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Modern Management of Hemorrhoids
Symposium on Colon and Anorectal Surgery
Modern Management of Hemorrhoids John G. Buls, MB., B.S.,* and Stanley M. Goldberg, M.D. t
Problems attributed to hemorrhoids have plagued western civilization for centuries; however, controversy still exists as to the causation and precise pathology of the condition. Moreover, there is no universal agreement as to the optimal management. Recently an anatomical and clinical study outlined the nature of hemorrhoids and this has given us a guideline to rational therapy for hemorrhoidal disease. 16 Furthermore, new techniques of management allow for individualization so that treatment can be fitted to the patient's special needs. Because of this, operative interventions have become less frequently indicated or necessary.6
Etiology The human anal canal is lined by specialized discrete submucosal vascular cushions that vary in size in different individuals. Such tissues can be demonstrated in the fetus and even the embryo so their presence does not constitute disease. Under certain conditions, other factors become operative, thus changing this normal state into one of disease. Repeated straining at defecation in an attempt to pass a hard, small volume stool will result in chronic engorgement of these cushions with possible bleeding. If such conditions persist, protrusion of the cushions may occur; this may become a permanent state. For the latter state of affairs to exist, rectal mucosal prolapse must accompany the prolapsing hemorrhoid. However, one must be aware that this condition can also occur independently of hemorrhoidal disease, although repeated straining in an attempt to pass hard stools appears to be a common causative factor. Recently, emphasis has been placed on dietary factors to explain the occurrence of hemorrhoids. Epidemiologic studies have pointed out the differing incidence of this and other diseases in different cultures. 5
"Senior Lecturer and Assistant Surgeon, University of Melbourne at St. Vincent's Hospital, Fitzroy, Australia; Formerly, Fellow, Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, Minnesota tClinical Professor of Surgery, and Director, Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, Minnesota Surgical Clinics of North America- Vol. 58, No, 3, June 1978
469
470
JOHN G. BULS AND STANLEY
M.
GOLDBERG
The western type low residue diet is implicated since correction of this by dietary regulation or addition of hydrophilic colloids to act as bulk formers may relieve hemorrhoidal symptoms and, in some cases, may reverse the early pathological changes.
Degrees of Hemorrhoidal Symptoms For a rational and individualized approach to the management of patients with hemorrhoidal disease, a classification of degree of symptoms is required: 10 First degree hemorrhoids are said to be present when the patient complains of painless, bright red bleeding associated with defecation. Examination of such patients will reveal internal hemorrhoids of variable size projecting into the lumen of the anal canal. If the symptoms consist of protrusion through the anal sphincter on straining, but spontaneous reduction on cessation of straining, second degree hemorrhoids are the problem. Protrusion may also occur without excessive straining following which it is necessary to replace the hemorrhoids digitally. This state usually occurs with defecation and is classified as third degree hemorrhoids. With longstanding disease, protrusion becomes chronic so that digital reduction is no longer possible and the hemorrhoids permanently protrude through the anus. In such instances,!ourth degree hemorrhoids are present. The anatomy of the venous drainage of the anal canal can be divided into two distinct parts which have connections. The internal hemorrhoidal plexus drains via the superior rectal veins, eventually into the portal venous system. The external hemorrhoidal plexus, situated under the perianal skin, drains into the somatic circulation. This external plexus is prone to spontaneous thrombosis, causing distressing symptoms of severe pain in the area. In the early stages this is readily treated by excision of the thrombosed external hemorrhoid under adequate local anesthesia. Incision and expression of the clot are unsatisfactory since the clots are usually multiple. Moreover, such a technique predisposes to the formation of skin tags. In the latter stages of the condition, when pain subsides, no active treatment apart from reassurance is necessary, as the condition will spontaneously resolve(Fig. 1). If this procedure is adequately performed, it may obviate the need for a subsequent hemorrhoidectomy. Repeated episodes of thrombosis or multiple thrombosed external hemorrhoids are indications for hemorrhoidectomy. TREATMENT OF INTERNAL HEMORRHOIDS Nonoperative Measures Nonoperative treatment include dietary education, the use of hydrophilic bulk-forming agents, sclerotherapy by submucosal injections, and rubber band ligation. DIET. In the majority of patients with Stage I hemorrhoids, infrequent hard stools are the basis for their complaints. In many cases this
471
MODERN MANAGEMENT OF HEMORRHOIDS
watching
4
9
10
11
12
13
14
time in days Figure 1.
Rational management of thrombosed external hemorrhoids.
problem can be reversed by dietary manipulation, whereby constipating foods, especially d3iry products, are avoided and higher fiber foods with increased amounts of fluids are encouraged. On occasion it may be necessary to add a hydrophilic bulk-forming agent. In all cases, it is necessary to perform a complete evaluation of the colon and rectum to exclude other pathology. In young patients a proctosigmoidoscopy will suffice; however, in older patients and in those with unusual symptoms, barium enema or colonoscopy may be necessary before treatment is commenced. SCLEROTHERAPY. Patients with Stage I or II disease may benefit from injection therapy, whereby a sclerosing agent such as 5 per cent phenol in vegetable oil is injected into the submucosa immediately above the hemorrhoids. I. 10 This will cause submucosal scarring with consequent fixation of the overlying mucosa. This technique is effective but is imprecise and should be used only for uncomplicated internal hemorrhoids with or without early protrusion. RUBBER BAND LIGATION. This is a simple effective technique for the management of patients with Stage I or II hemorrhoids. It may also be used in Stage III hemorrhoids, and it is the treatment of choice for most cases of rectal mucosal prolapse. I, 3, 4 As an outpatient procedure, a constricting rubber band is placed high in the anal canal on the most redundant portion of the rectal mucosa, immediately above the internal hemorrhoid. Incorporated tissue sloughs in approximately five to seven days, leaving a localized area of inflammation which results in sclerosis and fixation. Such a technique does not require anesthesia or analgesia since any excessive discomfort indicates that the band has been placed too low and should be removed immediately. This method provides a more precise result than injection therapy since there is a controlled loss of redundant mucosa. Repeated applications of the band to other internal hemorrhoidal areas may be carried out at six to eight week intervals until the patient's symptoms are totally relieved. Conservative Operative Procedures Conservative operative treatment has recently been introduced in an attempt to manage all patients with hemorrhoids as outpatients
472
JOHN G. BULS AND STANLEY
M.
