Treatment of hemorrhoids

TREATMENT G.

JOHNSON

OF HEMORRHOIDS HAMILTON,

M.D.

New York, New York

L

YNCH and I have Iong believed that many hemorrhoids were being excised which might be better treated by scIerosis or paIIiative measures. To test this hypothesis it was decided to study the records of a large enough group of consecutive cases of interna hemorrhoids seen in our private practice to shed some Iight on the foIIowing points: (I) the end resuIt of hemorrhoids treated by the three methods mentioned heretofore; (2) the symptoms which brought the patient to the doctor; (3) the associated pathologic disorders both Iocal and general; (4) the compIications which resuIted from the treatment whether postoperative, post-injection or paIIiative; (5) an evaIuation of a combination of methods. For the purpose of this investigation it was decided to consider onIy interna hemorrhoids which are definite varices of the superior hemorrhoida vesseIs; and that where these masses were co&I uent, they would nevertheless be described as made up of their component major vesseIs. Thus, a hemorrhoidal mass extending from one through five o’clock would be considered as three individua1 hemorrhoids arising at one, three and hve o’cIock, tweIve o’clock being anterior. SecondIy it was agreed that their etioIogy shouId be accepted as foIIows . Some degree of stasis is prone to occur in the Iong coIumn of bIood extending from the rectum to the Iiver especiaIIy since these veins have no vaIves. This leads to a IocaI rise in venous pressure with increased carbon dioxide and decreased oxygen content. This together with the sIuggish removal of toxins tends to injure the waIIs of the veins. Continuation of this condition leads to the repIacement of the intima and muscle cells by fibrous tissue. The occurrence of any great stress or strain or even a persistence of Iesser strain causes these weakened waIIs to become stretched and tortuous. As the insults are continued the waIIs become thickened and the Iumen reIativeIy smaI1. If this hypothesis is accepted, it is obvious that anything which increases the local venous pressure will tend toward the production of a

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672

hemorrhoid. Furthermore this increase in Iocal pressure may be due to a genera1 condition such as cardiac insuffrciency, hepatic congestion or to a IocaI condition such as pressure from a mass in the pelvis incIuding a pregnant uterus. AIso, it is obvious that to the deIayed elimination of toxins and products of metabolism may be added the presence of unusual quantities of either due to systemic diseases. In Iike manner it is obvious that poor grade veins will succumb to Iess trauma than wouId damage normal ones. Hence the diathesis toward the formation of hemorrhoids may foIIow the mendelian Iaws. It was decided that Iocal and genera1 disorders should be eIiminated as far as possibIe before deciding upon the treatment of hemorrhoids. The ruIes Iaid down for the treatment of hemorrhoids were as follows: Those hemorrhoids which were sufficiently thick-walled to be paIpabIe were to be treated by excision. Hemorrhoids which were impaIpabIe but visibIe and produced symptoms were to be treated by sclerosing therapy. Those which were impaIpabIe and asymptomatic although visible were to be treated palliatively. Needless to say certain hemorrhoids which should have been excised were first injected to control bleeding until a convenient time for operation arrived. To Iind IOO patients treated by sclerosing therapy it was necessary to study the charts of 278 consecutive patients in whom 951 individua1 hemorrhoids were described. The remainder of this series was made up of I I I patients who submitted to operation and sixty-seven who were seen in consuItation only. FINDINGS Symptoms. Bleeding brought 181 of these patients to our o&e. It was the sole complaint in fifty-one cases and in none of these was there any associated IocaI disorder. ProIapse was the major symptom in 108 patients and was associated with painIess bIeeding in fifty-four cases; 107 patients complained of pain. Pruritus ani was the soIe symptom in two cases and was mentioned by seven other patients as one of

