anorectal surgery—hemorrhoids

Diseases

COLON &' of the

R E C T U M

Vol. 23 May-June 1980 No. 4

Symposium

Anorectal Surgery Hemorrhoids*

Moderator." A. W. MARTIN MARINO, JR., M.D.?

Panelists; W. PATRICK ~IAZIER, M.D., ; BRIAN MORGAN, M.D.,w EUGENE P. SALVATI, M.D.," LEE E. SMITH, M.D.�82

This symposium was designed by the Program Committee to be a free-flowing exchange of princi- ples a n d p r o c e d u r e s o f a n o r e c t a l s u r g e r y . T h e pane l i s t s gave no f o r m a l p r e s e n t a t i o n s , bu t re- sponded to questions posed by the m o d e r a t o r and the audience.

T h e comple te tape o f the s y m p o s i u m has been edited and abr idged by the m o d e r a t o r in the interest o f conserving space in the Journa l .

Af te r i n t roduc ing the pane l and cha rac te r i z ing them as being eminent ly qualified by their training, e x p e r i e n c e a n d zeal, the m o d e r a t o r ini t ia ted the discussion.

DR. MARINO

Gent lemen, can we agree on a s t andard classification of hemor rho ids? Before we discuss the a l terna- tive methods of t r ea tment , we mus t know the na tu re of the disease and that may not be as easy as it sounds. William Gabriel , H o n o r a r y S u r g e o n to St. Mark 's Hospital for Diseases o f the Colon and Rectum, offers this classification in the 1963 revision of his textbook, and it is for internal h e m o r r h o i d s (Table 1).

TABLE 1. Gabriel Classification of Internal Hemorrhoids

* Symposium presemed at the meeting of the American Society of Colon and Rectal Surgeons, Atlanta, Georgia, June 10 to 14, 1979.

i" Brooklyn, New York. ,,- Ferguson Clinic, Grand Rapids, Michigan. w Royal Prince Alfred Hospital Medical Center, Newton, N.S.W.,

Australia. " Plainfield, New Jersey. �82 National Naval Medical Center, Bethesda, Maryland. Address reprint requests to Dr. Marino: One Hanson Place,

Brooklyn, New York 11243.

Degree Criteria

First

Second Third

Bleeding at defecation, hemorrhoid grasped by external sphincter

Prolapse at defecation, slips back spontaneously Prolapse on walking, standing, or extra

exertion; remains down till replaced by finger pressure

0012-3706/80/0500/0211/$01.10 �9 American Society of Colon and Rectal Surgeons [The above applies to copies of the entire symposium, pp. 2I 1-222. l

211

Dis. Col. & Rect, 212 SYMPOSIUM May-June lOSO

TABU 2. Dodd Classification

Degree Criteria

First

Second

Third

Veins of the anal canal are increased in number and size and may bleed at the time of defecation; there is no prolapse

Internal or mixed hemorrhoids which present to the outside during defecation but return spontaneously within the anal cana! where they remain the rest of the time

Internal and mixed hemorrhoids which remain con- stantly outside the anal sphincter

TABLE 3. American Classification A*

Degree Criteria

First

Second

Third

Fourth

Maintained persistently at their proper level within the anal canal

Prolapse with bowel movement, but spontaneously reduce on cessation of straining

Prolapse out of anal canal; manual reduction necessary

Prolapsed, often thrombosed; cannot be reduced

* Smith.

TABLE 4. American Classification B*

Degree Criteria

First

Second

Third

Fourth

Internal hemorrhoids with bleeding

Internal hemorrhoids with bleeding and protrusion with' spontaneous reduction

Interna! hemorrhoids with bleeding and protrusion that requires reduction

Internal hemorrhoids that are prolapsed and cannot be replaced

* Salvati.

Dodd , as q u o t e d in Ture l l ' s textbook, of fers this classification (Table 2) which he says is the one used by St. Mark ' s Hospi ta l in L o n d o n . No te that this is no t l imited to in terna l h e m o r r h o i d s .

Nex t is a classification pub l i shed by an A m e r i c a n a u t h o r in Oc tobe r 1978 (Table 3). Dr. Salvati, I wou ld like to ask you to c o m m e n t on this classification. I know you haven ' t seen it previously.