GOLDBERG
without the need for admission to the hospital. These methods include cryosurgery, anal dilatation, and partial internal sphincterotomy. CRYOSURGERY. By use of recently developed cryoprobes activated by carbon dioxide, nitrous oxide, or liquid nitrogen,12 it is possible to freeze hemorrhoidal tissues. This procedure can be undertaken without anesthesia; I. 14 however, at best, it causes extreme discomfort to the patient and, in most cases, pain. The technique is ultimately imprecise since the amount of tissue destroyed cannot be accurately predicted. The frozen tissue eventually sloughs, but the after-treatment is dominated by profuse anal discharge, pain, and prolonged wound healing (averaging six to eight weeks). Moreover, a relatively high incidence of secondary hemorrhage is being reported. By using this technique, many perianal skin tags are formed and the anatomical results fall short of conventional hemorrhoidectomy procedures. Since few advantages of this technique can be listed, it has failed to gain widespread acceptance and use. There appears to be little, if any, place for cryosurgery in the modern management of hemorrhoids. 13 ANAL DILATATION. It is believed by some that hemorrhoidal symptoms are due to anal outlet obstruction caused by constricting bands contained in the submucosa and subcutaneous tissues of the anal canal. To correct this, it is advocated that these bands be disrupted by maximal anal dilatation. l l Such a procedure is, of necessity, performed under general anesthesia, at which time the anal canal is slowly dilated to its maximal extent (eight fingers). Afterwards these patients have to continue dilatation by use of an anal dilator for as long as six months. This procedure has not gained widespread acceptance since it relies on uncontrolled damage to the anal sphincter. Not surprisingly, the incidence of postoperative incontinence is high and recurrence is common, particularly rectal mucosal prolapse. PARTIAL INTERNAL SPHINCTEROTOMY. This may be performed in patients with hemorrhoidal symptoms;2 however, the results are far from satisfactory. The incidence of recurrence is high and, as would be expected, incontinence is a problem. Moreover, this technique fails to obliterate any external hemorrhoids or tags and, in fact, predisposes to protrusion. Hemorrhoidectomy The main indications for hemorrhoidectomy are prolapse, pain, bleeding, and large hemorrhoids associated with other anorectal pathology requiring surgical management. In general, hemorrhoidectomy is reserved for patients having severe symptoms related to multiple thrombosed hemorrhoids or marked protrusion with redundancy which cannot be handled by the banding technique. 8 Hemorrhoidectomy may be indicated in the immediate postpartum period in women who have difficulties prior to pregnancy and in whom prolapse of thrombosed hemorrhoids occurred at the time of delivery. In most instances, hemorrhoids that appear to intensify during delivery resolve, but there is a small group of women in whom the problem is of such magnitude as to indicate operation. 15
MODERN MANAGEMENT OF HEMORRHOIDS
473
The principles upon which all operative procedures should be based include: removing all the diseased tissue, i. e., internal-external hemorrhoids and redundant rectal mucosa; leaving a minimal amount of scarring in the anal canal; avoiding interference with the sphincteric mechanism; and ending with an anal orifice large enough for a normal bowel movement without pain or discomfort. Although there are many variations, all hemorrhoid operations basically employ the ligature and excision technique; only the handling of the perianal skin differentiates various techniques. The technique of closed hemorrhoidectomy, originally described by Ferguson and Heaton,7 offers: (1) effective removal of hemorrhoidal tissues, (2) prompt healing of incisions, (3) elimination of mucus drainage by immediate lining of the anal canal with stratified squamous epithelium, (4) minimal inpatient and virtually no outpatient care, (5) acceptable postoperative discomfort, (6) no loss of continence, and (7) no need for anal dilatation. An adequate dissection-type closed hemorrhoidectomy may be carried out on acute, prolapsed, thrombosed, edematous hemorrhoids without fear of anal stenosis or stricture if meticulous dissection and preservation of normal skin are accomplished. This technique may be combined with other surgical procedures such as fissurectomy, fistulectomy, or excision of hypertrophied anal papillae. 9 PREOPERATIVE EVALUATION. All patients are completely assessed as to operative risk. A complete proctosigmoidoscopy is performed to exclude rectal disease, particularly inflammatory bowel disease and malignancy. Where the symptoms are unusual or the patient is older than 45 yeats, a barium enema examination is necessary. Inflammatory bowel disease, portal hypertension, and bleeding diatheses are relative contraindications to the procedure. 9 PREOPERATIVE PREPARATION. Complete explanation of the procedure will allay most unfounded fears in patients. No purgation or antibiotics are necessary. A small disposable phosphate enema the night before and one to two hours before operation is all that is required. 9 OPERATIVE PREPARATION. The procedure is most adequately performed with the patient in a prone jack-knife position - pelvis and chest supported on rolls. The buttocks are taped apart to aid in exposure. No shaving is undertaken and deliberate anal dilatation is unnecessary. An electrocoagulation grounding plate is taped to any convenient area, usually the thigh (Fig. 2). ANESTHESIA. Anesthesia is achieved by the use of 0.5 per cent xylocaine with epinephrine 1 :200,000 solution locally, supplemented with intravenous sedation. General anesthesia or regional anesthesia, caudal or spinal, may also be used. Intravenous fluids are deliberately kept to a minimum (Fig. 3).9 OPERATIVE TECHNIQUE. The hemorrhoidal tissue and the extent of the redundant mucosa are demonstrated by grasping the redundant mucosa with tissue forceps. Although every case does not conform to the classic three-quadrant distribution, the most frequently involved quadrants are the left lateral, right posterior, and right anterior. It is
474
JOHN G. BULS AND STANLEY
"
~ ~
~I
'
\'
Figure 3. Technique for infiltration of local anesthetic agent. (1) Cutaneous bleb. (2 and 3) Subcutaneous injection. (4) Deep injection into sphincter muscle and ischiorectal fossa.