American

Journal

of Surgery

HamiIton-Hemorrhoids severa compIaints. However, changes in the periana1 skin similar to those observed in patients who suffer with pruritis ani were seen frequently. Additional Local Conditions. Fissures were present in ninety-one cases, thrombosis in twenty-eight, hypertrophied papiIIae in twentysix, inflamed or torn crypts in seventeen, fistuIa in ten and adenomas in nine. It is interesting to note that al1 of the adenomas were asymptomatic. SURGERY

The

technic

empIoyed

in these

cases

was

simpIe Iigation and excision of the invoIved superior hemorrhoida vesseIs and then the inferior hemorrhoida vesseIs if necessary. Plain No. I catgut on a small curved needIe and smaI1 hemostats were used. Every effort was expended to avoid traumatizing tissue. The patients were prepared by several daily corn starch enemas before admission to the hospitat. No enema was administered within twenty-four hours; of .“operation A general diet was permitted. with the patient in the left Sims or Iithotomy positions the operative area was cleaned with IO per cent tannic acid in aIcoho1. Whenever there was no severe infection, the area was i&Iterated with >$ per cent novocain and this was followed by the injection of IO cc. of anucaine. This procedure was foIlowed in seventy-eight cases. Like all oil soIubIe anesthetics anucaine must be injected with considerable care to avoid pooIing and a resuItant pressure necrosis. It is used by us onIy to prevent postoperative pain and, therefore, only in those cases in which none of the fibers of the sphincter are divided since the effect of the anesthetic is produced by preventing spasm of the ana sphincters. During the war more than 4,867 operations on my service was performed under sodium pentotha1 anesthesia. I was greatly impressed with the vaIue of this anesthetic and its safety but I believed that a competent anesthetist should always be in attendance and shouId be prepared to insert an endotracheal tube if necessary. In this Iarge series of cases no complication considered worthy to record was encountered. Laryngeal spasm is of minor significance provided that an anesthetist is competent and properly equipped. Therefore, I have not used IocaI anesthesia since my return

December,

1948

673

aIthough I still use anucaine for the prevention of postoperative pain. Upon return to the bedroom the patient should be urged to urinate before faIIing asleep. It is our belief that much postoperative retention of urine is due to the fact that the patient faIIs asIeep in a semi-drugged state and does not appreciate the desire to micturate unti1 the bladder is overdistended. The patient should be informed that ample sedatives have been ordered but wiI1 be given onIy if requested; that the diet is unrestricted and that bathroom priviIeges are permitted. Patients are invited to smoke and have a highbalI if they desire. In fact, IO gr. of aspirin and 2 ounces of whiskey

are frequentIy of morphine.

more

efficacious

than

>d gr.

COMPLICATIONS

In this series of I I I cases one patient faiIed to void at the end of twelve hours and was catheterized once. Hemorrhage never occurred. Three patients deveIoped abscesses of the posterior trianguIar space. It is interesting to specuIate as to their cause. The first developed two weeks after the patient’s discharge from the hospita1 and two days after she had slipped whiIe attempting to adjust a window shade and severeIy contused the perineum. The second patient presented himself because of an external thrombotic hemorrhoid situated at five o’cIock and I am by no means sure that the abscess was not present and missed although an error in the injection technic cannot be excluded as a causative factor. The third abscess was in relation to an undiagnosed fistuIa at six o’cIock which was considered even at operation to be mereIy a fissure. However, when the abscess did appear and was incised, the thick fibrotic tract of the fistuIa was readily palpable and must have existed long before the operation. In two instances the hemorrhoidal stump failed to sIough because the Iigature was onIy tight enough to prevent hemorrhage. Both stumps were destroyed by fulguration in the offIce and the procedure was accomplished painlessly without anesthesia. SCLEROSING

THERAPY

Many technics have been advocated for the injection treatment of hemorrhoids and many of them have produced admirable results in the hands of their advocates. We do not propose to

