SURGICAL--STAPLED HEMORRHOIDECTOMY

3. SURGICAL TREATMENTS

Generally speaking, external and internal hemorrhoids can be treated by:
• Stapled hemorrhoidectomy treatment
• Clamp and cauterization,
• Ligature operations of hemorrhoids.

LONGO STAPLED HEMORRHOIDECTOMY.

Dr Longo is an Italian surgery who introduced his technique to the world in June 1998 in Rome. He reason that since piles are due to prolapse or displacement of enlarged, engorged anal cushions from the upper anus and lower rectum, why not pull them up to their normal positions from the inside instead of cutting them out from the outside.

Fig. 5: Longo hemorrhoidectomy stapling device.

Source: http://www.colon.com.sg/

If at the same time, you could cut down the flow of the very rich blood supply, you would reduce the congestion and cause the piles to regress and shrink. The beauty of this approach is that the cutting is on tissues, which carry no sensory nerve endings, so it is totally painless.

Fig. 6: Stapling of hemorrhoids in progress.

Source: Ibid

The Longo hemorrhoidectomy uses a purpose designed staple device to cut a 2 cm circumferential sleeve of lining of the rectum which will pull up the displaced piles to their normal positions, and will also interrupt their blood supply. Over a few days or weeks, the piles will regress to normal. Because of the circumferential cut, all piles are treated, unlike conventional surgery when smaller piles are often left behind to grow giving them a chance to recur.
The bonus of this procedure is once the external piles are fully pulled inside and regress to normal, the anal skin becomes smooth again.

With the conventional operation, skin tags are often formed even though the piles have been completely removed. Patients, especial women, do not like skin tags.

Fig. 7: Final result normal anatomy restored.

Source: op.cit

The other advantage of this procedure is that that patients can be discharged the same day later and return to normal activity much quicker, average 4 days to one week instead of two to three weeks for the conventional operation.
Possible complications. [continued]

SYMPTOMATIC AND SCHLEROSANT INJECTION OF PILES.

SYMPTOMATIC TREATMENT AND SCHLEROSANT INJECTION OF PILES.

General measures for stage 1, 2 and 3: Control constipation by laxative drugs such as mineral oil 15-50 ml per oral at bed time; Dulcolax [brand name, generic bisacodyl ] 5 mg /tablet per oral or suppository 10 mg at bed time; Tegaserod 2-4 mg twice per oral daily for chronic constipation.
Local measures: lubricant [petrolatum] to anal region, local anesthetic ointments for pain relief. Warm sit baths, 20-30 minutes twice daily.
Rubber band ligation for internal piles only; if for external piles can effect very severe pain.

The general and local measures can only reduced piles but do not heal the piles.


2. SCHLEROSANT INJECTION.

Injection is applicable for the small internal piles [stage 1 and 2]. Injection of piles with 1 ml of 0.5 % quinine solution or
solution phenol 5 % in vegetable oil through a 22-gauge needle in one day and repeated injections may be necessary
The piles may relief after a few injection.

The complication of schlerosant injection is about 2 % including bleeding, urinary retention and pelvic abscess. Recurrence is
common unless patients alter dietary habits to advisable diet.

3. Surgical treatments [hemorrhoidectomy]:

TREATMENT OPTION OF PILES

TREATMENT OPTION OF HEMORRHOIDS [PILES]

1. Medication and diet measures.
2. Schlerosant injection
3. Surgical treatment

First stage and second stage treatment usually with medication and diet treatment, or schlerosant injection, usually do not need surgery.
The third and fourth stage need surgery to have cured. Not infrequently third stage patient can be cured with medication and diet treatment.

1. MEDICATION AND DIET TREATMENT OF PILES.

Since 1982 the writer treated the piles with broad-spectrum antibiotics, antimicrobial and anti-protozoa[ameba, trichomoniasis, giardiasis], and anti anaerobic bacteria. combined with vitamins and diet measures.
This treatment was based on the writer experience and studied on the references about the cause of piles. The writer temporary conclusion that the basic cause of files was mainly multiple infections and inflammations in the rectum and anus had the long run effects on the mucosa and veins circulations to be the caused of piles.
This temporary conclusion need further research and development for confirmation or evidence.

