Time to think about Hemorrhoids

 

Shubham Maharudra Chopane¹, Mr. Dhonde. P¹, Avinash B. Thalkari², Pawan N. Karwa³

¹College of Pharmaceutical Sciences and Research, Ashti 414203

²Vasant Pharmacy College, Kaij

³Gurukrupa Institute if Pharmacy, Majalgaon Dist: Beed,431131

 

ABSTRACT:

Hemorrhoids are one of the most common causes of anal pathology of the  gastrointestinal disorder. It is blamed for virtually any anorectal complaint by patients and medical  professionals. Confusion often arises because the term "hemorrhoid" has been used to refer to  both normal anatomical structures and pathological structures. Hemorrhoidal venous  cushions are normal structures of the anorectum and are universally present unless a prior  intervention has taken place. Because of their rich vascular supply, highly sensitive location,  and tendency to engorge and prolapse, they are common causes of anal pathology Symptoms  can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal  bleeding, and while it is a common condition diagnosed in clinical practice, many patients are  too embarrassed to ever seek treatment. Consequently, the true prevalence of pathologic  hemorrhoids is not known. The various treatment of hemorrhoids are also been discussed.

 

 

1. INTRODUCTION:

“Hemorrhoid” word is originated from the Greek ‘haema’ (blood) and ‘rhoos’ (flowing) ⁽¹⁾ Haemorrhoids/ hemorrhoids, groups of vascular tissues, smooth muscles and connective tissues, which are present in all healthy individuals. They function as cushions, lie along the anal canal mainly in three positions; left lateral, right anterior, and right posterior and various numbers of minor cushions lie between them^.(2) Hemorrhoids or piles are a common ailment among adults. More  than half of men and women aged 50 years and older will develop  hemorrhoid symptoms during their lifetime^.(3) Hemorrhoids are rare  in children but now days several reports state the occurrence of  hemorrhoids in children^(4), and in elderly people^.(5)

 

Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for 3.3 million ambulatory care visits in the United States^(6). In United States three-quarter of individuals have hemorrhoids at some point in their lives, and about half of them over age 50 required treatment^(7), and  much smaller percentage approximately 4% seek medical treatment  for the condition. Hospital based proctoscopy studies show prevalence rates of hemorrhoids with a symptomatic state in 86% of patient^(8). According to The Merck  Manual definition hemorrhoids is “Varicosities of the veins of the hemorrhoidal plexus, often  complicated by inflammation, thrombosis, and bleeding”^(9). But a recent definition of hemorrhoids is “Vascular cushions, consisting of  thick submucosa containing both venous and arterial blood  vessels”⁽¹⁰⁾

 

Fig 1 :- Hemorrhoids

 

Epidemiology:

The reported prevalence of hemorrhoids in the United States is 4.4%, peaking between the ages of 45 and 65. Increased prevalence rates are seen in Caucasians and in individuals with higher socioeconomic status. Whether this is secondary to differences in health-seeking behavior rather than trueprevalence remains to be proven. The prevalence of hemor-rhoids is reported to have decreased during the later half othe 20th century; however, this is based on population-based surveys and needs to be interpreted with caution because it reflects self-reporting of symptoms without corroboration viaphysical examination.^.(11,12)

 

Classification and Grading Of Hemorrhoids:

A hemorrhoid classification system is useful not only to help in choosing between treatments, but also to allow the comparison of therapeutic outcomes among them. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Internal hemorrhoids originate from the inferior hemorrhoidal venous plexus above the dentate line and are covered by mucosa; while external hemorrhoids are dilated venules of this plexus located below the dentate line and are covered with squamous epithelium. Mixed (internoexternal) hemorrhoids arise both above and below the dentate line. For practical purposes, internal hemorrhoids are further graded based on their appearance and degree of prolapse, known as Goligher’s classification:

 

First-degree hemorrhoids (Grade I): The anal cushions bleed but do not prolapsed.

 

Second-degree hemorrhoids (Grade II): The anal cushions prolapse through the anus onstraining but reduce spontaneously.

 

Third-degree hemorrhoids (Grade III): The anal cushions prolapse through the anus onstraining or exertion and require manual replacement into the anal canal.

Fourth-degree hemorrhoids (Grade IV): The prolapse stays out at all times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids. Some authors proposed classifications based on anatomical findings of hemorrhoidal position, described as primary (at the typical three sites of the anal cushions), secondary (between the anal cushions), or circumferential, and based on symptoms described as prolapsing and non-prolapsing. However, these classifications are in less wide spread use.⁽¹³⁾

 

GRADES	BLEEDING/PROLAPSED
I	Bleeding only; no prolapse
II	Prolapse with defecation: spontaneous reduction.
III	Prolapse with defecation; must be manually reduced.
IV	Prolapsed incarcerate: cannot be manually reduced.