Hamilton-Hemorrhoids

674

urge anyone to adopt our method provided theirs is giving satisfactory results. The technic we utilize is as follows: The patient is placed in the Hanes position and a Tuttle proctoscope is inserted. This is a

interfere with the operator. The site of injection is cleansed \vith IO per cent tannic acid in alcohol and the injection is made with a 3 cc. Luer Lok syringe fitted \vith a No. 19 gauge needle 4”i Inches long and filled with a 5 per

TABLE OBSERVED

MORE

Complaint

:.S

rhoids Diagnosed

YEARS

7

-

Year s

,Contributin

Additional L”C2d Disorders

FIVE

-

7 Case No.

I

THAN

Hemor rhoids Exciwc I,! In;ectr< d Hemor rhoids

FaCtMS

pe r Hemorrhoid

NO.

IInjections

Visir:

Date Sinct _ast Ex- End <>f Complications amined Tren, t“lent s ..____

5549 5564 5581 5613 5617 5631 5663

0 Neuropsychrlsis 0 0

I I

Pain Blind, dizzy Bleed‘ing Prulapse, bleeding Pain Pain, prw lapse Prolapse,

2 2

0 0

0

I

0

I

2 0

0 2

0 0

3 3

(1

I

2 0

0 0

* I

_~

1/12/48 Z/Z”/47

r” 7

3/16/42 2/3”/47

7 11’;

0

II 18

2/21/47 2/20/46

12 I”

5/T/47

11

0

~.

0

I

I

12”

4

Fissure

(Zonstipatior

4

0

0

22

LO/l/47

1”

5

Crypt

Epithrlioms

0

0

0

5/14/43

5

2 3

4 Papilla 0

0 0

I

S/6/47 l/13/46

1” 1”

New pile

2 3 3 4

0

0 o 0 0

6/6/46 I l/8/46 z/12/47 2/l 5/4-

9 9 1” 1”‘;

Mucosal

0

4

Refuses at;“”

bleeding

5695E 5735

Pain, bleeding Prolapse, bleeding Bleeding Bleeding

5751 5766 5778 5786

Bleeding Prolapw Pain Pain

5671 5673

Fissure Polyp, IiSSUl‘C Fissure

2 I I In<,.

0

3

I

later 0 0 I 0

2 3 0 4

8 12 I 2”

0 0 1 0

oper-

stic-

t”rC?--re-

limed by one massage

5794 5806 5810 5818 592 I

Prolapse, bleeding Bleeding. prolapse Bleeding Pain, bleeding Prolapse

4 4 4 3

4

o

0

18

9/23/4-

3

0

0

12

l/10/48

I”

0 0

2 2

0 0

0

9/26/47 9/1”/47

I” I”

0

0

4

0 0

0

0

Fissure

Fissure

0

5

Fissure

0

z

0

X I (failed) x3 0

5

Fissure

0

0

2

I

0

5

4 I

5983 6043

Pain. bleeding Pain

“/ 18/46

9%

1Refused

7fe

oper-

ation 1”

3/17/47

6

21

9/13/46

7

1Refused

“per-

ation 7002

Bleeding

4

0

Papillas

0

3

2 I

7126

Pain, bleeding

IRefused

5

IRefused

0

0

2

5

3/26/w

0

3

0

15

2/24/47

-

0

3

0

29

l/14/4”

7

4

4denoma, fissure Papilla, Iiscrypt, S”rf 0

0

3

0

2,

z/19/47

6

4 4 3 4 4 4

I-hromboscd 0 0 0 ‘issurr %pilla

0 0 0 0 0 0

0 0 0 4 4 0

2 4 3 0 0 3

9 9 3 I2 3” 4

I /R/47 9/5/47 z/20/47 lo/U47 r/21/46 J/12/47

5% 6 6 6 5% 5

Bleeding

3

Prolapse, bleeding, pain Prolapse. bleeding Pain Bleeding Bleeding Prolapse Pain 3leeding