DR. SALVATI

I th ink this is an excel lent classification a nd one that I would agree with entirely.

DR. MARINO

A n d now, one m o r e classification o f a n o t h e r p r o m - inent A m e r i c a n a u t h o r (Table 4). I'll ask Dr. Smi th to c o m m e n t ,

DR, SMITH

I can see very little d i f f e r ence be tween this classifica t ion and the last one. I h a p p e n to p r e f e r the previ- ous one because I th ink it's mine . I d idn ' t pu t it there , and I agree with this one also; I th ink they are the same.

DR. MARINO

T h e th i rd classification was Dr. Smith ' s a n d this is Dr. Salvati's, isn't it, Gene?

DR. SALVATI

You sl ipped one in on me. Th i s is unpub l i s h e d . T h e only d i f f e rence is tha t t he re is a p r o l a p s e d internal th rombos i s in Dr. Smith 's , as I see now. T h e r e is n o t h i n g o f the f o u r t h d e g r e e in my classification.

DR. MARINO

Dr. Mazier, is there a classification of hemor rho ids used at Ferguson Clinic and what is its impor tance?

DR. MAZIER

We d o n ' t classify h e m o r r h o i d s because we feel tha t the pat ient ' s s y m p t o m a t o l o g y is m o r e i m p o r t a n t t h a n a n y t h i n g else. W e c e r t a i n l y w o n ' t o p e r a t e o n a h e m o r r h o i d because it be longs to a cer ta in classification. We th ink the mos t i m p o r t a n t th ing is the pa- t ient 's h i s to ry o f pain, b leeding, o r prolapse . We say the pat ient has in te rna l o r ex t e rna l h e m o r r h o i d s , with o r wi thou t th rombos i s , with o r w i thou t pro lapse .

DR. MARINO

Dr. Morgan , wha t classif ication is used in Austra l ia?

DR. MORGAN

We tend to be disciples o f Gabriel , bu t I agree with Dr. Mazier 's c o m m e n t s .

DR. SMITH

I th ink that the re is s o m e i m p o r t a n c e to .classifying h e m o r r h o i d s in o r d e r to be able to talk in g r o u p s like this. I f I am ta lk ing a b o u t r u b b e r b a n d i n g a f o u r t h - d e g r e e h e m o r r h o i d , a n d a n o t h e r s u r g e o n is ta lk ing

Volume 23 Number 4 HEMORRHOID SURGERY 2 13

about rubber banding a first-degree hemorrho id , we are going to get entirely d i f fe ren t results if we don' t know the type of hemorrhoids we are comparing, so I think it is impor tant that we make an ef for t to classify hemorrhoids .

DR. SALVATI

I would agree, because it is extemely important ; for example, I would never treat a four th -degree hemorrhoid solely with ligation because if you can't reduce the prolapse, then you can't ligate that patient, so it is impor tan t for us to know what we are talking about. I f we can all agree on a classification, then we can all compare oranges and oranges and pears and pears.

DR. MARINO

From this short dissertation, perhaps there is a place for a s tandardized classification, and maybe one of our residents would take that on as an project and try to devise a simplified classification. However , let's proceed with what we have. Let's ask the panel when they feel that injection t rea tment should be used.

DR. SALVATI

I use it primarily in f irst-degree hemorrhoids . I use it occasionally as a diagnostic test if I think a patient is bleeding f rom hemorrhoids and I don ' t wish to put him th rough a bar ium enema. I f you inject and they stop bleeding, the chances are very good that it is internal hemorrhoids because you can stop the bleeding almost immediately with injections. I also tend to use injections dur ing pregnancy for internal bleeding hemorrhoids .

DR. MAZlER

I use the inject ion fo rm of t r ea tmen t very in- frequently, usually for older, more debilitated patients, or fo r pat ients who have a simple min o r p r o b l e m - - m a y b e a little bleeding, a little prolapse. I also use it in combinat ion with rubber banding. Some- times dur ing a closed hemorrho idec tomy, if there is some accessory hemorrho ida l tissue left at the internal level, I might inject 2 or 3 cc of quinine and urea hydrochlor ide but, for the most part, we don ' t emphasize the use o f injection t rea tment for hemorrhoids.