 

Etiology Of Hemorrhoid:

 

 

Fig 2: Aetiology of Hemorrhoids

 

Pathophysiology:

The exact pathophysiology of symptomatic hemorrhoid disease is poorly understood. Previous theories of hemorrhoids as anorectal varices are now obsolete—as shown by Goenka et al, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids^.(18) Currently, the theory of sliding anal canal lining, which proposes that hemorrhoids occur when the supporting tissues of the anal cushions deteriorate, is more widely accepted. Advancing age and activities such as strenuous lifting, straining with defecation, and prolonged sitting are thought to contribute to this process. Hemorrhoids are therefore the pathological term to describe the abnormal downward displacement of the anal cushions causing venous dilatation^.(19) On histopathological examination, changes seen in the anal cushions include abnormal venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, and distortion and rupture of the anal subepithelial muscle. In severe cases, a prominent inflammatory reaction involving the vascular wall and surrounding connective tissue has been associated with mucosal ulceration, ischemia, and thrombosis^.(20)

 

Causes:

The actual cause of hemorrhoids is not known ^(21). Few of the earliest proposed cause include temperament, body habits, customs, passions, sedentary life, tight-laced clothes, climate, and seasons^(22). Hemorrhoids are common in patients with spinal-cord injuries, constipation, chronic diarrhea, poor bathroom habits, postponing bowel movements, and a poor-fiber diet are also considered to be contributing causes^(23). By recent studies implicate gravity intrinsic weakness of the blood vessel wall, heredity, genetic predisposition, increased intra-abdominal pressure from many causes, including  prolonged forceful valsalva defecation, obstruction of venous  outflow secondary to pregnancy, and constipated stool in the rectal ampulla^(24,25). Alcoholic cirrhosis or other causes of portal obstruction can cause severe hemorrhoids. More rarely but much more importantly, haemorrhoids may reflect collateral anastomotic  channels that develop as a result of portal hypertension^(26).

 

Signs And Symptoms Of Hemorrhoids:-

•       Rectal bleeding

•       Bright red blood in stool

•       Pain during bowel movement

•       Anal itching and irritation

•       Rectal prolapse (while walking, lifting weights)

•       Swelling around anus

•       Perianal pruritus

•       Mucous discharge

•       Anaemia

•       Thrombus

•       Leakage of faeces

•       Excoriation

•       Pain only on prolapse

•       A painful or sensitive lump near your anus.^(27,28)

 

Diagnosis of hemorrhoids:

Patient with rectal discomfort, swelling, pain, discharge, and bleeding at the time of defecation, it is prudent not to assume it is a  result of hemorrhoids, a full evaluation is necessary, including a  rectal examination, a proctoscopic examination, and in some cases a  sigmoidoscopy or colonoscopy.⁽²⁹⁾ The doctor will examine the anus  and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a close rectal exam with gloved, lubricated finger to feel for abnormalities, with an anoscope a  hollow lighted tube useful for view of internal hemorrhoids^.(30) Pain is absent unless complications supervene, for this reason, any  patient complaining of ‘painful hemorrhoids’ must be suspected of  having another condition, and examine accordingly.  Several other  diseases like rectal or anal carcinoma, colon cancer, and other digestive problem produce same symptoms like hemorrhoids, so it is  advisable to see a doctor if patient have any rectal bleeding^.(31,32)

 

Treatment of hemorrhoids:

The natural evolution of hemorrhoids is benign but hemorrhoids tend to get worse over time, and it should be treated as soon as it occurs The best treatment is always prevention. Despite thousands of years and millions of patients with pain, discomfort and perceived embarrassment of hemorrhoids, exact natural cause of hemorrhoids is yet not clear so slandered treatment are, at best, imperfect, but several surgical and non-surgical techniques are used to treat hemorrhoids.  

 

1.Non operative treatment:

Numbers of methods that do not involve surgical excision are available to treat patients with hemorrhoids. These procedures are usually performed in the office setting and do not require anesthesia.  