M.
GOLDBERG
Figure 2. Closed hemorrhoidectomy. (1) Prone jack-knife position. (2) Hemorrhoid exposed in operating anoscope. (3) Dissection commenced on perianal skin. (4) Anal sphincters exposed. (5) Hemostasis achieved by direct electrocautery of submucosal bleeders. (6) Anodermal flaps undercut and secondary hemorrhoids excised. (7) Anal wound sutured with continuous suture of chromic catgut without any tension. (8) Appearance of anus at end of operation.
MODERN MANAGEMENT OF HEMORRHOIDS
475
Figure 4. Closed hemorrhoidectomy. (1) Hemorrhoid exposed in operating anoscope. (2) Diagrammatic cross section of anal canal-submucosal excision. (3) Suture approximates cut mucosa and anchors it down to underlying sphincter. (4 to 6) Procedure repeated in as many areas as necessary.
not necessary to remove all hemorrhoidal tissue since the symptoms are related to the prolapsing hemorrhoids (Fig. 2).9 After exposure is accomplished with an operating anoscope, dissection is started on the perianal skin, and the hemorrhoidal mass is dissected off the sphincteric mechanism, taking care not to injure the internal sphincter muscle. The redundant rectal mucosa is excised as far as necessary above the anorectal ring to correct the redundancy even as high as the distal rectal valve. The mucous membrane and anoderm are then elevated and the hemorrhoidal tissue is dissected from beneath these flaps to remove the secondary hemorrhoidal complexes. Anoderm is preserved, and the mucous membrane is then approximated and sutured to the underlying sphincteric mechanism with running chromic catgut sutures. The perianal skin is closed without tension after the edges have been trimmed. This procedure is repeated in as many areas as necessary. At the completion of the operation, the anal canal should readily admit two fingers. An intraanal dressing is seldom used (Figs. 2 and 4).9 PROGNOSIS. Symptoms rarely reappear following an adequate hemorrhoidectomy. Reappearance of bleeding and prolapse following a hemorrhoidectomy is frequently related to inadequate removal of redundant rectal mucosa or hemorrhoidal tissue. The opponents of the primary closure technique express concern for the complications of infection and abscess formation with consequent pain and stenosis; however, these occur rarely.8 POSTOPERATIVE CARE. Patients are deliberately encouraged to restrict fluid intake until spontaneous voiding has occurred. By use of this regimen, the problem of postoperative acute retention of urine has been almost eliminated. Having voided, the patients are allowed food and fluids as desired and tolerated. Pain is managed by the use of me-
476
JOHN G. BULS AND STANLEY
M.
GOLDBERG
peridine "on demand" for the duration of the hospital stay. This is supplemented with an oral pain medication consisting of aspirin and meprobamate. Early activity is encouraged. Warm packs are applied to the perineum during the immediate postoperative period. After 24 hours, patients are encouraged to take as many warm sitz baths as desired for comfort and cleanliness. A small cotton dressing is put in the perianal area to collect whatever discharge or drainage may be present. No other local treatment is carried out. Metamucil (psyllium hydrophilic mucilloid), one package twice daily, and Kondremul (55 per cent liquid paraffin in Irish Moss emulsion) twice daily, are commenced immediately. Kondremul is discontinued after the first bowel movement. The first bowel movement usually occurs on the second or third postoperative day; if it does not, a tap water enema is given on the third postoperative day using a soft rubber catheter. 9 Routine anal dilatations are painful and unnecessary. Patients are usually discharged from the hospital when they are comfortable and have had a bowel movement, usually on the fourth or fifth day. Patients are instructed to do no lifting or straining; however, they may return to work whenever they wish if no heavy lifting is involved. Discharge medications consist of Metamucil, one package per day, and oral analgesics consisting of aspirin and meperidine to be used as necessary. The patients are reviewed in 10 to 14 days, at which time digital and anoscopic examinations are carried out. Follow-up at two week intervals is maintained until complete healing has occurred. 9 In a series of 500 of our patients recently reviewed, the advantages of a closed technique are readily apparent; 230 of the patients were females and 270 males. The age range was 17 to 83 years with an average of 46.6 years. In these patients the number of areas operated on varied between one and five; however, in the vast majority the standard three areas were operated on. The hospital stay averaged 4.3 days with a range of 1 to 22 days; however, no patient who was in hospital solely for a hemorrhoidal problem stayed longer than 10 days. On close review primary healing occurred in 32.4 per cent of the patients, whereas the remainder (67.6 per cent) healed by secondary intention but within an average time of 4.1 weeks. Thus even though in a large percentage of patients sutured wounds did break down, in all cases this was only partial since healing followed rapidly. Complications related to the technique were few and are listed in Table 1. As can be seen, 1.8 per cent of patients required a return to the operating room; of these, 1.2 per cent had bleeding problems, and the remainder had a superficial fistula-in-ano or a painful anal fissure. These results compare favorably with those reported from other centers where closed hemorrhoidectomy is the operative procedure performed for advanced stages of hemorrhoidal disease. 7-9
SUMMARY Hemorrhoids require therapy only when they cause symptoms. Early symptoms troubling the patient only occasionally are readily
477
MODERN MANAGEMENT OF HEMORRHOIDS
Table 1.