The drugs of choice and available for above criteria for treatment of piles are:

a. Fasigyn [brand name, generic: tinidazole] 500 mg/tablet once 4 tablets [2 gram] daily for 3 days; or
Flagyl [brand name, generic: metronidazole] 500 mg/ tablet-- once 4 tablets daily for 3 days.

b. Terramycin [brand name, generic: oxytetracycline] 250 mg/capsule-- thrice 2 capsules daily for 5-7 days or
doxycycline 100 mg/capsule twice daily for 7 days.

c, Vitamins: vitamin C 500-1000 mg daily; vitamin A 20 000 IU/tablet once daily; vitamin B-complex 2 tablets daily.

The side effects of Fasigyn or Flagyl are feeling of mild dry and mild bitter taste in mouth during treatment [3-5 days].
Fasigyn or tinidazol, Flagyl or metronidazole are contraindicated in first trimester pregnant women [the research in animal found fetotoxic effect in first trimester but not in women] , safe is safe it can be given or treated in the third trimester of pregnant women for piles or after delivery.
Terramycin is contraindicated for pregnant women because of fetotoxic effects, it can be replaced with spiramycin 500 mg/tablet-- thrice 2 tablet daily for 5 days.

The vitamin B-Complex effects to prevent side effects of antibiotics
and antimicrobial; vitamin A 20 000 IU daily to strengthen the epithelium of the mucous membrane, and vitamin C 500-1000 mg daily strengthen the collagen structure of connective tissue it necessary plays an important role in the laying-down of the new connective tissue which is essential to healing of mucous membrane and better vascular of blood vessel .
Treatment of multiple infections and inflammations combine with vitamin A, B-complex and C may have effects to heal and to paste the lax mucous membrane in piles to sub-mucous and smooth muscle of anus and rectum .
If the piles with bleeding the additional treatment vitamin K 5 mg once per oral daily and Adona [brand name, generic: carbazochrom sodium sulfonate] 10 mg/tablet per oral 3 times daily.
For itching give anti histamine such as Phenergan 10 mg twice daily.

The children dose : Terramycin for children is 20-25 mg/kg body weight in two divided doses, and the dose of
Fasigyn for children is 50-60 mg/kg body weight as single dose.

d. The diet treatment: Mild food or steam food during treatment. Avoid hard food and hot chili and pepper foods in the period of treatment and one month after treatment. After one month period to prevent recurrent piles, advice to the patients can eat mild hot chili and pepper foods and better no hot chili and pepper food.
Additional diet fruit treatment particularly with papaya and pineapple which contain proteinase enzyme such as papain .The action of papain is proteolytic enzyme activated by present of H2S [hydro sulfide] keratin-ase enzyme which catalyze hydrolytic reactions of keratin proteins to end products polypeptide and amino acids. [Source: Philip B. Hawk et al. 1954, p 157, 306, 317].
The portion of these fruits during treatment: papaya one cup 3-4 times daily, the pineapple the same 1 cup 3-4 times daily for 5 days; and then a half cup twice daily of papaya and pineapple respectively for preventive, other fruits are supplements.
The mechanism action of these fruit are not clear, may be the proteolytic and hydrolysis reactions of proteins by papain in the phlebitis of veins, may open the occlusion and better flow of blood in the veins plexus of hemorrhoids.

Since 1982 the writer had patients stage 1, 2 and 3 [no case stage 4] every year , all were healed or relieved; those only 2 recurrent patients due to eat the very hot chili and peppers food.
And after treated with Fasigyn,Terramycin and diet, both patients relieved. The recurrent piles may be because of large hot chili and peppers eaten by the patients caused inflammations of mucous membrane in rectum and anus, which induced piles.

Symptomatic treatment: [continued]

STAGE, EXAMINATION AND DIAGNOSE OF PILES

THE STAGE OF PILES

The stage of pile consists of:
First stage: small protrude of internal mucous of piles or small mass of external piles like polyp, while or after defecation.
Second: protrude of piles larger mass of internal mucous but can reduced spontaneously after defecation; Slight or profuse bright red bleeding, usually at stool with protrusion following defecation, at first reduced spontaneously but later requiring manual replacement; soreness, sense of incomplete evacuation and lumbar discomfort.
Third: protruded or prolapsed of larger mass and can not spontaneously reduced but the piles can be pushed back to above ano-rectal line.
Fourth stage: larger mass protruded and can not be push manually into abdomen above ano-rectal line, it need emergency treatment to prevent strangulation and putrefaction.

