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A modern look at the problem of hemorrhoids
MARCH
The
American
dournal
1972
of Surgery VOLUME
123
NUMBER
3
EDITORIAL
A Modern Look at the Problem of Hemorrhoids Robert furell, MD, New York, New York
The writing of this editorial is prompted by a recent publication on two newer forms of therapy, especially that concerning anal dilation under anesthesia. Since therapeutic maneuvers have been legion, a modern look or reappraisal of this problem appears to be in order. Investigations of the cause of hemorrhoidal disease have remained controversial or inconclusive (a conclusion in which nothing is concluded). The only available solid information is: (1) the experimental evidence of reverse of flow of venous hemorrhoidal blood in the absence of valves within the hemorrhoidal veins in adults which could lead to stasis in the vascular tree and (2) and the clinical observation of a familial tendency toward the formation of hemorrhoidal disorders in many patients. Hemorrhoidal disease in three generations of the same family is encountered frequently. Also, occupational strain may precipitate prolapse of existing internal hemorrhoids (as well as produce anoperianal hematomas). In view of this limited knowledge of the cause, therapy naturally leaves much to be desired. In a past editorial it was stated that the management of piles may be effected by three alternative methods: They may be neglected, injected, or resected. To these we may now add rubber band ligation and anal dilation.
From the Department of Surgery, Albert Einstein College of Medicine, New York, New York 10461. Reprint requests should be addressed to Dr Turell. 25 East 83rd Street, New York, New York 10028.
Volume 123, March 1972
In a personal clinical experience I determined that 20 to 25 per cent of patients with anatomic mixed hemorrhoids which are either asymptomatic or mildly symptomatic require no treatment. Another 30 per cent of patients with small to medium-sized internal bleeding and/or prolapsing, but spontaneously reducible, hemorrhoids are ideal for injectional sclerosing therapy, For the past decade I have treated approximately 300 patients with such lesions by anal dilation, without anesthesia, utilizing a speculum of 2.5 cm in diameter or larger. The patients usually become symptom-free after one or two dilations. Seldom are more than four weekly anal dilations required for the control of bleeding. To date, no untoward reaction or complications have been encountered. Over 70 per cent of patients remain symptom-free for variable periods of time. Anal. dilation, however, does not appear to be a “cure”; the size of the hemorrhoids is seldom reduced. After a limited trial of rubber band ligation in the treatment of a similar group of patients I abandoned this procedure for reasons which will be given subsequently. For patients with large internal and external (mixed) hemorrhoids with or without prolapse, partitularly when the prolapse is not spontaneously reducible, I continue to advise resection, that is, the open type of nontraumatizing hemorrhoidectomy which is curable. After this operation there is simply no need for therapeutic crutches or props be they frequent postoperative digital or instrumental anal
245
Editorial
dilations, topical applications of a variety of medications to promote wound healing, injections of either ethyl alcohol or slowly absorbing anesthetic drugs at the time of operation, or anal sphincterotomy. These so-called aids are mere camouflages and poor substitutes for experience, refinements of technic, gentleness in handling of tissue during operation, and the preservation of sufficient elastic integument between wounds. These last considerations are in complete consonance with Halsted’s solid concepts and principles of surgery. In recent years a number of so-called plastic or other high sounding technics of hemorrhoidectomy have been proposed; hardly a year passes without a description of a new procedure. However, the large number of innovations and technics of hemorrhoidectomy that have been proposed and abandoned (they are said to be as numerous as the number of surgeons performing them) at once shows considerable therapeutic disappointment by many qualified surgeons with the operation and suggests that cures are not obtained in all patients and that convalescence is anything but smooth or uneventful.
246
In the treatment of mixed hemorrhoids neither injectional sclerotherapy, nor anal dilations, nor rubber band ligations are substitutes for a properly performed hemorrhoidectomy. Despite the present day popularity I regard rubber band ligation as incomplete in scope. Significantly, this procedure does not provide a specimen for microscopic examination. The exclusion of histologic examination of tissue destined to necrose may be of crucial significance in some instances. Adenocarcinoma or melanoma within the hemorrhoidal mass is occasionally detected by the pathologist when not at all suspected by the clinician. This has occurred in two of my patients. As stated elsewhere, the recurrence of hemorrhoids after a well performed hemorrhoidectomy may be the result of incomplete removal of the primary varices, which is preventable, or the inevitable result of enlargement with the passage of time of the secondary hemorrhoidal varices that were inconspicuous at the time of the original operation. It is believed that the latter cause comes into play more often than is usually appreciated; absence of proof is no proof of absence.