Complications in 500 Patients Undergoing Closed Hemorrhoidectomy
COMPLICATION
PERCENTAGE
Primary hemorrhage Secondary hemorrhage Abscess formation Fistula-in-ano (superficial) Anal fissure (painful wound) Acute urinary retention Incontinence (temporary) Anal stenosis (asymptomatic) Pruritus ani Fecal impaction Thrombosed external hemorrhoid Proctalgia Skin tags
0.8 4.0 0 0.4 0.2 10.0 0.4 1.0 2.2 0.4 0.2 0.2 6.0
OUTCOME
Reoperation in all Reoperation in 0.4% Reoperation in all Reoperation Catheterization Complete resolution Complete resolution Complete resolution Resolved with enemas Resolved Resolved Excision under local anesthesia
managed by dietary measures that increase the intake of fluids and fiber, such as bran, often supplemented by hydrophilic bulk-forming colloids, so that a bulky, soft stool is produced regularly. Rubber band ligation is the treatment of choice for small or moderate sized hemorrhoids with minimal prolapse, whether or not they bleed. Such bands should be applied to the mucosa at the anorectal junction and not directly to the hemorrhoidal tissue .. Patients with large prolapsing or acutely thrombosed hemorrhoids are best managed by a closed type of hemorrhoidectomy. This technique is effective and safe and has great advantage with rapid healing and minimal postoperative care, which provides the patient with the maximum comfort. Complications are few and, in particular, anal stenosis or stricture is rare. Hemorrhoids occurring in association with other conditions require specific treatment only if they are responsible for symptoms in their own right, distinct from the associated condition. Other treatments discussed are effective but have particular disadvantages that make them unsuitable for routine use. Moreover,they offer no advances on the treatment regimens proposed.
REFERENCES 1. Alexander-Williams, J., and Crapp, A. R.: Conservative management of hemorrhoids. I. Injection, freezing and ligation. Clin. Gastroenterol., 4 :595-601, 1975. 2. Allgower, M.: Conservative management of hemorrhoids. III. Partial internal sphincterotomy. Clin. Gastroenterol., 4 :608-617, 1975. 3. Blaisdell, P. C.: Office ligation of internal hemorrhoids. Am. J. Surg., 96:401,1958. 4. Barron, J.: Office ligation treatment of hemorrhoids. Dis. Colon Rectum, 6:109,1963. 5. Burkitt, D. P.: Hemorrhoids, varicose veins and deep vein thrombosis: Epidemiologic features and suggested causative factors. Canad. J. Surg., 18:483-488, 1975. 6. Editorial: To tie, to stab; to stretch; perchance to freeze. Lancet, 2 :645-646, 1975. 7. Ferguson, J. A., and Heaton, J. R.: Closed hemorrhoidectomy. Dis. Colon Rectum, 2: 176-179, 1959. 8. Ferguson, J. A., Mazier, W. P., Ganchrow, M. E., et al.: The closed technique of hemorrhoidectomy. Surgery, 70:480-484,1971.
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M.