EXAMINATION AND DIAGNOSE

Inspection, palpation and proctoscopy for non protruded piles reveal a globular expansible mass covered by mucous membrane. Protruded piles are visible as protuberant purple nodules covered by mucosa.

Fig. 4: Indirect inspection of the rectum and sigmoid.[a and b]. Suitable positions for proctoscopic and sigmoidoscopic examination.

[c] With the obturator in position the instrument, directed toward the umbilicus, is passed through the sphincter muscles. The obturator now is removed, the rectum inflated [d] and the insertion of the instrument continued under visual control. [e] Shows the usual lateral deviation of the sigmoidoscope when passed from the rectum into the sigmoid.

TREATMENT OPTION OF HEMORRHOIDS [continued]

CAUSES SYMPTOMS AND SIGNS OF PILES

THE CAUSES OF PILES OR HEMORRHOIDS?

What are the causes of piles?
The causes include reduced vascular drainage of the pelvic organs such as pregnancy, constipation; repeated trauma to rectum and anus due to sodomy , sexual perversion, large and hard stool which can followed by mucous fissures, sitting on the toiled for a long time. Infection and ruptured blood vessels and increased venous pressure in portal hypertension. Bacterial infection may develop in the venous circulation, producing peri-phlebitis and endo-phlebitis.
Bacterial infection may cause proctitis or rectitis [inflammation of the rectum caused mucosa dilatation] may be due to staphylococcus, streptococcus, pseudomonas aeroginosa, gonorrhea, lymphopathya venereum, amebiasis dysentery, anaerobic bacteria
Thrombosis or rupture of vessels often results in slough and ulceration.

Symptoms and signs

There are 4 principle symptoms:
Pruritus ani: the itching is usually localized anal circle; distressing symptoms of a underlying local or general disorder , it occurs because the sensitive, often moist perinea [pudenda] skin is exposed to irritating fecal material retained in anal recesses. The perinea skin may be erythematous [reddish], moist or bleeding.
Pain: mild or severe pain is the result of constriction, edema, or strangulation of piles; severe pain usually in external piles due to the sensitive of the skin; the internal piles mucosa is less sensitive than the skin.
Bleeding: which may be mild or severe occur with mucous laceration, venous distention, obstruction, or ulceration of prolapsed internal piles as a result of straining or difficult defecation.
Prolapse: protrusion of piles may occur suddenly after sub-mucous rupture of veins, thrombosis or strangulation of internal piles.

The stage of pile consists of: [continued]

HEMORRHOIDS OR PILES AND TREATMENT OPTION

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HEMORRHOIDS AND TREATMENT OPTION

What is the hemorrhoid?

Hemorrhoids or piles are ano-rectal varicose dilatation involving the hemorrhoids plexus of veins, there are lax pelvic veins and venous stasis Inadequate peri-vascular support and may be the absence of valves permit reversed venous flow in the hemorrhoids plexus.

Figure 1: Anatomy of venous drainage of the rectum and anus showing the superior or internal and the inferior or external hemorrhoid plexuses; these called as "anal cushions."


Figure 2: Prolapsed or protruded piles stage 3 or stage 4.

Source: http://www.colon.com.sg/

In the West, it has been estimated that at least 50 percent of individuals over the age of 50 years have at some time experienced piles complaints. A part of women have hemorrhoids, which often develop during pregnancy or delivery, sedentary habits, erect posture, and venous congestion and dilatation accentuate this varicose. Hemorrhoids can occur at any age and affect both sexes female and male.Hereditary factors may predispose to piles.

What types or varieties of piles?

There are external, internal and mixed piles.

External piles are those of the inferior hemorrhoids plexus, are covered by anal skin and arise below the ano-rectal line.

Internal piles implicate the superior hemorrhoids plexus of veins, are covered by mucous membrane and have their origin above the ano-rectal line.

Mixed piles are partly within and partly outside the ano-rectal canal and both are covered by mucosa and skin.

Fig. 3: Cross section of prolapsed internal and external hemorrhoids or mixed hemorrhoids or piles.

Source: Ibid.

There are a few questions about piles or hemorrhoids:

What are the causes, symptoms and signs of hemorrhoids?

How about the examination and diagnose of hemorrhoids or piles?
What are the option of treatments?
What are about the prognosis of the treatments?
What are the potential complication of treatments?

The answers for these questions are as the follows : [continued]