1. Haemorrhoidal disease
Prof Walid El shazly
Assisstant professor
MD of Surgery

2. Haemorroidal disease How common?
The most frequently observed anal pathology
Overall prevalence 80% population
No difference in prevalence between men and women
Women are slightly more symptomatic than men
80% of all patients attending colorectal clinic present with symptoms of piles

3. Anal Cushions Constant position
R anterior (11 o’clock)
R posterior (7 o’clock)
L lateral (3 o’clock)
Rich intercommunicating blood supply from superior, middle and inferior rectal arteries

6. Etiology of haemorrhoids
Thomson
“Vascular Cushion Theory”
Anatomical support of muscularis submucosae weakens (degeneration, disintegration)
Aging (deterioration after the third decades)
Straining effort
Hormonal influence
Genetic predisposition

8. Haemorroidal disease

15. Classification Internal haemorrhoids Arise above the dentate line
Microscopically covered by transitional or columnar epithelium
External haemorrhoids
Appear at perianum
Situated below dentate line
Microscopically covered by modified skin epithelium (no skin appendages)
Skin tags
Residue from previous external haemorrhoids

16. Classification First degree No prolapse Second degree
Spontaneously reducible
Third degree
Prolapse requiring manual replacement
Fourth degree
Permanent prolapse

17. First degree piles

19. Second degree piles

21. Third degree piles

23. Fourth degree piles

25. Symptoms Bleeding Prolapse Burning or pressure sensation
Pain (not a prominent symptom except at the time of thrombosis)
Pruritis

26. Bleeding Bright red (AV shunts) Mucosal erosion Episodic
May or May Not associates with motion
Drip or Squirt into toilet bowl
Staining tissue paper
Severe anaemia (uncommon)

27. Prolapse Usually not associates with pain in the early stage
May be unaware of the protruding anal cushions
Spontaneous reduction
Manual reduction

28. Burning sensation Engorgement with blood Swelling
Increase pressure sensation
Temporary
Subsides over few days
Sustained  Thrombosis  Pain

29. Complications
Complications

36. strangulation

38. Treatment
Treatment

39. Non-surgical treatment
Dietary advise
Recommend high fiber diet with sufficient fluid intake
Modify defecatory habit
Straining has never been proved to have a causative role in piles
Excessive straining precipitates symptoms or worsens existing ones
Avoid constipation

40. Non-surgical treatment
Topical treatment (cream / suppository)
antiseptic
local anaesthetic
steroids (atrophy of anoderm, eczema)
Nonsteriodal
Vasoactive
anti-thrombotic
Oral drug – phlebotropic drug
Daflon (micronized purified flavonoid fraction)

41. Surgery Milligan and Morgan: Open technique (UK)
Ferguson and Heaton: Closed technique (USA)
Whitehead (circumferential) haemorrhoidectomy
Parks (submucosal) haemorrhoidectomy

42. Open haemorrhoidectomy
Described by two surgeons in St Marks Hospital in 1935
E.T.C. Milligan
C. Naughton Morgan
Fulfilled three criteria
1. Acceptable post-op pain
2. Low risk
3. Low recurrence rate
Initiated modern surgical treatment for haemorrhoids

43. Haemorroidectomy

49. Closed haemorrhoidectomy
Described in 1959 by
Ferguson and Heaton
Proponents believed that primary wound closure decreases post-op pain
No difference shown in terms of pain, complication rate, hospital stay and post-op recovery
Wolfe et al 1979 Dis Colon Rectum
Roe et al 1987 Br J Surg

52. Submucosal haemorrhoidectomy
Described in 1952 by Sir Alan Parks
Not been widely adopted (even in UK)
Technically demanding and time consuming
Preserve anal mucosa during haemorrhoidectomy in order to
Minimize post-op pain
Minimize stenosis
Minimize faecal continence disturbance

53. Whitehead haemorrhoidectomy
Introduced in 1882 by Walter Whitehead
Contraindications
Small haemorrhoids
Excess scar from previous operation
Chronic diarrhea
Incontinence
Thin and tight anoderm
Obsolete rarely done

55. Complications Early Urinary retention (within 24-48 hrs)
Reactional haemorrhage
Intermediate
Faecal impaction
Haemorrhage (7-16 days post-op)
Late complications
Anal stricture
Incontinence
Ectropion
Anal tags
Rectal stricture
Fissure / ulcer
Fistula
Pseudopolyps
Recurrence