GOLDBERG
9. Goldberg, S. M.: Closed hemorrhoidectomy. Operative Surgery. Edition 3. London, Butterworth & Co., 1977, pp. 338-343. 10. Goligher, J. C.: Surgery of the Anus, Rectum and Colon. Springfield, Illinois, Charles C Thomas, 1975, pp. 124-169. 11. Lord, P. H.: Conservative management of hemorrhoids. II. Dilatation treatment. Clin. Gastroenterol., 4 :601-609, 1975. 12. O'Connor, J. J.: The role of cryosurgery in management of anorectal disease: A study of cryosurgical techniques. Dis. Colon Rectum, 18 :301-303, 1975. 13. Ross, S. T., and Bernstein, W. C.: The role of cryosurgery in management of anorectal disease: The loyal opposition. Dis. Colon Rectum, 18 :298-300, 1975. 14. Savin, S.: The role of cryosurgery in management of anorectal disease: Preliminary report on results. Dis. Colon Rectum, 18 :292-297, 1975. 15. Schottler, J. L., Balcos, E. G., and Goldberg, S. M.: Postpartum hemorrhoidectomy. Dis. Colon Rectum, 16 :395, 1973. 16. Thomson, W. H. F.: The nature of hemorrhoids. Br. J. Surg., 62:542-552, 1975. Department of Surgery Division of Colon and Rectal Surgery University of Minnesota Medical School Minneapolis, Minnesota 55455 (Dr. Goldberg)
Modern Management of Hemorrhoids John G. Buls, MB., B.S.,* and Stanley M. Goldberg, M.D. t
Problems attributed to hemorrhoids have plagued western civilization for centuries; however, controversy still exists as to the causation and precise pathology of the condition. Moreover, there is no universal agreement as to the optimal management. Recently an anatomical and clinical study outlined the nature of hemorrhoids and this has given us a guideline to rational therapy for hemorrhoidal disease. 16 Furthermore, new techniques of management allow for individualization so that treatment can be fitted to the patient's special needs. Because of this, operative interventions have become less frequently indicated or necessary.6
Etiology The human anal canal is lined by specialized discrete submucosal vascular cushions that vary in size in different individuals. Such tissues can be demonstrated in the fetus and even the embryo so their presence does not constitute disease. Under certain conditions, other factors become operative, thus changing this normal state into one of disease. Repeated straining at defecation in an attempt to pass a hard, small volume stool will result in chronic engorgement of these cushions with possible bleeding. If such conditions persist, protrusion of the cushions may occur; this may become a permanent state. For the latter state of affairs to exist, rectal mucosal prolapse must accompany the prolapsing hemorrhoid. However, one must be aware that this condition can also occur independently of hemorrhoidal disease, although repeated straining in an attempt to pass hard stools appears to be a common causative factor. Recently, emphasis has been placed on dietary factors to explain the occurrence of hemorrhoids. Epidemiologic studies have pointed out the differing incidence of this and other diseases in different cultures. 5
"Senior Lecturer and Assistant Surgeon, University of Melbourne at St. Vincent's Hospital, Fitzroy, Australia; Formerly, Fellow, Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, Minnesota tClinical Professor of Surgery, and Director, Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, Minnesota Surgical Clinics of North America- Vol. 58, No, 3, June 1978
469
470
JOHN G. BULS AND STANLEY
M.
GOLDBERG
The western type low residue diet is implicated since correction of this by dietary regulation or addition of hydrophilic colloids to act as bulk formers may relieve hemorrhoidal symptoms and, in some cases, may reverse the early pathological changes.
Degrees of Hemorrhoidal Symptoms For a rational and individualized approach to the management of patients with hemorrhoidal disease, a classification of degree of symptoms is required: 10 First degree hemorrhoids are said to be present when the patient complains of painless, bright red bleeding associated with defecation. Examination of such patients will reveal internal hemorrhoids of variable size projecting into the lumen of the anal canal. If the symptoms consist of protrusion through the anal sphincter on straining, but spontaneous reduction on cessation of straining, second degree hemorrhoids are the problem. Protrusion may also occur without excessive straining following which it is necessary to replace the hemorrhoids digitally. This state usually occurs with defecation and is classified as third degree hemorrhoids. With longstanding disease, protrusion becomes chronic so that digital reduction is no longer possible and the hemorrhoids permanently protrude through the anus. In such instances,!ourth degree hemorrhoids are present. The anatomy of the venous drainage of the anal canal can be divided into two distinct parts which have connections. The internal hemorrhoidal plexus drains via the superior rectal veins, eventually into the portal venous system. The external hemorrhoidal plexus, situated under the perianal skin, drains into the somatic circulation. This external plexus is prone to spontaneous thrombosis, causing distressing symptoms of severe pain in the area. In the early stages this is readily treated by excision of the thrombosed external hemorrhoid under adequate local anesthesia. Incision and expression of the clot are unsatisfactory since the clots are usually multiple. Moreover, such a technique predisposes to the formation of skin tags. In the latter stages of the condition, when pain subsides, no active treatment apart from reassurance is necessary, as the condition will spontaneously resolve(Fig. 1). If this procedure is adequately performed, it may obviate the need for a subsequent hemorrhoidectomy. Repeated episodes of thrombosis or multiple thrombosed external hemorrhoids are indications for hemorrhoidectomy. TREATMENT OF INTERNAL HEMORRHOIDS Nonoperative Measures Nonoperative treatment include dietary education, the use of hydrophilic bulk-forming agents, sclerotherapy by submucosal injections, and rubber band ligation. DIET. In the majority of patients with Stage I hemorrhoids, infrequent hard stools are the basis for their complaints. In many cases this
471
MODERN MANAGEMENT OF HEMORRHOIDS
watching
4
9
10
11
12
13
14
time in days Figure 1.
Rational management of thrombosed external hemorrhoids.