 

A] Sclerotherapy:

Morgan in Dublin first described it in 1869, and it is reserved for first and second-degree hemorrhoids. A submucosal injection of 5 ml of 5 % phenol in oil, 5 % quinine and urea, or hyper tonic (23.4 %) salt solution at the base of the hemorrhoidal complex causes thrombosis of vessels, sclerosis of connective tissue, and shrinkage  and fixation of overlying mucosa. It takes only minutes to perform though an anoscope^. Khoury et.al., performed trial and found 89.9 % of the patient’s quared, who had initially been treated with medical therapy^. Sclerotherapy is minimally invasive it cause some complications, like pain variably reported in 12 % - 70 % of patients, Impotence, urinary retention and abscess anaphylactic shock⁽³³⁾

 

B] Cryotherapy:

Cryotherapy used for internal hemorrhoids, and in which enlarged internal hemorrhoids destroyed, initial report related efficacy of  techniques were enthusiastic^. It is a time-consuming techniques as compare the techniques and subsequent reports have shown disappointing results. Complications with cryotherapy are prolonged pain, foul-smelling discharge, and greater need for addition therapy^. It is cumbersome to perform and is associated with severe rectal pain and discharge. So now days cryotherapy is rarely used for treatment of hemorrhoids patients^.(34)

 

C] Rubber Band Ligation (RBL):

Rubber Band Ligation is most commonly used for first-second or  third degree hemorrhoids^. Some authorities also recommended RBL  for fourth degree hemorrhoids after operative reduction of the ncarcerated prolapseRBL relies on tight encirclement of  redundant mucosa connective tissue and blood vessels in the  hemorrhoidal complex. Internal hemorrhoids ligation can be  performed in the office setting with one of several commercially  available advance instruments so procedure becomes a one-person effort. Endoscopic variceal ligators have also been shown to be effective tools for hemorrhoid ligation. In one session RBL can be performed up to 3 hemorrhoids^. About 80 % of success rate was found by Wroblesski et al with five years of follow-up after  treatment.The most common complication of RBL is pain, reported in 5 %-60%  of treated patients Other complication with RBL is abscess,  urinary retention, band slippage, prolapse and thrombosis of  adjacent hemorrhoids, and bleeding from ulcer occur in < 5 % of  patients, Necrotizing pelvic sepsis (rare complication) prolapse ⁽³⁵⁾

 

E] Current electrotherapy:

Direct current electro coagulation was utilized in 1876, and explained by Wilbur E. Keesey, MD in 1934, but doctors today oddly considered it as one of the new generation of modalities^(36). Direct-current electrotherapy required the prolonged up to 14 minutes application of 110-V direct current to the base of hemorrhoidal complex well above the transition zone^. Multiple treatments to same site are required in up to 30 % of patients, and time of electric treatment depends upon the degree of hemorrhoids. A direct-current electrotherapy technique has not been widely accepted because of the lengthy treatment time and the limited control of prolapse in higher-grade hemorrhoids. Complication observed after direct-current therapy was pain (33%), ulcer formation (4%), and bleeding (10 %) and bleeding were the most frequent reoccurrent ⁽³⁷⁾

 

D] Bipolar Diathermy:

Bipolar diathermy is applied one-second pulse of 20 W until the underlying tissue coagulates. Several complications like pain, bleeding, fissure or spasm of the internal spincter was observed in about 12% of the patients^(38). For second and third degree hemorrhoids multiple application of bipolar diathermy to the same site are required Successes rate in bipolar diathermy was ranging from 88% to 100%. Prolapsing tissue dose not eliminate by bipolar diathermy and up to 20 % patients will required excisional hemorrhoidectomy^.(39)

 

F] Infrared photcoagulation (IRC):

IRC was introduced in late seventies by Nath^(40). In IRC coagulation of the tissue is done by focuses of infrared radiation from a tungsten- halogen lamp via a polymer probe tip^. During the IRC treatment mechanical presser and radiation energy are applied simultaneously in a manner that can eliminate the disadvantage occur in electro  coagulation like grounding the patients and charring of the tissue^(41). At one time 2-6 hemorrhoids can be treated by IRC treatments.As such IRC is free from any hazards and has proved to be an  effective and safe method for treatment of early grade bleeding internal hemorrhoids while in electro coagulation an obvious risk  electric current passing through the body, which may cause pain  full muscular spasms. By the randomized studies with IRC, 67%- 96% of success rets of patients with first or second degree bleeding hemorrhoids has been reported.⁽⁴²⁾ It is an expensive process.

 

G] Manual anal dilatation (Lord’s procedure):

This procedure indicated mostly for second- and third- degree hemorrhoids was advocated by Lord in 1969. It  aims to dilate the anal sphincter to accept 4 fingers of each  hand and to maintain sphincter laxity by regular use of  a dilator^(43). General anesthesia is required, but the patient can go home the same day. It is now largely abandoned due to the frequently occurring complication of incontinence, especially when combined with open hemorrhoidectomy^.(44)

 

H] LASER hemorrhoidectomy:

The hemorrhoid is vaporized or excised using carbon dioxideor NdYag LASER^.(45) The smaller LASER beam allows  for precision and accuracy; and, usually, rapid, unimpaired healing. It is painless. LASER therapy may be used alone or in combination with other modalities. In a study of 750 undergoing LASER treatment for hemorrhoids, 98% successful result was reported. Patient satisfaction was 99%. It is an outpatient procedure reserved mostly for first-, second- and some third-degree hemorrhoids^.(46)

 

I] Atomizing hemorrhoids:

The atomizer wand is an innovative wave form of electrical current wherein a specialized electrical probe excises or vaporizes one or more cell layers at a time, reducing the hemorrhoids to minute particles of fine mist or spray, which are immediately vacuumed away. The hemorrhoids are essentially disintegrated into an aerosol of carbon and water molecules. Results are similar to those of LASER hemorrhoidectomy except that there is less bleeding using the atomizer and that the atomizer costs less. The procedure is suitable for hemorrhoids of grades I, II and III. Patient does not require hospital stay. Presently, atomizing hemorrhoids is offered exclusively in Arizona, USA. (47)

 

J] Doppler-guided hemorrhoidal artery ligation:

This is also a new technique first described by the Japanese surgeon Kazumasa Morinaga in 1995, who identified the hemorrhoidal arteries by means of a Doppler (ultrasound) technique^(48).The specially designed proctoscope contained a Doppler transducer and a window through which the surgeon can identify and ligate the hemorrhoidal arteries by placing a suture around them. All the hemorrhoidal arteries are ligated in this procedure. It is a day care procedure suitable for first-, second- and some selected third-degree hemorrhoids, and the patient goes home after sedation wears off. There is little or no bleeding postoperatively. George et al. concluded in their study that the procedure is a safe and effective alternative to hemorrhoidectomy. Pure external hemorrhoids would not respond to this procedure^.(49)

 

K] The harmonic ultrasonic scalpel hemorrhoidectomy:

The harmonic scalpel uses ultrasonic energy, which allows for both cutting and coagulation of hemorrhoidal tissue at precise points of application, resulting in minimal lateral thermal damage^. It uses temperatures lower than those of electro-surgery or LASERs. Coaptive coagulation of bleeding vessels is achieved at temperatures between 50°Cand 100°Ccompared to the obliterative coagulation (burning) by electrocautery at 150°C. The vibrating blade at 55, 500 Hz couples with protein and denaturesit to form a coagulum that seals bleeding vessels. It is an outpatient procedure reserved for first- and second-degree hemorrhoids. It however has longer operating time and more pain when compared to the ligasure hemorrhoidectomy^.(50)

 

2. Operative procedures:

Bowel preparation before operation minimizes fecal contamination and keeps the colon quiet for the first few  days of the operative period. 

 

A] Clamp and cautery hemorrhoidectomy:

This method is now obsolete but has the advantage in not having any form of dissection of tissue planes. The hemorrhoid is grasped in-between the insulated blades of Smith’s pile clamp. The greater part of the hemorrhoid mass is then cut away with scissors, leaving only a stump, which is burned with heated copper cautery to arrest bleeding. The copper cautery is usually heated over a gas ring, which is seldom available in a modern operation theatre today. The electric cautery or diathermy knives are unsatisfactory substitutes because they are ineffective in arresting hemorrhage and because the coagulating current may penetrate tissues too  deeply. The operation is reserved for second- to fourth-degree hemorrhoids and it is done under general anesthesia^.(51)

 

B] Open hemorrhoidectomy (Milligan-Morgan method):

This is the most commonly used technique and is widely considered to be the most effective surgical technique for treating hemorrhoids. We routinely  carry out open hemorrhoidectomy at our center.  Adotey and Jebbin in Port Harcourt, Nigeria, showed that open hemorrhoidectomy was the predominant surgical method for treating hemorrhoids^. in Jos, Nigeria, also concluded in their studies that open hemorrhoidectomy was safe, simple and cost-effective, with postoperative pain, acute urine retention and bleeding being the commonest complications. It is the procedure of choice or third- and fourth-degree hemorrhoids. This method was developed in the United Kingdom by Drs. Milligan and Morgan in 1937, mainly for hemorrhoids of grades II-IV. AV-shaped incision by the scalpel in the skin around the base of the hemorrhoid is followed by scissors dissection in the submucous space to strip the entire hemorrhoid from its bed. The dissection is carried cranially to the pedicle, which is ligated withstrong catgut and the distal part excised. Other hemorrhoids are similarly treated, leaving a skin bridge in- between to avoid stenosis. The wound is left open and a hemostatic gauze pad left in the anal canal. The procedure is done under general or epidural anesthesia.  Postoperative pain and acute urine retention are common complications^.(52)

 

C] Closed hemorrhoidectomy (Ferguson’s technique):

