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Immediate radical surgery for hemorrhoidal disease with acute extensive thrombosis
Immediate
Radical
Surgery for Hemorrhoidal
Disease with Acute Extensive
Thrombosis’”
PHILIP M. HOWARD, M.D. ANDJAMES H. PINGREE, M.D., Salt hke
From the Departments of Surgery, Holy Cross Hospital University of Utah College of Medicine, Salt Lake City, Gtuh.
tory process is seen only around the area of ulceration. Marked edema seen in acute thrombosed hemorrhoids is secondary to obstruction of the venous and lymphatic return and is not due to infection. Laurence and Murray [Z] discovered that there is no difference in inflammatory infiltrate between hemorrhoidal disease with thrombosis and uncomplicated hemorrhoidal disease, and that only in the presence of ulceration was there significant inflammatory reaction. However, in the presence of ulceration, the inflammatory reaction is limited to the surface areas and does not involve the deep tissues where the usual surgical procedure is involved. Stern [3] postulates that even though the anal canal has many organisms, the tissues are able to cope with the bacterial flora that is normally present, as are the tissues of the oral cavity. Therefore, it seems that the fear of severe complications after surgery for hemorrhoidal disease with acute thrombosis is borne out neither by the pathologic findings nor by reports of actual cases. We have found that by operating early on patients with acute thrombosed hemorrhoids, the severe painful process is converted into one of more comfort and affords the patient a shorter stay in the hospital. There is also the added benefit of having performed a definitive surgical procedure. In the twenty-five patients of our series which extends over a five year period, there were no serious complications such as pylephlebitis, hemorrhage, stricture formation, or infection. This corresponds with the results in thirtynine cases reported by Tinckler and Baratham
and
DISEASE with aCUte extensive H EMORRHOIDAL thrombosis causes severe pain and disability which are prolonged by the use of conservative management. Resolution eventually takes place but gangrenous ulceration and sloughing are common sequelae. The patient is often incapacitated for two to three weeks while undergoing supportive treatment, such as packs, bedrest, heat, and analgesics. Replacement of the prolapsed hemorrhoids with thrombosis usually cannot be maintained and is always severely painful. There has been no alternative to conservative treatment because of the fear that surgery for hemorrhoidal disease with acute thrombosis is dangerous. This fear was based on the risk of spreading the supposed infection causing pylephlebitis, secondary hemorrhage or stricture formation, or embolization with abscess in the liver and lungs. However, Ackland [2 ], in searching the literature, found only one case of pylephlebitis and this followed routine hemorrhoidectomy. He found two cases of gangrene of the rectum, one after routine hemorrhoidectomy and the other after hemorrhoidectomy for acute thrombosed hemorrhoids. However, he also found one case of gangrene after conservative therapy without surgery. Therefore, these surgical complications seem very rare indeed. The reason for this is probably that infection per se is not observed on histologic sections unless the mucosal or skin surfaces are ulcerated, and then the inflamma-
* Presented at the Twentieth Annual Meeting of the Southwestern Denver, Colorado, April 22-25, 1968. Vol. Illi.
November
1968
City. C,+trrir
777
Surgical Con,yress,
771
Howard
[4], in fifteen cases by Smith [5], the series of Salvati, Hamandi, and Kratzer [6], and nineteen cases by Stern [7]. The following is an illustrative case from our series of twenty-five. CASE
REPORT
The patient (H.M.), a forty year old male truck driver, was admitted to the hospital with a history of severe rectal pain. Physical examination showed a prolapsed hemorrhoidal mass with extensive thrombosis and edema around the entire anal canal. He was taken to surgery on the day of admission. With the use of a modified Whitehead anoproctoplasty procedure, as reported by Howard and Deles [8], the prolapsed hemorrhoidal disease with thrombosis was corrected. The following method was employed. The anal sphincter was gently dilated with a gauged David anoscope and the prolapsed edematous skin grasped with Allis forceps. A circular incision was made just beyond the pectinate line to separate the anoderm from the mucosa. The dissection was carried down to the sphincter mechanism until the normal rectal mucosa was encountered. The dissected mucosal disease, which included the thrombosed vein segments, was excised. Many large thrombosed vein segments involved with the anoderm were removed. All of the specialized anal skin was preserved. The anoderm was then sutured to the rectal mucosa around the entire periphery, using interrupted No. 20 chromic catgut, thus relining the anal canal. The patient had relief of acute symptoms and was discharged without complications on the fourth postoperative day. A postoperative follow-up study re-
and
Pingree vealed complete cure of the previous hemorrhoidal disease. SUMMARY
Immediate surgical removal of acute thrombosed hemorrhoids has proved to be a safe and effective way of converting a very painful and long process into a short and more comfortable convalescence. Serious complications have not occurred in our series. We recommend consideration of this technic in the treatment of hemorrhoidal disease with acute extensive thrombosis. REFERENCES 1. ACKLAND, T. H. The
2.