problem can be reversed by dietary manipulation, whereby constipating foods, especially d3iry products, are avoided and higher fiber foods with increased amounts of fluids are encouraged. On occasion it may be necessary to add a hydrophilic bulk-forming agent. In all cases, it is necessary to perform a complete evaluation of the colon and rectum to exclude other pathology. In young patients a proctosigmoidoscopy will suffice; however, in older patients and in those with unusual symptoms, barium enema or colonoscopy may be necessary before treatment is commenced. SCLEROTHERAPY. Patients with Stage I or II disease may benefit from injection therapy, whereby a sclerosing agent such as 5 per cent phenol in vegetable oil is injected into the submucosa immediately above the hemorrhoids. I. 10 This will cause submucosal scarring with consequent fixation of the overlying mucosa. This technique is effective but is imprecise and should be used only for uncomplicated internal hemorrhoids with or without early protrusion. RUBBER BAND LIGATION. This is a simple effective technique for the management of patients with Stage I or II hemorrhoids. It may also be used in Stage III hemorrhoids, and it is the treatment of choice for most cases of rectal mucosal prolapse. I, 3, 4 As an outpatient procedure, a constricting rubber band is placed high in the anal canal on the most redundant portion of the rectal mucosa, immediately above the internal hemorrhoid. Incorporated tissue sloughs in approximately five to seven days, leaving a localized area of inflammation which results in sclerosis and fixation. Such a technique does not require anesthesia or analgesia since any excessive discomfort indicates that the band has been placed too low and should be removed immediately. This method provides a more precise result than injection therapy since there is a controlled loss of redundant mucosa. Repeated applications of the band to other internal hemorrhoidal areas may be carried out at six to eight week intervals until the patient's symptoms are totally relieved. Conservative Operative Procedures Conservative operative treatment has recently been introduced in an attempt to manage all patients with hemorrhoids as outpatients
472
JOHN G. BULS AND STANLEY
M.
GOLDBERG
without the need for admission to the hospital. These methods include cryosurgery, anal dilatation, and partial internal sphincterotomy. CRYOSURGERY. By use of recently developed cryoprobes activated by carbon dioxide, nitrous oxide, or liquid nitrogen,12 it is possible to freeze hemorrhoidal tissues. This procedure can be undertaken without anesthesia; I. 14 however, at best, it causes extreme discomfort to the patient and, in most cases, pain. The technique is ultimately imprecise since the amount of tissue destroyed cannot be accurately predicted. The frozen tissue eventually sloughs, but the after-treatment is dominated by profuse anal discharge, pain, and prolonged wound healing (averaging six to eight weeks). Moreover, a relatively high incidence of secondary hemorrhage is being reported. By using this technique, many perianal skin tags are formed and the anatomical results fall short of conventional hemorrhoidectomy procedures. Since few advantages of this technique can be listed, it has failed to gain widespread acceptance and use. There appears to be little, if any, place for cryosurgery in the modern management of hemorrhoids. 13 ANAL DILATATION. It is believed by some that hemorrhoidal symptoms are due to anal outlet obstruction caused by constricting bands contained in the submucosa and subcutaneous tissues of the anal canal. To correct this, it is advocated that these bands be disrupted by maximal anal dilatation. l l Such a procedure is, of necessity, performed under general anesthesia, at which time the anal canal is slowly dilated to its maximal extent (eight fingers). Afterwards these patients have to continue dilatation by use of an anal dilator for as long as six months. This procedure has not gained widespread acceptance since it relies on uncontrolled damage to the anal sphincter. Not surprisingly, the incidence of postoperative incontinence is high and recurrence is common, particularly rectal mucosal prolapse. PARTIAL INTERNAL SPHINCTEROTOMY. This may be performed in patients with hemorrhoidal symptoms;2 however, the results are far from satisfactory. The incidence of recurrence is high and, as would be expected, incontinence is a problem. Moreover, this technique fails to obliterate any external hemorrhoids or tags and, in fact, predisposes to protrusion. Hemorrhoidectomy The main indications for hemorrhoidectomy are prolapse, pain, bleeding, and large hemorrhoids associated with other anorectal pathology requiring surgical management. In general, hemorrhoidectomy is reserved for patients having severe symptoms related to multiple thrombosed hemorrhoids or marked protrusion with redundancy which cannot be handled by the banding technique. 8 Hemorrhoidectomy may be indicated in the immediate postpartum period in women who have difficulties prior to pregnancy and in whom prolapse of thrombosed hemorrhoids occurred at the time of delivery. In most instances, hemorrhoids that appear to intensify during delivery resolve, but there is a small group of women in whom the problem is of such magnitude as to indicate operation. 15
MODERN MANAGEMENT OF HEMORRHOIDS
473
The principles upon which all operative procedures should be based include: removing all the diseased tissue, i. e., internal-external hemorrhoids and redundant rectal mucosa; leaving a minimal amount of scarring in the anal canal; avoiding interference with the sphincteric mechanism; and ending with an anal orifice large enough for a normal bowel movement without pain or discomfort. Although there are many variations, all hemorrhoid operations basically employ the ligature and excision technique; only the handling of the perianal skin differentiates various techniques. The technique of closed hemorrhoidectomy, originally described by Ferguson and Heaton,7 offers: (1) effective removal of hemorrhoidal tissues, (2) prompt healing of incisions, (3) elimination of mucus drainage by immediate lining of the anal canal with stratified squamous epithelium, (4) minimal inpatient and virtually no outpatient care, (5) acceptable postoperative discomfort, (6) no loss of continence, and (7) no need for anal dilatation. An adequate dissection-type closed hemorrhoidectomy may be carried out on acute, prolapsed, thrombosed, edematous hemorrhoids without fear of anal stenosis or stricture if meticulous dissection and preservation of normal skin are accomplished. This technique may be combined with other surgical procedures such as fissurectomy, fistulectomy, or excision of hypertrophied anal papillae. 9 PREOPERATIVE EVALUATION. All patients are completely assessed as to operative risk. A complete proctosigmoidoscopy is performed to exclude rectal disease, particularly inflammatory bowel disease and malignancy. Where the symptoms are unusual or the patient is older than 45 yeats, a barium enema examination is necessary. Inflammatory bowel disease, portal hypertension, and bleeding diatheses are relative contraindications to the procedure. 9 PREOPERATIVE PREPARATION. Complete explanation of the procedure will allay most unfounded fears in patients. No purgation or antibiotics are necessary. A small disposable phosphate enema the night before and one to two hours before operation is all that is required. 9 OPERATIVE PREPARATION. The procedure is most adequately performed with the patient in a prone jack-knife position - pelvis and chest supported on rolls. The buttocks are taped apart to aid in exposure. No shaving is undertaken and deliberate anal dilatation is unnecessary. An electrocoagulation grounding plate is taped to any convenient area, usually the thigh (Fig. 2). ANESTHESIA. Anesthesia is achieved by the use of 0.5 per cent xylocaine with epinephrine 1 :200,000 solution locally, supplemented with intravenous sedation. General anesthesia or regional anesthesia, caudal or spinal, may also be used. Intravenous fluids are deliberately kept to a minimum (Fig. 3).9 OPERATIVE TECHNIQUE. The hemorrhoidal tissue and the extent of the redundant mucosa are demonstrated by grasping the redundant mucosa with tissue forceps. Although every case does not conform to the classic three-quadrant distribution, the most frequently involved quadrants are the left lateral, right posterior, and right anterior. It is
474
JOHN G. BULS AND STANLEY
"
~ ~
~I
'
\'
Figure 3. Technique for infiltration of local anesthetic agent. (1) Cutaneous bleb. (2 and 3) Subcutaneous injection. (4) Deep injection into sphincter muscle and ischiorectal fossa.