56. Injection Sclerotherapy
1869 John Morgan
5% Phenol in almond oil
Mechanism
Inject a solution that will cause fibrosis
Causing a low grade & long-standing inflammatory reaction
Binds down the mucosa and scleroses the submucosal tissues
Thus shrinking the haemorrhoids
Retricted to smaller haemorrhoids
(1st or early 2nd degree) in which bleeding is the predominant symptom
Sclerotherapy to achieve prolapse associates with high incidence of failure

58. Rubber band ligation Initially performed in 19th century
Not popular till reintroduction in 1958 by Blaisdell
Further modified by Barron in 1963
Nowadays still the most widely practiced office procedure for symptomatic piles despite the development of other modalities
Mechanism
Local obliteration of submucosal vessels
Ischaemic necrosis
Ulceration (7-10 days post banding)
Fixation of mucosa by fibrosis
(the area healed by 3-4 weeks)

68. Haemorrhoidal artery ligation
Haemorrhoidal anatomy
“Hypervascularisation of the anorectum contributes to the growth of haemorrhoids rather than being a consequence”
Aigner et al 2006
Vascular
Supporting structures
As earlier slide
Superior rectal artery (SFA) blood flow increased in patients with haemorrhoids
The vascular nature of haemorrhoids; J Gastrointest Surg. 2006; 10(7):

69. DGHAL/HALO First described by Morinaga et al 1995
Developed by Scheyer et al
Controlled trial reported by Bursics et al 2003

70. DGHAL/HALO

72. Fissure (1.7%), perianal thrombosis (6.7%)
Year
Author N=
“Overall” success
Complications
1995
Morinaga et al
(5-12 months)
116
87%
None
2001
Sohn et al
(?12 months) 60
90%
Fissure (1.7%), perianal thrombosis (6.7%)
2002
Arnold et al
(1-2 months)
105
86%
Fissure (1.9%), perianal thrombosis (2.8%), infection (0.9%)
2003
Shelygin et al
(12 months)
102
82.6%
?none
2004
Bursics et al (12 months, RCT) 30
93%
2006
Greenberg et al
100
94%
This slide summarises other published series, with follow-up periods up to 12 months, and low complication rates.

73. Ligation Anopexy

74. After
Before

75. Before
After

76. Thermal Methods
Thermal methods been used for hundreds of years ranging from heating to freezing
Infrared
Laser
Diathermy
Cryotherapy
Recently Harmonic Scalpel and ligasure

77. Infrared Thermocoagulation
Mechanism
Infrared radiation penetrates the tissue to a predetermined depth
Instantly converted into heat (slightly above 100 0C)  protein denaturation
Results
Safe and well-tolerated
Almost immediate return to normal activity
Less post-treatment discomfort
Inferior to rubber band ligation
Higher rate of recurrence (54% vs 27%)
Need multiple treatments

78. Bipolar diathermy and DC electrocoagulation
Principle is similar to infrared coagulation
Tissue destruction by heat
Out-patient procedure without anaesthesia
Safe and well-tolerated
20% pain
24% rectal ulceration
More tedious to perform

79. Diathermy haemorrhoidectomy
Before
After
OP procedures

81. Cryotherapy First used in the latter half of 1960s
Application of liquid nitrogen cryo-probe
Rapid freezing (temp down to –60 to –120 0C)
Frozen tissue becomes a white solid mass
Circumferential limit of freezing may be clear cut but the depth of freezing is not apparent
Not widely accepted
Most patients considered “unpleasant”
Results
More than 2/3 suffer from recurrent symptoms within 10 yrs of cryotherapy treatment
Much worse than results of standard haemorrhoidectomy

82. Laser haemorrhoidectomy
No differences between laser and conventional haemorrhoidectomy with regards to effectiveness and complications
Major drawbacks
Expensive equipment and maintenance cost
Additional precaution to protect staff
High recurrence rate

83. Haemorrhoidectomy
Surgical excision is one of the oldest treatments for piles
Most effective and long-term cure
<5% recurrence rate
Several described techniques
None has been shown to be the best

84. Stapled haemorrhoidopexy
Originated in Italy by Dr Antonio Longo in 1993
Fully developed and released in 1997
More than operations been done
Mechanism
Not really haemorrhoidectomy
Better described as prolapsectomy or anopexy
Reduction and fixation of the prolapse
Same principle as RBL and sclerotherapy

93. Thank you