4

-

7

Fissure

7159

7281 7289 73”I 7324A 7324B 7435

3/14/47

3

7139

7201

8

XI XI (I railed) I

-

-

cyIindrica1 instrument without a bevelled edge and, therefore, does not distort the existing condition. It has a distal Iight and so does not

-

L

-

-

oper-

ation

14bscess dnvs

in 1”

I -

cent solution of phenol in aImond injection is given at the cephaIad origin of the hemorrhoid and into

American

opcr-

ation

oiI. The point of the sub-

Journal of Surgery

673

Hamilton-Hemorrhoids mucosal layer. One can determine that the needle is in the proper Iayer by observing the free motility of its point. Any tibrosis limiting this motility or impeding the injection is a contraindication to this form of therapy because of the danger of pressure necrosis and the possibility that hemorrhage may result. Should a hemorrhage occur, surgical intervention is contraindicated since the extreme friability of the tissues makes its success unlikely. Hemostasis shouId he obtained by pressure after vT,hich a hot enema (I IO’F.) should be administered. The injection should he given very slowly and continued until striae are visible on the surface of the mucosa but stopped before blanching occurs. Rarely, and as a palliative measure, 15 per cent phenol in almond oil may be injected into the stalk of a polypoid hemorrhoid. We prefer to inject one hemorrhoid at a time at weekly intervals. FrequentIy one hemorrhoid may require two or even three injections. No hemorrhages, sloughs or abscesses occurred in our patients who received the injection treatment. EVALUATION

OF METHODS

The efhcacy of a procedure can be determined only by foIlowing a large series of cases over a long period of years. This we have found most difficult to do. In less than one year 207 cases disappeared from our ken and of the entire series of 278 patients it was possible to follow only thirty-three for more than five years. However, most of these continue to come in for their semi-annua1 check-up and have been studied for eight to ten years. Of this group nineteen submitted to surgery and fourteen were treated by injection. In the surgical group sixty-five hemorrhoids were observed and fifty-two were excised. Of the remaining thirteen none have needed surgical excision and only one has had to be reinjected. In the fourteen patients treated by sclerosis forty-seven hemorrhoids were observed and thirty-one injected. Of the remaining sixteen one was injected later. In other words this smal1 group of thirty-three cases (Table I) presented I 12 hemorrhords of which twenty-nine were treated palliatively and there were only two faiIures. Expressed in another manner 25 per cent of the damaged veins were not removed and have remained asymptomatic for more than five years.

December,

1948

It is worth whiIe to judge each individual hemorrhoid on its own merits. Surgery, injections and paIliation all have their respective places in the armamentarium of a proctologist. DISCUSSION

JOHN CHELEDEN (PhiIadeIphia, Pa.): Dr. HamiIton has presented us with a thought-provoking topic with many points for discussion. Within the limited time avaiIabIe only one or two items can be stressed. After receiving and studying Dr. Hamilton’s I conferred with several of my coIIeagues report, at Jefferson Hospital. Two of the men are now compIeting a ten-year survey comprising 1,000 individuaIs with a foIIow-up of over 50 per cent of the patients. I have their permission to use some of the figures in a report as yet unpublished. The foIIowing is a pooIed summary of the opinion of the members of our department regarding this point: Whereas ten years ago we were injecting hemorrhoids in over 50 per cent of al1 individuaIs with symptoms, that figure has decreased graduaIIy so that in the past year 25 per cent or less of a11

hemorrhoids We arrived large

group

receive the injection form of therapy. at our concIusion onIy after study of a of patients