3.
4.
5. 6.
7.
8.
treatment of prolapsed gangrenous hemorrhoids. Australian & New Zealand J. Surg., 30: 201, 1961. LAURENCE, A. E. and MURRAY, A. J. Histopathology of prolapsed and thrombosed hemorrhoids, Dis. Colon. 6 Rectum, 5: 56, 1962. STERN, W. Thrombosed hemorrhoids: immediate surgical treatment. M. J. Australia, 2: 635, 1964. TINCKLER, L. F. and BARATHAM, G. Immediate hemorrhoidectomy for prolapsed piles. Lance& 2: 1145, 1964. SMITH, M. Early operation for acute hemorrhoids. &it. J. Surg., 54: 141, 1967. SALVATI, E. P., HAMANDI, W. J., and KRATZER, G. L. Acute hemorrhoidal disease. J. Internat. Coil. Surg., 34: 662, 1960. STERN, W. Painless hemorrhoidectomy. Follow-up after 100 operations. M. J. Australia, 1: 715, 1966. HOWARD, P. M. and DELES, V. D. A new look at an old disease. Am. J. Surg., 106: 566, 1963.
The American
Journal
of Surgery
Radical
Surgery for Hemorrhoidal
Disease with Acute Extensive
Thrombosis’”
PHILIP M. HOWARD, M.D. ANDJAMES H. PINGREE, M.D., Salt hke
From the Departments of Surgery, Holy Cross Hospital University of Utah College of Medicine, Salt Lake City, Gtuh.
tory process is seen only around the area of ulceration. Marked edema seen in acute thrombosed hemorrhoids is secondary to obstruction of the venous and lymphatic return and is not due to infection. Laurence and Murray [Z] discovered that there is no difference in inflammatory infiltrate between hemorrhoidal disease with thrombosis and uncomplicated hemorrhoidal disease, and that only in the presence of ulceration was there significant inflammatory reaction. However, in the presence of ulceration, the inflammatory reaction is limited to the surface areas and does not involve the deep tissues where the usual surgical procedure is involved. Stern [3] postulates that even though the anal canal has many organisms, the tissues are able to cope with the bacterial flora that is normally present, as are the tissues of the oral cavity. Therefore, it seems that the fear of severe complications after surgery for hemorrhoidal disease with acute thrombosis is borne out neither by the pathologic findings nor by reports of actual cases. We have found that by operating early on patients with acute thrombosed hemorrhoids, the severe painful process is converted into one of more comfort and affords the patient a shorter stay in the hospital. There is also the added benefit of having performed a definitive surgical procedure. In the twenty-five patients of our series which extends over a five year period, there were no serious complications such as pylephlebitis, hemorrhage, stricture formation, or infection. This corresponds with the results in thirtynine cases reported by Tinckler and Baratham
and
DISEASE with aCUte extensive H EMORRHOIDAL thrombosis causes severe pain and disability which are prolonged by the use of conservative management. Resolution eventually takes place but gangrenous ulceration and sloughing are common sequelae. The patient is often incapacitated for two to three weeks while undergoing supportive treatment, such as packs, bedrest, heat, and analgesics. Replacement of the prolapsed hemorrhoids with thrombosis usually cannot be maintained and is always severely painful. There has been no alternative to conservative treatment because of the fear that surgery for hemorrhoidal disease with acute thrombosis is dangerous. This fear was based on the risk of spreading the supposed infection causing pylephlebitis, secondary hemorrhage or stricture formation, or embolization with abscess in the liver and lungs. However, Ackland [2 ], in searching the literature, found only one case of pylephlebitis and this followed routine hemorrhoidectomy. He found two cases of gangrene of the rectum, one after routine hemorrhoidectomy and the other after hemorrhoidectomy for acute thrombosed hemorrhoids. However, he also found one case of gangrene after conservative therapy without surgery. Therefore, these surgical complications seem very rare indeed. The reason for this is probably that infection per se is not observed on histologic sections unless the mucosal or skin surfaces are ulcerated, and then the inflamma-
* Presented at the Twentieth Annual Meeting of the Southwestern Denver, Colorado, April 22-25, 1968. Vol. Illi.
