Minimally Invasive Treatment options for Hemorrhoids & Piles
Dr Arun Prasad, MS, FRCS, FRCSEd
Senior Consultant Surgeon Minimal Access Surgery
Apollo Hospital, New Delhi, India
Contents ( Please click )
WHICH DISEASE ??
|PILES / HEMORRHOIDS||++++||+||+||piles|
Please select from the above table, the most appropriate disease you may be looking for. The above is a rough guideline and needs to be confirmed with local examination by a specialist doctor.
Piles in India is generally used as a loose common term to include piles, hemorrhoids, fistulas and fissures with skin tags.
Fistulas are an abnormal small opening next to the anus from where discharge keeps occurring. This is due to a tunnel like tract between the anal canal and the skin. This condition always requires surgery for cure.
Fissure with skin tags lead to painful bleeding due to a small cut at the anal margin. It is usually associated with skin tags that are mistakenly called piles. This condition resolves in majority of the patients by use of creams and medicines to treat constipation. Skin tags can sometimes be a source of great irritation due to micro-incontinence. Rarely the patient needs surgery.
True piles are those that present with PAINLESS BLEEDING due to swelling up of blood vessels in the anal canal.
In this article, only piles and their treatment are dealt and fistulas and fissures will be covered in a subsequent article.
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CAUSES AND TYPES
Piles and their symptoms, which are one of the most common afflictions in the Western world, are also seen commonly in India. Not many people like to talk about it hence true statistics in India are not available. In the west over half the population over the age of 50 suffer from it. However they can occur at any age and can affect both women and men.
Because the presence of pile tissue is normal, it acts as a compressible lining which allows the anus to close completely. Disease should be thought of as pile tissue that causes significant symptoms. Unfortunately, piles tend to get worse over time, and disease should be treated as soon as it occurs.
An exact cause is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Other contributing factors include:
Whatever the cause, the tissues supporting the veins stretch. As a result, the veins dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened veins protrude.
Piles may be caused by more than one factor. Piles can be either internal or external, and patients may have both types. External piles occur below the dentate line and are generally painful. When inflamed they become red and painful, and if they become clotted, they can cause severe pain and be felt as a painful mass in the anal area. Internal piles are located above the dentate line and are usually painless. Dentate line is a line seen in the anal canal that demarcates the area with pain sensation from that without it.
Piles that protrude into but do not prolapse out of the anal canal they are classed as grade I; if they prolapse on defecation but spontaneously reduce they are grade II; piles that require manual reduction are grade III; and if they cannot be reduced they are grade IV. Piles that remain prolapsed may develop thrombosis and gangrene.
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Symptoms of piles/ hemorrhoids can include
Internal hemorrhoids cannot cause cutaneous pain, but they can bleed and prolapse. Prolapsing internal hemorrhoids can cause perianal pain by causing a spasm of the sphincter complex. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. The discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain.
Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders.
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DIAGNOSIS AND INVESTIGATIONS
The diagnosis is made by examining the anus and anal canal, and it is important to exclude more serious causes of bleeding, such as cancer. No relation between piles and cancer has been found. A simple look inside is done by a procedure called proctoscopy where a 3 inch long hollow instrument with a diameter of about 1 inch is introduced in the rectum and with the help of a torch, the inside is looked at by the doctor. The procedure is painless but uncomfortable and lasts about 1 minute and is done in the OPD. A more detailed look can be done by a procedure called sigmoidoscopy that is done under sedation or anesthesia and a look upto 25 cm can be done to rule out any sinister disease that may be associated.
Occasionally, a barium examination or colonoscopic examination of the large intestine may be required if other diseases are suspected.
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PREVENTION OF PILES
The best way to prevent haemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Increased fibre in the diet helps reduce constipation and straining by producing stools that are softer and easier to pass. If the diet cannot be modified in this way, adding bulk laxatives may be necessary; they can prevent worsening of the condition. There are numerous creams and suppositories that can relieve anal irritation and pain, but they rarely provide long term benefit.
In addition, a person should not sit on the toilet for a long period of time.
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Symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, have a small role in the treatment of hemorrhoidal symptoms.
Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis.
Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after one month of conservative therapy. Treatment is directed solely at symptoms and not at the hemorrhoids’ appearance. Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. It has been said, "You can’t make an asymptomatic patient feel better." Treat hemorrhoids only if they cause the patient problems. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.
The treatment choices for piles include :
Cryosurgery (cold probe),
Rubber band ligation,
Infrared coagulation (photocoagulation),
Direct current/ bipolar coagulation,
Hemorrhoidal arterial ligation (HAL),
Scalpel (standard) surgery,
Laser surgery and
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OUT PATIENT PROCEDURES
For patients with grade I or grade II piles or who have larger piles but wish to avoid surgical treatment, outpatient procedures, such as injection sclerotherapy, infrared coagulation, rubber band ligation, and cryotherapy, may be appropriate.
Injection Sclerotherapy is usually indicated only in first and second degree lesions.
Cryotherapy is little used because of the profuse and prolonged discharge, the complications such as excessive sloughing and muscle injury that occur occasionally. It is essential that local treatments be applied to the lining above the piles; if applied too low, they may cause excessive pain.