carefuIIy

watched

over

a

long period of time. We believe, just as Dr. HamiIton does, that it is worth whiIe to judge each individual hemorrhoid on its own merits. We admit that at times we have been surprised at the resuIts obtained with injection of some hemorrhoids that were designated as requiring surgery at the time of initial examination, but the patients refused surgery. Careful foIIow-up of this group, however, reveaIed that the recurrence rate was too high and that subsequent injection or surgery was eventuaIIy carried out. We cannot agree with the premise that many hemorrhoids are better treated by scIerosis or paIIiative injections. In a few instances, injections may give as good a resuIt but never a better one than carefu1 excision. In too many instances foIlowing injection, we never fee1 as secure as we wouId foIIowing excision. KENNETH E. SMILEY (Los AngeIes, Calif.): I want to compIiment Dr. HamiIton on the compIeteness of this detailed statistical report. It is a difIicuIt and tedious task to review a Iarge series of cases and to evaIuate the resuIts, and it is difficult to foIIow any Iarge series for five years or more is indicated by his charts. I am sure that it wouId benefit a11 of us if we couId foIIow a fairIy adequate number of cases for severa years, but I am incIined to believe that we shouId be abIe to make an unbiased evaluation of our work as we go along

676

HamiIton-Hemorrhoids

and that we shouId reach concIusions that are accurate. My own opinions are based on such observations but I am not abIe to produce statistical data to substantiate these opinions. To me visuahzation of hemorrhoids is a much more accurate method of determining their characteristics than their paIpabiIity or non-palpabiIity. The vesseIs are so easiIy compressed by the palpating finger that IittIe information is gained, and I wouId not care to rely on that to determine the type of treatment necessary. In fact, there are many other factors that shouId be considered, such as age, genera1 heaIth, occupation and bowel habits, but I reaIize that it wouId be diffrcuIt to evaIuate them in a statistica study. Long ago I decided that the exact method of remova of hemorrhoids is not of great importance. Dr. HamiIton has described an adequate, simple method which gives excellent results with a minimum of compIications. The use or non-use of anesthetic agents in oil for subcutaneous injections wiI1 probably remain a controversiai subject for some time. It seems to me that the abscesses are of frequent enough occurrence, and the trophic disturbances with resuIting deIay in healing of enough consequence to contraindicate the use of such anesthetic agents and to reIy on other means to control postoperative pain. It is my opinion that the treatment of hemorrhoids by the injection of sclerosing solution has perhaps faIIen too far into disrepute, and I am gIad that Dr. HamiIton has again brought the method to our attention. My own opinion in the matter is that few if any hemorrhoids are cured by injections but that in properIy seIected cases the symptoms can be controIIed for varying periods. I can see no objection to such treatment if the operator fuIly understands the shortcomings of the method and if the patient is frankIy advised as to the resuIts he may expect. It is certainIy true, and we11 borne out by Dr. HamiIton’s paper, that smaI1, bleeding, uncompIicated, interna hemorrhoids can usuaIIy be controIIed for a considerabIe Iength of time by the injection of sclerosing solution. On the other .hand, the injection treatment of large hemorrhoids, or those compIicated by other conditions shouId not be attempted under ordinary circumstances for the resuIts are poor and the inevitabIe surgica1 treatment is made more difficult for both the patient and the surgeon. ROBERT V. TERRELL (Richmond, Va.): The subject of hemorrhoids is one that I cannot Iet pass without saying a word. Things have been said here this morning about the injection treatment which I believe I must defend. I enjoyed the paper very much and agree with Dr. HamiIton’s remark that the treatment must be taiIored in each case to suit the pathoIogic condition and there is no one