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Figure 2. Closed hemorrhoidectomy. (1) Prone jack-knife position. (2) Hemorrhoid exposed in operating anoscope. (3) Dissection commenced on perianal skin. (4) Anal sphincters exposed. (5) Hemostasis achieved by direct electrocautery of submucosal bleeders. (6) Anodermal flaps undercut and secondary hemorrhoids excised. (7) Anal wound sutured with continuous suture of chromic catgut without any tension. (8) Appearance of anus at end of operation.
MODERN MANAGEMENT OF HEMORRHOIDS
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Figure 4. Closed hemorrhoidectomy. (1) Hemorrhoid exposed in operating anoscope. (2) Diagrammatic cross section of anal canal-submucosal excision. (3) Suture approximates cut mucosa and anchors it down to underlying sphincter. (4 to 6) Procedure repeated in as many areas as necessary.
not necessary to remove all hemorrhoidal tissue since the symptoms are related to the prolapsing hemorrhoids (Fig. 2).9 After exposure is accomplished with an operating anoscope, dissection is started on the perianal skin, and the hemorrhoidal mass is dissected off the sphincteric mechanism, taking care not to injure the internal sphincter muscle. The redundant rectal mucosa is excised as far as necessary above the anorectal ring to correct the redundancy even as high as the distal rectal valve. The mucous membrane and anoderm are then elevated and the hemorrhoidal tissue is dissected from beneath these flaps to remove the secondary hemorrhoidal complexes. Anoderm is preserved, and the mucous membrane is then approximated and sutured to the underlying sphincteric mechanism with running chromic catgut sutures. The perianal skin is closed without tension after the edges have been trimmed. This procedure is repeated in as many areas as necessary. At the completion of the operation, the anal canal should readily admit two fingers. An intraanal dressing is seldom used (Figs. 2 and 4).9 PROGNOSIS. Symptoms rarely reappear following an adequate hemorrhoidectomy. Reappearance of bleeding and prolapse following a hemorrhoidectomy is frequently related to inadequate removal of redundant rectal mucosa or hemorrhoidal tissue. The opponents of the primary closure technique express concern for the complications of infection and abscess formation with consequent pain and stenosis; however, these occur rarely.8 POSTOPERATIVE CARE. Patients are deliberately encouraged to restrict fluid intake until spontaneous voiding has occurred. By use of this regimen, the problem of postoperative acute retention of urine has been almost eliminated. Having voided, the patients are allowed food and fluids as desired and tolerated. Pain is managed by the use of me-
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peridine "on demand" for the duration of the hospital stay. This is supplemented with an oral pain medication consisting of aspirin and meprobamate. Early activity is encouraged. Warm packs are applied to the perineum during the immediate postoperative period. After 24 hours, patients are encouraged to take as many warm sitz baths as desired for comfort and cleanliness. A small cotton dressing is put in the perianal area to collect whatever discharge or drainage may be present. No other local treatment is carried out. Metamucil (psyllium hydrophilic mucilloid), one package twice daily, and Kondremul (55 per cent liquid paraffin in Irish Moss emulsion) twice daily, are commenced immediately. Kondremul is discontinued after the first bowel movement. The first bowel movement usually occurs on the second or third postoperative day; if it does not, a tap water enema is given on the third postoperative day using a soft rubber catheter. 9 Routine anal dilatations are painful and unnecessary. Patients are usually discharged from the hospital when they are comfortable and have had a bowel movement, usually on the fourth or fifth day. Patients are instructed to do no lifting or straining; however, they may return to work whenever they wish if no heavy lifting is involved. Discharge medications consist of Metamucil, one package per day, and oral analgesics consisting of aspirin and meperidine to be used as necessary. The patients are reviewed in 10 to 14 days, at which time digital and anoscopic examinations are carried out. Follow-up at two week intervals is maintained until complete healing has occurred. 9 In a series of 500 of our patients recently reviewed, the advantages of a closed technique are readily apparent; 230 of the patients were females and 270 males. The age range was 17 to 83 years with an average of 46.6 years. In these patients the number of areas operated on varied between one and five; however, in the vast majority the standard three areas were operated on. The hospital stay averaged 4.3 days with a range of 1 to 22 days; however, no patient who was in hospital solely for a hemorrhoidal problem stayed longer than 10 days. On close review primary healing occurred in 32.4 per cent of the patients, whereas the remainder (67.6 per cent) healed by secondary intention but within an average time of 4.1 weeks. Thus even though in a large percentage of patients sutured wounds did break down, in all cases this was only partial since healing followed rapidly. Complications related to the technique were few and are listed in Table 1. As can be seen, 1.8 per cent of patients required a return to the operating room; of these, 1.2 per cent had bleeding problems, and the remainder had a superficial fistula-in-ano or a painful anal fissure. These results compare favorably with those reported from other centers where closed hemorrhoidectomy is the operative procedure performed for advanced stages of hemorrhoidal disease. 7-9
SUMMARY Hemorrhoids require therapy only when they cause symptoms. Early symptoms troubling the patient only occasionally are readily
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Table 1.