DR. MORGAN

We very commonly use the injection me thod but, of cour se , on ly for f i r s t - d e g r e e h e m o r r h o i d s a n d p e r h a p s occas iona l ly fo r s o m e b o d y wi th ea r ly

second-degree hemorrhoids , because it can be done in one sitting and it is more comfor table for the patient than banding.

DR. SMITH

Essentially I do not use injection. Having tried it in the past, I've changed my style. I don ' t use it at all.

DR. MARINO

All right, Lee, then when is banding the p rocedure of choice? I presume that is what you use in your outpat ient facility.

DR. SMITH

Yes. I use rubber banding effectively in most first- degree hemorrhoids . In what I call a f i rs t-degree hemorrho id (those that are in their p rope r place in the anal canal) the main complaint is bleeding and, if I can isolate a bleeder , I can very well treat it with just a simple banding. I am able to treat most o ther first- degree hemorrhoids with just diet plus stool softners, and the patients get over their symptoms rapidly.

Second-degree hemor rho ids respond very well to band ligation. As I classify them, s e c o n d - d e g r e e hemorrhoids will prolapse and spontaneously reduce; they are usually not quite so large as those that have to be manually reduced. Also, I will add another g roup that I will rubber band, the th i rd-degree hemorrhoids in the elderly and in patients who are poor risks for operative hemorrho idec tomy.

DR. ~ORGAN

I use rubber banding fairly extensively, but it is not very commonly used in ei ther Britain or Australia except by people who are colorectal surgeons. I find that it can be uncomfor tab le and seldom apply more than one band at a time. This means, of course, that the patient has to come back three or four times, and I think this is a nuisance for him.

DR. MAZIER

T h e majority of patients we have are t reated with closed hemor rho idec tomy; however, we do use elastic ligation and especially in those patients who are poor risks and with minimal symptomatology who might be a little bit more worr ied than normal. For instance, they might have repea ted episodes o f bleeding, but the hemor rho ida l symptoms are not severe enough to w a r r a n t o p e r a t i o n . As I said b e f o r e , I n o t in- f requent ly combine rubbe r banding with injection therapy. Most o f these patients are t reated in the clinic, not in the opera t ing room.

Dis. Col. & Rect. 214 SYMPOSIUM May-J .... t980

FIG. 1. Hemorrhoids of one year's duration, in a 63-year-old man in otherwise excellent health.

DR. SALVATI

We would use the internal ligation technique for first, second, and th i rd -degree hemor rho ids , and we use it also in the t r ea tmen t of acute h e m o r r h o i d a l disease where we reduce the prolapse and then do an immedia te three- or fou r -quad ran t ligation. At the presen t time, we do approx imate ly two-thirds of the patients that we see for pu re hemor rho ida l disease with internal h e m o r r h o i d a l ligation. We have done some 2,000 patients, r ep resen t ing close to 10,000 lig- ations. We do not use the rubbe r band technique in patients with associated anorectal pathology, such as fissure, fistula, or stricture; and we don ' t use it in patients who have r ecu r ren t ex te rna l th romboses , as they requ!re hemor rho idec tomy .

DR. MARINO

T e n yea r s ago , P e t e r L o r d o f f e r e d a n o t h e r moda l i ty - -d i !a ta t ion . What is your exper ience , if any, with dilatation for hemor rho ids?

DR. SALVATI

i have never used this par t icular technique. I 've seen it done, and I don ' t think I would want to try it.

DR. SMITH

I don ' t employ it. I consider it to be a m e t h o d of avulsion of the sphincter .

DR. NIORGAN

I have used it. I have watched Peter Lo rd doing it and, as you know, he dilates the anus to the ex ten t that he can get eight f ingers into the lower rec tum. He describes a process of i roning out the pe r ineum. He does it in a surpris ingly gentle fashion. I have observed my pat ients subsequent ly and there is no doubt that their symptoms are very common ly re- lieved. However , if you actually look at the a p p e a r - ance of the anus, it doesn ' t seem to have changed very much, but the patients are satisfied. Now the big risk, o f c o u r s e - - a n d there are increasing repor ts , part icu- larly in Britain where this is very common ly u sed - - i s tha t o f incon t inence ; and I warn , very s t rongly , against using this technique in the elderly, or in par- tur ient females who have a th inned-ou t pe r ineum, because of the risk of incontinence. It 's a small risk, but it's there, and you 've only got to have one.