Developed in the United States by Drs. Ferguson and Heaton in 1952, this is a modification of Milligan- Morgan method described above. The indications for this procedure are similar to those of Milligan-Morgan procedure. Here the incisions are totally or partially closed with absorbable running suture, following surgical excision of the hemorrhoids. The Ferguson method has no advantage in terms of wound healing because of the high rate of suture breakage at bowel movement. There are several modifications of this method.(53)

 

D] Submucosal hemorrhoidectomy (Parks procedure):

This procedure was developed in the 1950s by Parks, who published results and details of the technique in 1956. It was designed to reduce postoperative pain and avoid anal and rectal stenosis. It is indicated for second- to fourth- degree hemorrhoids. A Parks retractor is inserted. A point just below the dentate line at the hemorrhoid is grasped with a hemostat. A 30-40–mL saline containing 1:400,000 parts adrenaline is injected submucosally to open up tissue planes and to reduce bleeding. Scissors are used to excise a small diamond of anal epithelium around the hemostat.  The incision is continued cranially for 2.5 cm, creating two mucosal flaps on each side, which are each grasped with further hemostats, and submucosal dissection is commenced to remove the hemorrhoidal plexus from underlying internal sphincter muscle and overlying mucosa. This dissection is continued into the rectum, where the resulting broad base of tissue is suture-ligated and divided. The mucosal flaps are then allowed to flop back into position. No suture or any intra- anal dressing is used. Parks advocated use of suture for only prolapsed hemorrhoid to reconstitute the mucosal ligament,’ but most contemporary descriptions advocate suturing the mucosal flaps loosely together and to the underlying internal  sphincter. The same procedure is carried out on the other hemorrhoids. Parks hemorrhoidectomy is done under general or epidural anesthesia. It is safe and associated with low rates of complications and recurrence. It however takes longer time and is more difficult to learn. A recent study by Yang et al., 2005, concludes that the modified lift-up submucosal hemorrhoidectomy is an easier operative method compared with the procedure originally developed by Parks^.(54)

 

E] Whitehead’s circumferential hemorrhoidectomy: This procedure, also known as total or circumferential hemorrhoidectomy, was first described by Dr. Walter Whitehead in 1882. After initial success, the procedure was later abandoned due to the high complication rates encountered: hemorrhage, anal stenosis, and ectropion (Whitehead’s deformity). The procedure entails circumferential removal of the hemorrhoid, hemorrhoid-bearing. rectal mucosa just proximal to the dentate line. Incisions are made by curved double-operating scissors just proximal to the dentate line and continued along this path around the anal  canal in stages. Clamps are used to lift the cut edge of the hemorrhoid rectal -bearing mucosa and mucosal prolapse.  The hemorrhoidal masses are then suture-ligated and excised, followed by closure of the incisions by suture. Here, a retractor is used to stretch the internal sphincter, so that the suture goes through the endoderm to the neo-dentate line. A hemostatic sponge is left in the anal canal. The procedure is reserved only for circumferential hemorrhoids, and it is done under general or epidural anesthesia. Recent works by Maria et al. have shown that the Whitehead’s hemorrhoidectomy still has a place in selected cases of circumferential hemorrhoids^{. (55)}

 

F] Stapled hemorrhoidectomy: 

This procedure is also known as circumferential mucosectomy or ‘procedure for prolapse and hemorrhoids’ (PPH). It was first described in 1998 by Longo for prolapsing second- to fourth-degree hemorrhoids. He suggested that stapled resection of a complete circular strip of mucosa above the dentate line lifts the hemorrhoidal cushions into the  anal canal. In PPH, the prolapsed tissue is pulled into a circular stapler that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. A circular anal dilator is introduced into the anal canal. The prolapsed mucous membrane falls into the lumen after removing the dilator. A purse-string suture anoscope is then introduced through the dilator, to make a submucosal purse-string suture around the entire anal canal circumference. The circular stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string suture, which is then tied with a closing knot.  The entire casing of the stapler is then pushed into the anal canal, tightened and fired to staple the prolapse. Firing the stapler releases a double-staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue, thereby removing a circumferential column of mucosa from the upper anal canal. The staple line is then examined with the anoscope for bleeding, which if present may be controlled by placement of absorbable sutures. The staple line should be maintained at a distance of 3-3.5 cm from the anal verge to avoid postoperative rectal stenosis and pain. Patients experience less pain and achieve a quicker return to work compared to conventional procedures; and bleeding is less^.(56)

 

G] Radiofrequency ablation and suture fixation of  hemorrhoids:

It is an innovative procedure designed in 1998 by Gupta for hemorrhoids of grades III and IV^. The procedure entails  the use of an Ellman dual-frequency, 4-MHz radiofrequency  generator for ablation of hemorrhoids. Radiofrequency waves ablate tissue by converting radio waves into heat.  The alternating current generates changes in the direction of ions within the tissue fluid. This creates ionic agitation and frictional heating, leading to coagulative necrosis of tissue. Thereafter, the hemorrhoids are plicated using strong absorbable sutures. The plication begins from the most distal end of the hemorrhoid at the anal verge and is  carried towards the pedicle in a continuous locking manner  and knotted at the pedicle, thereby fixing the hemorrhoidal mass^. It gives better results in terms of postoperative pain and bleeding than stapled hemorrhoidectomy and Doppler- guided hemorrhoidal artery ligation. ⁽⁵⁷⁾

 

H] Pile ‘suture’ method:

Also called the pile stitching method, it was first described in 1978 by Faraq for hemorrhoids of grades II and III. The method entails use of three interrupted sutures to secure the hemorrhoids in place without excision. Recurrence is a common postoperative complication of this procedure. ⁽⁵⁸⁾

 

I] Bipolar diathermy hemorrhoidectomy:

This operation is indicated mostly for second- to fourth- degree hemorrhoids. With the aid of a bipolar diathermy set on cutting and coagulation, dissection is carried fromhemorrhoid unto the pedicle, which is dissected and divided. The diathermy is set on coagulation only during dissection and division of the pedicle. No ligature is used.  A randomized trial study by Andrews et al. showed that diathermy hemorrhoidectomy has no significant advantage over the Milligan-Morgan procedure^.(59)

 

J] Ligasure and Starion hemorrhoidectomy with  submucosal dissection:The ligasure vessel-sealing generator is an isolated-output  electrosurgical generator that provides power for vessel  sealing and bipolar surgery.It provides precise thermal  energy delivery and electrode pressure to vessels to achieve  complete and permanent fusion of the vessel lumen. The Starion thermal welding system is similar to the ligasure generator but uses the tissue-welding technology to  simultaneously fuse vessels and tissue structures closed.  The operating temperature is less than 100°C, thereby producing less heat and collateral tissue damage. The  operation is done under general or epidural anesthesia.  A Vshaped incision at the junction of the hemorrhoid and the peri-anal skin is made by a scalpel, followed by  dissection of the hemorrhoidal bundles off the underlying  sphincter. The ligasure or Starion handset is applied to the dissected hemorrhoids and activated to seal mucosal edges and divide the pedicle. A hemostatic sponge is inserted into the anal canal. Wang et al. demonstrated that the Starion hemorrhoidectomy has less postoperative pain and parenteral analgesic requirement than ligasure hemorrhoidectomy, but both have the same advantages of  shorter operating time and less

blood loss. (59)

Conclusion:

A haemorrhoid is a common discomfort, that is getting worse by  prolonging immediate treatment, in the adult, which directly affect  the economy. Apart form the prominent symptoms of bleeding and  pain; colonoscopy and proctoscopy give the correct state of condition. Non-operative treatment methods are used for the patients with the first second and third degree hemorrhoids; very few patients with fourth degree haemorrhoids need surgery calltreatment. As in case of every disease prevention is the best common treatment, haemorrhoids can also be reduced by changes in life style, diet habit, and intake of appropriate dose of respectivebotanicals, which can also intervene in the pathogenesis to decrease vascular integrity

  

REFRENCES:

1.      E. Leff (1987). Hemorrhoids: Current approaches to an ancient problem, Postgrad. Med. 82(7), 95-101.

2.      W. H. Thomson (1975). The nature of haemorrhoids, Br J Surg. 62, 542-552.

3.      Bailey HR: Innovations for age-old problem: hemorrhoids in the  female patient. Female Patient. 2004; 29:17-23.

4.      4Heaton ND, Davenport M, Howard ER: Symptomatic  hemorrhoids and anorectal varices in children with portal  hypertension. J Pediatr Surg.1992; 27(7): 833-835.

5.      5Navarra L, Pietroletti R, Maggi G, Leardi S, Simi M: Diagnosis and treatment of haemorrhoids in the eldery: results from 291  patients. Techniques in Coloproctology. 2000; 3(3): 127-130.

6.      Everhart J E, Ruhl C E. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology. 2009;136(2):376–386. [PubMed] [Google Scholar]

7.      Liebach JR, Cerda JJ: Hemorrhoids:modern treatment methods.  Hosp Med. 1991; 53: 68. 

8.      Madoff RD, Fleshman JW: American Gastroenterological Association technical review on the diagnosis and treatment of  hemorrhoids. Gastroenterol. 2004; 126:1463–1473.