Complications in 500 Patients Undergoing Closed Hemorrhoidectomy
COMPLICATION
PERCENTAGE
Primary hemorrhage Secondary hemorrhage Abscess formation Fistula-in-ano (superficial) Anal fissure (painful wound) Acute urinary retention Incontinence (temporary) Anal stenosis (asymptomatic) Pruritus ani Fecal impaction Thrombosed external hemorrhoid Proctalgia Skin tags
0.8 4.0 0 0.4 0.2 10.0 0.4 1.0 2.2 0.4 0.2 0.2 6.0
OUTCOME
Reoperation in all Reoperation in 0.4% Reoperation in all Reoperation Catheterization Complete resolution Complete resolution Complete resolution Resolved with enemas Resolved Resolved Excision under local anesthesia
managed by dietary measures that increase the intake of fluids and fiber, such as bran, often supplemented by hydrophilic bulk-forming colloids, so that a bulky, soft stool is produced regularly. Rubber band ligation is the treatment of choice for small or moderate sized hemorrhoids with minimal prolapse, whether or not they bleed. Such bands should be applied to the mucosa at the anorectal junction and not directly to the hemorrhoidal tissue .. Patients with large prolapsing or acutely thrombosed hemorrhoids are best managed by a closed type of hemorrhoidectomy. This technique is effective and safe and has great advantage with rapid healing and minimal postoperative care, which provides the patient with the maximum comfort. Complications are few and, in particular, anal stenosis or stricture is rare. Hemorrhoids occurring in association with other conditions require specific treatment only if they are responsible for symptoms in their own right, distinct from the associated condition. Other treatments discussed are effective but have particular disadvantages that make them unsuitable for routine use. Moreover,they offer no advances on the treatment regimens proposed.
REFERENCES 1. Alexander-Williams, J., and Crapp, A. R.: Conservative management of hemorrhoids. I. Injection, freezing and ligation. Clin. Gastroenterol., 4 :595-601, 1975. 2. Allgower, M.: Conservative management of hemorrhoids. III. Partial internal sphincterotomy. Clin. Gastroenterol., 4 :608-617, 1975. 3. Blaisdell, P. C.: Office ligation of internal hemorrhoids. Am. J. Surg., 96:401,1958. 4. Barron, J.: Office ligation treatment of hemorrhoids. Dis. Colon Rectum, 6:109,1963. 5. Burkitt, D. P.: Hemorrhoids, varicose veins and deep vein thrombosis: Epidemiologic features and suggested causative factors. Canad. J. Surg., 18:483-488, 1975. 6. Editorial: To tie, to stab; to stretch; perchance to freeze. Lancet, 2 :645-646, 1975. 7. Ferguson, J. A., and Heaton, J. R.: Closed hemorrhoidectomy. Dis. Colon Rectum, 2: 176-179, 1959. 8. Ferguson, J. A., Mazier, W. P., Ganchrow, M. E., et al.: The closed technique of hemorrhoidectomy. Surgery, 70:480-484,1971.
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9. Goldberg, S. M.: Closed hemorrhoidectomy. Operative Surgery. Edition 3. London, Butterworth & Co., 1977, pp. 338-343. 10. Goligher, J. C.: Surgery of the Anus, Rectum and Colon. Springfield, Illinois, Charles C Thomas, 1975, pp. 124-169. 11. Lord, P. H.: Conservative management of hemorrhoids. II. Dilatation treatment. Clin. Gastroenterol., 4 :601-609, 1975. 12. O'Connor, J. J.: The role of cryosurgery in management of anorectal disease: A study of cryosurgical techniques. Dis. Colon Rectum, 18 :301-303, 1975. 13. Ross, S. T., and Bernstein, W. C.: The role of cryosurgery in management of anorectal disease: The loyal opposition. Dis. Colon Rectum, 18 :298-300, 1975. 14. Savin, S.: The role of cryosurgery in management of anorectal disease: Preliminary report on results. Dis. Colon Rectum, 18 :292-297, 1975. 15. Schottler, J. L., Balcos, E. G., and Goldberg, S. M.: Postpartum hemorrhoidectomy. Dis. Colon Rectum, 16 :395, 1973. 16. Thomson, W. H. F.: The nature of hemorrhoids. Br. J. Surg., 62:542-552, 1975. Department of Surgery Division of Colon and Rectal Surgery University of Minnesota Medical School Minneapolis, Minnesota 55455 (Dr. Goldberg)