Fig. 9.1
a, b Segmental, third grade hemorrhoidal prolapse (digital reposition possible)
The staging of hemorrhoids is carried out by thorough history taking and a meticulous proctological examination. In this case, proctoscopy is not a static diagnostic measure but a functional investigation.
Tip
Even if it might be unpleasant for the patient, only by pressing can the extent of prolapse and thus the correct staging be determined.
First-stage hemorrhoids are diagnosed exclusively by proctoscopy. Inspection or digital exploration alone is of no diagnostic value. Even coloscopy in inversion may not detect the correct stage, since the degree of prolapse remains obscured.
Based on permanent anatomical changes within the anal canal due to the enlarged and prolapsing hemorrhoidal vascular convolutes, a complex of symptoms ensues which is predominantly a consequence of a disturbed fine continence, the clinical hemorrhoidal complex. It is noteworthy that the symptoms caused by hemorrhoids may be very variable and may also be independent of the morphology of the hyperplastic hemorrhoids. A frequent symptom is hematochezia, which is a consequence of mechanical stress to the prolapsed mucosa during defecation. The visible, bright-red blood does not originate from the arteriovenous plexuses but from congested arterial mucosal vessels which run near the surface of the hemorrhoidal convolutes. The disturbance of fine continence produces wetting and stool soiling.
Tip
Soiling, once noticed, is often erroneously interpreted as sphincteric insufficiency.
As a result of temporary or permanent mucosal prolapse, a moist perianal milieu is produced, causing irritative–toxic anal eczema with pruritus. In addition, the prolapse causes a blunt pressing sensation similar to the impression of a foreign body in the anal area.
Pains which are precisely localized are not characteristic for hyperplastic hemorrhoids. Exceptionally, they may be associated with a thrombosed hemorrhoidal convolute (◘ Fig. 9.2).
Fig. 9.2
Acutely thrombosed hemorrhoidal prolapse
Treatment
Hemorrhoidal disease is one of the most frequent proctological diseases and is often referred to as a civilization disease. It has been estimated that up to 40% of the population of an industrial nation suffer from enlarged hemorrhoidal plexuses. At least every sixth person is affected by symptoms and sequelae of hemorrhoidal disease.
The primary aim of treatment is a long-lasting or permanent resolution of hemorrhoidal symptoms by restoration of the original anatomical and physiological conditions, usually achieved by creating hemorrhoids of normal size.
Tip
The need for treatment of enlarged hemorrhoids is tightly linked to symptoms and the degree of suffering of the patient. In the case of asymptomatic enlarged hemorrhoids, treatment is not mandatory!
The treatment of hemorrhoidal disease is determined by the stage classification described before. Independently, some additional basic treatment is recommended. Its rationale is the regulation of bowel movements by fiber-rich diet, increase of stool volume, and teaching of physiological defecation. Furthermore, anal hygienic measures are of importance such as cleansing with normal tap water, avoidance of moist cleansing towels, and possibly the regular administration of skin-caring substances, for example, soft zinc paste.
The application of ointments/pastes and suppositories is no causative treatment, which means it has no influence on the hyperplastic hemorrhoidal convolutes. Topical substances may only influence and significantly reduce hemorrhoidal symptoms. A «restitutio ad integrum» may only be achieved by active medical intervention.
Tip
Hyperplastic hemorrhoidal convolutes are often misinterpreted as varices. There is, however, no plausible rationale for treatment with drugs that enhance the venous tonus, such as flavonoids which are useful for treating real varices.
The term «conservative hemorrhoidal therapies» comprises nonoperative procedures such as sclerosing therapy, rubber band ligation, and infrared therapy.
Conservative Treatment: Sclerosing Therapy
The sclerosing of hemorrhoids can be accomplished according to two different techniques, the method according to Blond and that according to Blanchard.
Indication
Sclerosing therapy is the method of choice in first-stage hemorrhoids.
Personnel Requirements
All conservative treatments may be, in principle, carried out by the treating doctor alone. For litigation reasons, however, it is advisable to have assisting personnel present.