The least expensive and possibly the most widely used equipment is a rubber band ligator. This is suitable for first to third degree piles. The treatment can cause severe pain if the bands are placed too low. Rubber band treatment works effectively on internal piles that protrude during defecation. The procedure sometimes produces mild discomfort and bleeding, but it is generally the treatment of choice for patients who have piles and for whom piles surgery is considered too radical, or when the patient specifically wishes to avoid surgical excision.
Hemorrhoidal Arterial Ligation (H.A.L.) is performed using a modified proctoscope in conjunction with a Doppler ultrasound flowmeter.
The infrared coagulator
is for outpatient treatment of internal first and second
degree piles. A special bulb provides high intensity infrared light that coagulates vessels and tethers the lining to subcutaneous tissues.
The radiofrequency coagulation unit uses a disposable probe with an electrical current flowing between two flat electrodes (positive and negative) aligned at the tip. Activating the unit for two seconds in three or four areas of the same pile complex effectively coagulates the vessels.
Bipolar Coagulation is applied for a directed coagulation effect of the mucous membrane near the hemorrhoid.
The direct current units use a probe with two sharp points as electrodes. They are promoted for use in all grades of piles but seem to have two drawbacks. Firstly, each treatment takes eight to 12 minutes of probe contact. This is considerably longer than the six to 10 seconds required for infrared and radiofrequency units. Secondly, the probes can penetrate deeply unless the operator is careful to stabilise them during treatment.
Hemorrhoidolysis: Therapeutic galvanic waves applied directly to the hemorrhoid, produces a chemical reaction that shrinks and dissolves the tissue.
Excessive activity of the internal anal muscle is often associated with bleeding; for such patients gentle anal stretch under general anaesthesia is advisable. It is important to recognise that stretching the muscle inevitably attenuates the external muscle as well as the internal; spasms of the internal muscle may be relieved by injections of botulinum toxin or topical application of nitroglycerine ointment.
If symptoms recur after topical treatment the patient can be treated with a further application, a different treatment may be applied topically, or piles surgery may be considered for more definitive control of symptoms.
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Piles surgery (Standard Scalpel surgery) is necessary when clots repeatedly form in external piles, ligation fails to treat internal piles, the protruding pile cannot be reduced, or there is persistent bleeding. Piles surgery is done under general anaesthesia and requires admission to hospital.
The standards task force of the American Society of Colon and Rectal Surgeons states that surgery should be reserved for those who "fail more conservative measures" or who have "third and fourth degree piles ... with severe symptoms.
Several operative techniques have been described. The surgeon's choice of technique is primarily based on personal experience and technical training, and only a competently performed technique produces satisfying results. If technical guidelines are rigorously followed, the feared complications associated with surgical procedures, such as anal narrowing and muscle injuries, are largely reduced. Furthermore, certain medicines suppress postoperative pain, increase patients' satisfaction, and allows them to return to work earlier.
A lot has been talked about Laser Surgery. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, most studies across the world have shown that Laser piles surgery has no advantages over standard techniques; it is also quite expensive and no less painful.
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MINIMALLY INVASIVE TREATMENT
Studies suggest that Stapled Piles Surgery ( also known as PPH - procedure for prolapse and hemorrhoids or MIPH - Minimally invasive procedure for hemorrhoids ) is an effective treatment, reducing operative bleeding, postoperative pain, the length of hospital stay, and encouraging a rapid return to normal activities when compared with conventional piles surgery. This technique potentially provides a tool for reducing some of the problems associated with conventional surgery, provided that the operator has the technical experience. The pile masses are compressed into a cup like cavity inside the stapler. When fired, the staples cut and seal simultaneously, thus causing minimal bleeding and as the cut line is above the nerves, there is reduction in post operative pain. However, stapling increases operative costs.
STAPLER BEING APPLIED TO PILES
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The clear advantages of the modern methods for outpatient treatment of internal piles are that they are quick and relatively painless. Patients lose little if any time from work, the complications are minor, and the cure rates are high. Pain is generally attributable to placing the treatment probes too far down.
Patients may have a little spotting of blood for a few days and slightly more bleeding may occur after 10-14 days, when the eschar sloughs, but major bleeding do not occur as in the old style surgical approaches. No episodes of infection, death, or impotence have been reported with the newer methods. The failure rates are reported to be 1-5%, but all that is needed is further treatment.
Formal surgical intervention is still occasionally necessary, but patients dislike it because of the associated severe pain and morbidity. Modern treatment methods may be mastered by doctors, and they provide a prompt effective treatment in most cases.
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The first step is to show to a surgeon who can confirm the diagnosis of hemorrhoids and the staging. The consultation and proctoscopic examination could be between Rs 900 to 1500 for registration, consultation and examination by proctoscope. Rs 5000 for injection sclerotherapy or banding. Rs 45,000 appx for hemorrhoidectomy in General Ward.(For Stapled Hemorrhoidectomy an extra Rs 20,000 for the stapler i.e. a total of Rs 65,000 appx).
The author Dr Arun Prasad MS, FRCS is a senior Gastro-Intestinal and laparoscopic surgeon at Apollo Hospital, New Delhi. He has been trained in Proctology Surgery at the prestigious Charing Cross Hospital in London after qualifying for the FRCS. He is one of the first surgeons in India to have started the Stapled Hemorrhoidectomy procedure and is a trainer in India for same.
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