar electrothermal device which is used to excise the hemorrhoidal tissue with the intention to reduce bleeding with minimal thermal damage of adjacent tissues.
22.214.171.124 Hemorrhoidectomy by Ultrasonic Scalpel (HUS)
Harmonic scalpel relies on ultrasonic waves producing simultaneously cutting and coagulation effect with minimal lateral thermal damage to the adjacent soft tissue and minimal bleeding. That is why this method is also known as bloodless ultrasonic scalpel hemorrhoidectomy (BUSH). This method is making scientifically proven positive waves in the method of management of grade III and IV hemorrhoids all over the world (Bulus et al. 2014). Ideally, HUS is indicated in one to two columns of grade II and grade IV hemorrhoids. Though it can be used for all three-column hemorrhoidectomy, a stapled hemorrhoidopexy is more preferable in such circumferential disease in my view (Chung et al. 2005; Tsunoda et al. 2011).
US blade vibrates longitudinally at a speed of 55.5 Hz per second, which is equivalent to 55,500 cycles per second, transferring mechanical energy to tissue. An electrical signal causes the peizoelectric ceramics in the hand piece of the US blade to expand and contract, converting electrical energy to mechanical motion which is transmitted to the blade extender. As the ultrasonic wave leaves the blade extender, its motion is amplified as it travels to the blade tip where maximum motion occurs. The blade tip moves longitudinally in a distance range of 50–100 μm.
126.96.36.199.2 Coaptive Coagulation
The coagulation effect occurs through the transfer of mechanical energy to the tissue which causes internal cellular friction thus breaking down the hydrogen bonds. It leads to protein denaturation thereby forming a sticky coagulum that seals small vessels of size <3 mm. This occurs at a temperature under 100 °C therefore minimizing smoke and charring (Tsunoda et al. 2011). Comparatively, electrocautery causes water vaporization and desiccation at a temperature between 100–150 °C, while the laser causes tissue burning and charred scab formation at a temperature of 150–400 °C.
As grip force is applied to the tissue; in combination with the blade motion, the tissue gets separated. Energy is transferred to the tissue through the active blades under applied force which minimizes lateral thermal spread.
188.8.131.52.3 Cavitation Effect
As the active blade of the US blade vibrates over the static passive blade with the tissue included in between, there is a cavity created with a low-pressure zone that causes tissue dissection. Vapors from the tissue fluid expand and spread in adjacent tissue thus causing separation of tissue layers and planes. This visualization of vascular and tissue planes enhances the precision and quality of dissection.
The US blade has several different surfaces for cutting and coagulation (Fig.3.9).
Ultrasonic scalpel blade surfaces (With Permission from Ethicon, Mumbai, India)
The comparative advantages of US blade:
Compared to other electrosurgical devices, US blade offers better control and precision for cutting and coagulation.
The lateral thermal damage with US blade is 1–3 mm which is the least as compared to bipolar (2–6 mm), laser (4–8 mm), or monopolar (4–12 mm) electrocautery (Abo-hashem et al. 2010; Bulus et al. 2014).
There is less smoke and charring.
No stray energy (jumping current sparks to adjacent tissue).
There is no neuromuscular stimulation as it is heat energy and not electrical energy.
No electricity passing through patient’s body, as in monopolar electrocautery, therefore reducing potential risk of burns especially at the exit cautery grounding plate area thus making it safe to be used in patients fitted with other electrosurgical devices like pacemakers, etc.
The procedure can be done under spinal or local anesthesia with IV sedation. Mark the area to be dissected with US tip/nose spot coagulation dots taking care to involve less anoderm but complete pedicle. Saline/lignocaine + adrenaline infiltration is done in the subcutaneous and submucosal area. This achieves better hemostasis and also causes separation of tissue planes between submucosa, where the vessels lie, and the internal anal sphincter (IAS).
A charred plastic-like rolled up coagulum is formed by the use of electric or ultrasonic devices on skin surface. In my view, the skin incision is better taken by a cold knife or scissors. This minimum one to two drops of bleeding is worth the loss than an augmented wound edge which may affect the wound healing due to increased wound edema and slough which is a potential reason for secondary wound infection and other potential complications. As it is, this minimal bleeding is reduced by the infiltration and can be easily controlled by light pressure for some time with a gauze piece held by an assistant over the wound. Being in the correct plane of dissection, which a surgeon will master eventually after operating a few cases, is the key to bloodless field of dissection.
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