Instrumental Requirements
Generally, all proctological interventions may be carried out in lithotomy position, in side position, and in knee–elbow position. Most comfort to the patient is offered by a special examination and treatment chair which allows direct visual contact between the patient in lithotomy position and the treating doctor. Commercially available proctoscopes are the ones according to Morgan with an open front end and according to Blond with a lateral window. For the sclerosing procedure, a suitable sterile solution such as polidocanol is drawn into a 1-ml single-use syringe with a cannula (e.g., 20G/0.9 mm, 70 mm length). A suction device for removal of stool residues and an infrared coagulator (see below) for hemostasis may be helpful.
Practical Execution
With the Blond method, the sclerosing agent is submucosally directly injected into the hemorrhoidal tissue in a circular fashion. On the other hand, with the Blanchard method, the agent is injected next to the vessels in 3, 7, and 11 o’clock lithotomy position to reduce arterial inflow (◘ Fig. 9.3). Treatment sessions should be repeated 3–5 times over several weeks.
Tip
Left out, because of no use for the English-speaking market!
Conservative Treatment: Rubber Band Ligation
Indication Rubber band ligation is the therapy of choice in the treatment of second-stage hemorrhoids.
Personnel Requirements
As for sclerosing treatment
Instrumental Requirements
As in sclerosing treatment. Rubber band ligation requires a proctoscope with frontal opening and an applicator system for the rubber ring, either a rubber band suction applicator or a mechanical ligation instrument (e.g., according to Rudd or McGivney/Schütz) with a hemorrhoidal grasping clamp.
Practical Execution
During rubber band ligation according to Barron (◘ Fig. 9.4), by means of a special applicator, a rubber ring is placed around the base of a hemorrhoidal convolute through the proctoscope. In order to avoid a slippage of the rubber ring, an additional injection of a sclerosing agent into the occluded hemorrhoidal node may be done. The occlusion of the hemorrhoidal tissue results in a necrosis within a few days, with the result of a sequestration of the necrotic tissue during the following 1–3 weeks.
When applying the rubber band, it is of utmost importance to position it well above the dentate line in a pain-free area. If the patient expresses pain during or directly following application of the rubber band (ask!), the rubber band should be removed (use of fistula hook is helpful!) and placed a new some distance more orally from the previous position.
Clinically relevant hemorrhages due to sequestration of the necrotic tissue within 1–3 weeks are observed in less than 1% of cases. They may, however, become relevant in cases of anemia and then require an intervention, usually by stitch ligation of the bleeding spot.
Therefore, it is mandatory to inform the patient about the possibility of this rare complication and to supply emergency phone numbers and emergency addresses.
Tip
In patients with allergy to latex, special latex-free rubber bands should be used for the ligation.
For economic reasons, a simultaneous ligation of all enlarged hemorrhoidal convolutes might be desirable. However, this might be followed by an increase of potential complications such as bleeding, vasovagal syncope and disturbances of micturition and defecation.
Conservative Treatment: Infrared Therapy
Indication Infrared therapy is suitable for achieving hemostasis in first- and second-stage hemorrhoids.
Personnel Requirements
As in sclerosing therapy
Instrumental Requirements
As for sclerotherapy
Infrared therapy requires a proctoscope with frontal opening and an infrared coagulator (◘ Fig. 9.5).
Fig. 9.5
a, b Infrared coagulator (b with permission from Lumatec)
Practical Execution
In infrared therapy, a pistol-shaped infrared coagulator with exchangeable protective cap is introduced via the proctoscope with a frontal opening. By direct contact of the coagulator tip with the bleeding site, by means of heat application, localized tissue necrosis with hemostatic properties is induced.
Tip
Infrared coagulation is also suitable for stopping bleedings arising from a stitch canal injury following sclerosing therapy.
Semi-operative Treatment: Doppler-Guided Hemorrhoidal Artery Ligation (HAL) with/without Recto-anal Repair (RAR)
In HAL (◘ Fig. 9.6), second- and third-stage enlarged hemorrhoidal convolutes are treated in a semi-operative fashion, usually requiring brief anesthesia or analgo-sedation. Using a specifically designed proctoscope with a Doppler ultrasonic probe, the hemorrhoidal artery is localized and stitch ligated under sonographical control. Recently it has been advocated that HAL should be combined with a recto-anal repair (RAR) where concomitantly the prolapsing hemorrhoidal convolutes are tied up.