The American Journal of Surgery
The
American
dournal
1972
of Surgery VOLUME
123
NUMBER
3
EDITORIAL
A Modern Look at the Problem of Hemorrhoids Robert furell, MD, New York, New York
The writing of this editorial is prompted by a recent publication on two newer forms of therapy, especially that concerning anal dilation under anesthesia. Since therapeutic maneuvers have been legion, a modern look or reappraisal of this problem appears to be in order. Investigations of the cause of hemorrhoidal disease have remained controversial or inconclusive (a conclusion in which nothing is concluded). The only available solid information is: (1) the experimental evidence of reverse of flow of venous hemorrhoidal blood in the absence of valves within the hemorrhoidal veins in adults which could lead to stasis in the vascular tree and (2) and the clinical observation of a familial tendency toward the formation of hemorrhoidal disorders in many patients. Hemorrhoidal disease in three generations of the same family is encountered frequently. Also, occupational strain may precipitate prolapse of existing internal hemorrhoids (as well as produce anoperianal hematomas). In view of this limited knowledge of the cause, therapy naturally leaves much to be desired. In a past editorial it was stated that the management of piles may be effected by three alternative methods: They may be neglected, injected, or resected. To these we may now add rubber band ligation and anal dilation.
From the Department of Surgery, Albert Einstein College of Medicine, New York, New York 10461. Reprint requests should be addressed to Dr Turell. 25 East 83rd Street, New York, New York 10028.
Volume 123, March 1972
In a personal clinical experience I determined that 20 to 25 per cent of patients with anatomic mixed hemorrhoids which are either asymptomatic or mildly symptomatic require no treatment. Another 30 per cent of patients with small to medium-sized internal bleeding and/or prolapsing, but spontaneously reducible, hemorrhoids are ideal for injectional sclerosing therapy, For the past decade I have treated approximately 300 patients with such lesions by anal dilation, without anesthesia, utilizing a speculum of 2.5 cm in diameter or larger. The patients usually become symptom-free after one or two dilations. Seldom are more than four weekly anal dilations required for the control of bleeding. To date, no untoward reaction or complications have been encountered. Over 70 per cent of patients remain symptom-free for variable periods of time. Anal. dilation, however, does not appear to be a “cure”; the size of the hemorrhoids is seldom reduced. After a limited trial of rubber band ligation in the treatment of a similar group of patients I abandoned this procedure for reasons which will be given subsequently. For patients with large internal and external (mixed) hemorrhoids with or without prolapse, partitularly when the prolapse is not spontaneously reducible, I continue to advise resection, that is, the open type of nontraumatizing hemorrhoidectomy which is curable. After this operation there is simply no need for therapeutic crutches or props be they frequent postoperative digital or instrumental anal
245
Editorial
dilations, topical applications of a variety of medications to promote wound healing, injections of either ethyl alcohol or slowly absorbing anesthetic drugs at the time of operation, or anal sphincterotomy. These so-called aids are mere camouflages and poor substitutes for experience, refinements of technic, gentleness in handling of tissue during operation, and the preservation of sufficient elastic integument between wounds. These last considerations are in complete consonance with Halsted’s solid concepts and principles of surgery. In recent years a number of so-called plastic or other high sounding technics of hemorrhoidectomy have been proposed; hardly a year passes without a description of a new procedure. However, the large number of innovations and technics of hemorrhoidectomy that have been proposed and abandoned (they are said to be as numerous as the number of surgeons performing them) at once shows considerable therapeutic disappointment by many qualified surgeons with the operation and suggests that cures are not obtained in all patients and that convalescence is anything but smooth or uneventful.
246
In the treatment of mixed hemorrhoids neither injectional sclerotherapy, nor anal dilations, nor rubber band ligations are substitutes for a properly performed hemorrhoidectomy. Despite the present day popularity I regard rubber band ligation as incomplete in scope. Significantly, this procedure does not provide a specimen for microscopic examination. The exclusion of histologic examination of tissue destined to necrose may be of crucial significance in some instances. Adenocarcinoma or melanoma within the hemorrhoidal mass is occasionally detected by the pathologist when not at all suspected by the clinician. This has occurred in two of my patients. As stated elsewhere, the recurrence of hemorrhoids after a well performed hemorrhoidectomy may be the result of incomplete removal of the primary varices, which is preventable, or the inevitable result of enlargement with the passage of time of the secondary hemorrhoidal varices that were inconspicuous at the time of the original operation. It is believed that the latter cause comes into play more often than is usually appreciated; absence of proof is no proof of absence.
The American Journal of Surgery