November
1968
City. C,+trrir
777
Surgical Con,yress,
771
Howard
[4], in fifteen cases by Smith [5], the series of Salvati, Hamandi, and Kratzer [6], and nineteen cases by Stern [7]. The following is an illustrative case from our series of twenty-five. CASE
REPORT
The patient (H.M.), a forty year old male truck driver, was admitted to the hospital with a history of severe rectal pain. Physical examination showed a prolapsed hemorrhoidal mass with extensive thrombosis and edema around the entire anal canal. He was taken to surgery on the day of admission. With the use of a modified Whitehead anoproctoplasty procedure, as reported by Howard and Deles [8], the prolapsed hemorrhoidal disease with thrombosis was corrected. The following method was employed. The anal sphincter was gently dilated with a gauged David anoscope and the prolapsed edematous skin grasped with Allis forceps. A circular incision was made just beyond the pectinate line to separate the anoderm from the mucosa. The dissection was carried down to the sphincter mechanism until the normal rectal mucosa was encountered. The dissected mucosal disease, which included the thrombosed vein segments, was excised. Many large thrombosed vein segments involved with the anoderm were removed. All of the specialized anal skin was preserved. The anoderm was then sutured to the rectal mucosa around the entire periphery, using interrupted No. 20 chromic catgut, thus relining the anal canal. The patient had relief of acute symptoms and was discharged without complications on the fourth postoperative day. A postoperative follow-up study re-
and
Pingree vealed complete cure of the previous hemorrhoidal disease. SUMMARY
Immediate surgical removal of acute thrombosed hemorrhoids has proved to be a safe and effective way of converting a very painful and long process into a short and more comfortable convalescence. Serious complications have not occurred in our series. We recommend consideration of this technic in the treatment of hemorrhoidal disease with acute extensive thrombosis. REFERENCES 1. ACKLAND, T. H. The
2.
3.
4.
5. 6.
7.
8.
treatment of prolapsed gangrenous hemorrhoids. Australian & New Zealand J. Surg., 30: 201, 1961. LAURENCE, A. E. and MURRAY, A. J. Histopathology of prolapsed and thrombosed hemorrhoids, Dis. Colon. 6 Rectum, 5: 56, 1962. STERN, W. Thrombosed hemorrhoids: immediate surgical treatment. M. J. Australia, 2: 635, 1964. TINCKLER, L. F. and BARATHAM, G. Immediate hemorrhoidectomy for prolapsed piles. Lance& 2: 1145, 1964. SMITH, M. Early operation for acute hemorrhoids. &it. J. Surg., 54: 141, 1967. SALVATI, E. P., HAMANDI, W. J., and KRATZER, G. L. Acute hemorrhoidal disease. J. Internat. Coil. Surg., 34: 662, 1960. STERN, W. Painless hemorrhoidectomy. Follow-up after 100 operations. M. J. Australia, 1: 715, 1966. HOWARD, P. M. and DELES, V. D. A new look at an old disease. Am. J. Surg., 106: 566, 1963.
The American
Journal
of Surgery