9.      Berkow R (ed). The Merck Manual of Diagnosis and Therapy.  16th ed. Rahway, NJ: Merck; 1992: 855-856.

10.   Thomson WH: The nature of haemorrhoids. BrJ Surg. 1975; 62:542-552.

11.   Johanson JF, Sonnenberg A. The prevalence of hem- orrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990;98(2):380-386.

12.   JF, Sonnenberg A. Temporal changes in the occur rence of hemorrhoids in the United States and England. Dis Colon Rectum 1991;34(7):585–591; discussion 591–593

13.   Barron J. Office ligation treatment of hemorrhoids. Dis Colon Rectum. Mar- Apr 1963; 6:109-13.

14.   Thornton SC. Sclerotherapy of hemorrhoids. In: Selected Topics in Colon and Rectal Surgery. vol 5. 1992:72-5. 

15.   Leff EI. Hemorrhoidectomy—laser vs. nonlaser: outpatient surgical experience. Dis Colon Rectum. Aug 1992; 35(8):743-6. 

16.   Corman M. Hemorrhoids. In:  Colon and Rectal Surgery. Philadelphia, Pa: Lippincott- Raven; 1998:154-6. 

17.   Goenka M K, Kochhar R, Nagi B, Mehta S K. Rectosigmoid varices and other mucosal changes in patients with portal hypertension. Am J Gastroenterol. 1991;86(9):1185–1189. [PubMed] [Google Scholar]

18.   Thomson W H. The nature of haemorrhoids. Br J Surg. 1975;62(7):542–552. [PubMed] [Google Scholar]

19.   Morgado P J, Suárez J A, Gómez L G, Morgado P J Jr. Histoclinical basis for a new classification of hemorrhoid disease. Dis Colon Rectum. 1988;31(6):474–480. [PubMed] [Google Scholar]

20.   Madoff RD, Fleshman JW: American Gastroenterological  Association technical review on the diagnosis and treatment of  hemorrhoids. Gastroenterol. 2004; 126:1463–1473

21.   Dennison AR, Whiston RJ, Rooney S, Morris DL: The management  of hemorrhoids. Am J Gastroenterol. 1989; 84:475-481.

22.   Yarnell E: Naturopathic Gastroenterology, Wenatchee WA,  HealingMountain Publishing 2000.

23.   Pfenninger JL, Surrell J: Nonsur gical treatment options for  internal hemorrhoids. Am Fam Phys 1995; 52:821-834. 25Parks AG: Surgical treatment of haemorrhoids. Br J Surg. 1956; 43:337-338.

24.   Ramzi S. Cotran, Tucker Collins, Vinay Kumar: Robbin’s pathologic basis of diseases. 6^th edition 1999,WB Saunders company

25.   Mazier WP. Hemorrhoids surgery of  the colon. In: Rectum and Anus. WB  Saunders: Philadelphia, Pa; 1995:229- 54. 

26.   Esser S, Khubchandani I, Rakhmanine  M. Stapled hemorrhoidectomy with  local anesthesia can be performed  safely and cost-efficiently. Dis Colon  Rectum. Jul 2004; 47(7):1164-9.

27.   Loder PB, Kamm MA, Nicholls RJ, Phillips RK: Haemorrhoids:pathology, pathophysiology and aetiology. Br J Surg. 1994; 81: 946–954.

28.   www. Hemorrhoids.net, information retrieved on 20^th July 2009.   www.fascg.org., information retrieved on 19^th Aug 2009

29.   www. digestive. niddk.nih.gov/index.htm, information retrieved on Sept 2009

30.   Barwell J, Watkins R M, Lloyd-Davies E, Wilkins D C. Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case. Dis Colon Rectum. 1999;42(3):421–423. [PubMed] [Google Scholar]

31.   Yang R, Migikovsky B, Peicher J: Laine Randomized, prospective  trial of direct current versus bipolar electrocoagulation for  bleeding internal hemorrhoids. Gastrointest Endosc. 1993; 39:766-769

32.   Buchmann P, Seefeld U: Rubber band ligation for piles can be  disastrous in HIV-positive patients. Int. J of Colo Dise. 1989; 4(1): 57-58

33.   Keesey WE: Obliteration of hemorrhoids with negative  galvanism. Arch Phys Ther X-ray Radium. 1934; 1:533546.

34.   Varma JS, Chung SC, Li AK: Prospective randomised comparison  of current coagulation and injection sclerotherapy for the  outpatient treatment of haemorrhoids. Int J Colorectal Dis. 1991;6:42

35.   Randall GM, Jensen DM, Machicado GA, Hirabayashi K, Jensen ME,  You S, Pelayo E: Prospective randomized comparative study of  bipolar versus direct current electrocoagulation for treatment of  bleeding internal hemorrhoids. Gastrointest Endosc. 1994; 40: 403–410.