Fig. 9.6
a–c Doppler-guided ligation of hemorrhoidal artery (HAL) (b and c from Lange et al. 2012). In the text: hemorrhoidal arteries, rectum, ligature window, ultrasound Doppler sensor, hemorrhoids
The actual evidence concerning HAL with or without RAR is not solid enough yet as to recommend the strategy for a routine situation. HAL–RAR is to be looked at as an intermediate procedure between nonoperative and operative–resectional treatments, to be used, for example, as an option following unsuccessful rubber band ligation in second-stage hemorrhoids.
Operative Treatment
When third-stage hemorrhoids are diagnosed which do not retract spontaneously after defecation and therefore have to be repositioned manually, operative treatment is indicated.
The operative treatment is not an endoscopic procedure, but it appears to be essential to give an overview of the actual procedures, since endoscopic procedures might become necessary after the operation and knowledge about the differential indications in relation to conservative procedures is most relevant. For more details, textbooks for surgery should be consulted.
There are two different approaches for the operative procedures: anoderm-resecting and anoderm-preserving techniques.
Popular Operative Procedures
Anoderm-resecting procedures:
Open hemorrhoidectomy according to Milligan–Morgan
Closed hemorrhoidectomy according to Ferguson
Anoderm-preserving procedures:
Submucous hemorrhoidectomy according to Parks
Reconstructive hemorrhoidectomy according to Fansler–Arnold
Supraanodermal hemorrhoidopexy (stapler) according to Longo
In the frequently applied open hemorrhoidectomy according to Milligan–Morgan (◘ Fig. 9.7), the enlarged hemorrhoidal convolutes are excised together with the adjacent anoderm, leaving the closure of the defect to secondary wound healing.
Fig. 9.7
Segmental hemorrhoidectomy (Milligan–Morgan operation). a Preoperative finding with segmental anal hemorrhoidal prolapse and mariscas at 5 o’clock lithotomy position. b Segmental resection of hypertrophic hemorrhoidal tissue preserving the adjacent M. sphincter ani internus. c Postoperative result
The also frequently applied stapler hemorrhoidopexy according to Longo (◘ Figs. 9.8, 9.9, and 9.10) combines the resection of the prolapsing hemorrhoidal convolutes with a lifting of the prolapsed hemorrhoids, avoiding injury to the pain-sensitive anoderm. The stapler procedure is therefore well suited for third-stage circular hemorrhoids which can be repositioned. This procedure is not indicated for fourth-stage fixed anal prolapse, however!
Fig. 9.8
Stapler hemorrhoidopexy (Longo operation)
Fig. 9.9
Stapler hemorrhoidopexy (Longo operation). a Preoperative finding with circular anal hemorrhoidal prolapse. b Insertion of the opened stapler. c Before closure of the stapler and after tying the purse-string suture. d Postoperative result
Fig. 9.10
Stapler hemorrhoidopexy (Longo operation). a Preoperative finding with circular prolapse. b Postoperative result
9.2 Anal Fistula (AWMF Kryptoglanduläre Analfisteln; Heitland 2012)
General Aspects: Pathogenesis and Symp toms
Anal fistulae (◘ Fig. 9.11) usually originate from the anal cryptae in the area of the dentate line. Starting with a so-called «cryptoglandular» infection of the regional proctodeal glands, a primary abscess is established which normally shows an unapparent clinical course, resulting either in a spontaneous healing or a drainage into the anal canal. If, however, a propagation of the inflammation along regional structures and along the lowest resistance into different spaces is the consequence (submucosal, subanodermal, intersphincteric, transsphincteric, suprasphincteric), a secondary abscess ensues, causing the clinically apparent anal abscess. When this abscess spontaneously finds its way to the skin or neighboring structures, a fistula is constituted. Therefore, anal abscess and anal fistula, as far as etiology is concerned, are the same disease entity: the anal abscess is the acute and the anal fistula the chronic manifestation of the same underlying disorder.
Fig. 9.11
Classification of anal fistulae: 1 suprasphincteric, 2 subanodermally, 3 intersphincteric, 4 transsphincteric
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