treatment that can be expected to cure a11 types of hemorrhoids. The statement has been made by the discussers, however, that the injection treatment does not cure permanentIy, and with this I wish to take exception. Approximately 75 per cent or more of the hemorrhoids that I am now seeing are being treated by the injection of quinine urea HCI excIusiveIy. As many of you know, we have been doing this in Richmond for a Iong time and see very few recurrences. In properIy selected cases the only reason that hemorrhoids should recur after treatment is that the treatment was not continued Iong enough. In other words, treatment must not be discontinued just as soon as the symptoms disappear, but must be continued unti1 the interna hemorrhoids are actuaIIy observed to disappear compIeteIy. The patient who has interna hemorrhoids and no other anorecta1 disorder is advised that he may expect a cure by the injection method fuIIy as compIete as if the hemorrhoids had been surgicaIIy removed. Treatments are given at intervaIs of one to two weeks and each internal hemorrhoid is injected at each visit. The hemorrhoida mass wiI1 be seen to grow smaIIer with each injection unti1 eventuaIIy it wiI1 disappear aItogether although bIeeding and protrusion usually cease after the first injection. OccasionaIIy a patient wiI1 concIude that he is cured and discontinue treatment as soon as freed of symptoms; in such cases recurrence is to be expected. A hemorrhoidectomy is, of course, indicated when both interna and externa1 hemorrhoids are present, but when interna hemorrhoids onIy are present surgery is unnecessary. Surgery means loss of time from work as we11 as greater expense and discomfort to the patient and there are sometimes undesirabIe sequeIae such as skin tags and abscesses. Dr. HamiIton records an incidence of postoperative abscesses of nearIy 3 per cent which is, of course, unusuaIIy high. Neither of these complications are seen following the injection method, nor do we see sIoughs, infections or hemorrhages when the proper technic is used. Finding hospita1 beds is currentIy so difIicuIt that we are forced to treat many patients by injections who have cIear indications for surgery; such patients are gratefu1 for the temporary reIief obtained and are advised to have surgery Iater on when a hospita1 bed can be found. In summary, I would Iike to say that we beIieve that faiIure to obtain a Iasting cure by the injection method in suitabIe cases of uncompIicated interna hemorrhoids is due to inadequate treatment and that complications are due to errors of judgment in seIection of cases or to poor technic. CLAUDE C. TUCKER (Wichita, Kan.): In the majority of our cases we remove a11 of the diseased

American

Journal

of Surgery

HamiIton-Hemorrhoids tissue, incIuding the externa1 as well as internal hemorrhoids. By microscopic examination of the tissue we have found that 98 per cent of our cases have externa1 as we11 as internal hemorrhoids. Ninety-eight per cent of our cases show infected anaI ducts either acute or chronic which is the primary cause of the hemorrhoids. About 60 per cent of these cases show thrombi which are IocaIized or extend around the anal margin. These thrombi are aIso caused by infection in the ana ducts. Therefore, if you inject a scIerosing soIution into interna hemorrhoids which have to sweI1 before shrinking, you are blocking drainage from the ducts. Thus, you are hoIding the injection. Furthermore, when there are external hemorrhoids and thrombi, injections are contraindicated. LOUISE. ‘MOON(Omaha, Neb.): I wish to take issue with some of those who have discussed Dr. HamiIton’s paper. I think that as far as the treatment of hemorrhoids is concerned, the remova of them is the proper treatment. It cannot and shouId not be done on every individual. We do occasionaIIy see invaIids and oId peopIe whom we have to treat by the injection method, but as a working ruIe, I think

December,

1948

677

we, as representatives of the American ProctoIogic Society, shouId recommend the remova of hemorrhoids rather than the injection of them. The injection treatment does not cure hemorrhoids, regardless of what anyone says. It does scIerose the vessels and it shrinks the redundant tissue for the time being and it aIIays bIeeding, but in a year or two, or Iater, the circuIation in the hemorrhoid is re-estabIished and your redundant tissue is again present. This excess of tissue has to be removed before the hemorrhoid is cured. I do not beIieve that our Society should go on record as having said that the injection treatment of hemorrhoids is preferable to the operative treatment. I beheve that a11 hemorrhoids should be removed; but if we do find a patient who cannot withstand an operative procedure, we can then suggest paIIiative measures and one of the paIIiative measures is the injection treatment. If we are to treat our patients properIy, we, as proctoIogists, shouId not try to see how many hemorrhoids we can inject; but we should see that the treatment is proper for the patient and in most hemorrhoid cases the remova of the hemorrhoid is the proper treatment.