36.   Hinton CP, Morris DL: A randomized trial comparing direct current therapy and bipolar diathermy in the outpatient  treatment of third-degree hemorrhoids. Dis Colon Rectum. 1990; 33: 931–932.

37.   Nath G, Kreitmaier A, Kiefhaber P: Neue Infrarot koagulation  smethode. Verhandl ungsband des 3 Kongresses der Deutscher  Gesellschaft fur Gastroenterolgie.Munchen 1976, S. 17.Erlangen: Permed Verlag.

38.   Pravin J Gupta: Infrared coagulation:A preferred option in  treating early hemorrhoids. Acta Cirurgica Brasileria. 2004; 19(1):74-78.

39.   Walker AJ, Leicester RJ, Nicholls RJ, Mann CV: A prospective  study of infrared coagulation, injection and rubber band ligation  in the treatment of haemorrhoids. Int J Colorectal Dis 1990; 5:  113–116.

40.   Konsten J, Baeten CG. Hemorrhoidectomy Vs Lord’s method: 17- year follow-up of a prospective randomized trial. Dis Colon Rectum  2000;43:503-6.

41.   Mortensen PE, Olsen J, Pedersen LK, Christiansen J. A randomized study  on haemorrhoidectomy combined with anal dilatation. Dis Colon Rectum 1987;30:755-7. 

42.   Zahir KS, Edwards RE, Vecchia A, Dudrick SJ, Tripodi G. Use of the  NdYag laser improves quality of life and economic factors in the treatment  of hemorrhoids. Conn Med 2000;64:199-203.

43.   Atomizing Hemorrhoids. Available From: www.proctology.us/atomizing. php. [Last accessed on 2010 July 10].

44.   K, Hasuda K, Ikeda TA. Novel therapy for hemorrhoids: Ligation  of the hemorrhoidal artery with a newly devised instrument(Moricorn) in  conjunction with a Doppler flow meter. Am J Gastroenterol 1995;90:610-3.

45.   Felice G, Privitera A, Ellul E, Klaumann M. Doppler- Guided Haemorhoidal Artery ligation: An alternative to Haemorrhoidectomy. Dis Colon Rectum 2005;48:2090-3.

46.   Kwok SY, Chung CC, Tsui KK, Li MK. Double blind randomized trial comparing Ligasure and Harmonic Scalpel hemorhoidectomy. Dis Colon  Rectum 2005;48:344-8.

47.   Chamberlain J, Johnstone JM. The results of hemorrhoidectomy by clamp and cautery. Surg Gynaecol Obstet 1970;131:745-7.

48.   Uba AF, Obekpa PO, Ardill W. Open versus closed haemorrhoidectomy.  Niger Postgrad Med J 2004;11:79-83

49.   Pescatori M. Closed hemorrhoidectomy. Ann Ital Chir 1995;66:787-90. 

50.   Yang HK, Lim CH, Shin HK, Kang CH, Jeong SK, Choi JP. Lift-up sub  mucosal Hemorrhoidectomy. J Korean Soc Colo proctol 2005;21:145-51. 

51.   Maria G, Alfonsi G, Nigro C, Brisinda G. Whiteheads’ hemorrhoidectomy.  A useful surgical procedure in selected cases. Tech Coloproctol 2001;5:93-6.

52.   Longo A. Treatment of haemorrhoidal disease by reduction of mucosa and haemorrhoidal prolapse with a circular stapling device: A new procedure.  6th world congress of Endoscopy Surgery. Naples: Mundozzi Editore;  1998. p. 77784.

53.   Gupta PJ. Radio-ablation and suture fixation of advanced grades of hemorrhoids. An effective alternative to staplers and Doppler-Guided  ligation of hemorrhoids. Rev Esp Enferm Dig 2006;98:1- 20.

54.   Faraq AE. Pile Suture: A new technique for the treatment of hemorrhoids.  Br J Surg 1978;65:293-5. 

55.   Andrew BT, Layer GT, Jackson BT, Nicholls RJ. Randomized trial comparing  diathermy hemorrhoidectomy with the scissor dissection Milligan–Morgan  operation. Dis Colon Rectum 1993;36:580-3.

56.   Wang JY, Tsai HL, Chen FM, Chu KS, Chan HM, Huang CJ, et al.  Prospective randomized, controlled trial of Starion Vs Ligasure  hemorrhoidectomy for prolapsed hemorrhoids. Dis Colon Rectum  2007;50:1146-51. 

 

 

Received on 27.10.2019         Modified on 07.02.2020

Accepted on 21.02.2020       ©A&V Publications All right reserved