DR. MARINO

W h a t is y o u r e x p e r i e n c e with c r y o s u r g e r y fo r hemorrho ids?

DR. ~IORGAN

I have tried it; I have found it messy and I gave it up.

DR. MAZlER

I have never used it.

DR. SALVATI

I have tried it and I have given it up.

DR. SMITH

I have tr ied it and I also have given it up.

DR. ~IARINO

Here are the hemor rho ids of a 63-year-old gentle- m a n , c o m p l a i n i n g o f p r o t r u s i o n on p r o l o n g e d s tanding and bleeding on defecat ion, o f one year 's dura t ion (Fig. 1). He is otherwise in excellent health. Sigmoidoscopy to 25 cm f r o m the anal verge is unre- vealing and bar ium colon x-ray with air contras t dis- closed no proximal abnormali ty . Wha t should this gen t leman be advised?

DR. SMITH

I feel tha t this pa t ien t shou ld have an elective hemor rho idec tomy .

VolLtme 23 Number 4 HEMORRHOID SURGERY 2 1 5

DR. MORGAN

I would certainly opera te on this person. I would do it wi th g r e a t ca re to m a i n t a i n a d e q u a t e mucocutaneous bridges, because I believe that this is the sort of patient in whom too much skin and mucous membrane can be removed in an a t tempt to clear all the abnormal vessels, and one does run the risk of gett ing an anal stenosis. But I think this man needs an operat ion. 1 think he will have a lot more symptoms than you describe, and if he hasn't got mucous dis- charge and discomfort , I 'd be very surprised.

DR. NIAZ IER

Oftentimes, these patients who have this picture are pratically pain free. It's amazing that they could have all this prolapse and very little discomfort . The chief complaint is usually o f something hanging out, or messiness, or seepage, etc. Even so, they should be o f fe red elective hemor rho idec tomy unless they become thrombosed, at which time pain develops. How- ever, in the ope ra t ing room, the physician, using about 50 ml of 1/2 per cent Xylocaine | and epinepr ine injected perianally in that immediate area, will reduce these hemorrho ids with pressure and shrink them to the point where he can comfortably do a s tandard th ree-quadran t closed hemor rho idec tomy with very little risk involved, with no skin loss or sloughing or anything. In short, I think this situation looks a lot worse than it actually is and once the hemorrho ids are reduced, they will look a whole lot better.

DR. MARINO

Dr. Salvati, what is the best t r e a tmen t for this patient?

DR. SALVATI

T he best treatment for this patient is hemorrhoidectomy.

DR. MARINO

What are alternative treatments?

DR. SALVATI

Alternative t rea tment is to inject this man on the spot wi th 9 ml o f }i pe r cen t M a r c a i n e | with 100,000-200,000 o f ep inepr ine to which has been added 1 ml of hyaluronidase, 150 T R units; inject with a 30-gauge needle directly into the edematous mass on both sides; take a tissue and massage it and

you will reduce the prolapse immediately. Th en , jus t put a rubber band ligature on all three quadrants .

DR. MARINO

Have you ever done this, Pat?

DR. MAZIER

No, sir. We would excise these hemorrhoids .

DR. MORGAN

I must have the wrong views about the action of hyaluronidase, Mr. Chairman. I can't imagine how it could possibly have any influence on non thrombosed hemorrhoids .

DR. SMITH

No, I would not do anything other than suggest operat ion.

DR. MARINO

Dr. Salvati, what would inf luence you in your choice between the two, opera t ion and your alternative t reatment?

DR. SALVATI

Well, I think one o f the impor tan t considerations is age. It has been my exper ience that elective hemorrho idec tomy past the age of 60, in the male, can give you a lot of problems. Frequent ly you end up with prostatic problems, and they don ' t seem to tolerate the o p e r a t i o n tha t well. Also, t h e r e would be a tendency to do a little bit more than you had to do; it's easy to do too much with as much disease as you see there, and I think that if there is any question about the patient's status, if he were obese, if he didn ' t take the sigmoidoscopic examinat ion well, I would be very inclined to treat him conservatively.

DR, MARINO

Opera t ion was advised, in this instance, and was carr ied out u n d e r saddle block anesthesia in the Buie inverted position. This is the technique that was used in this case. T h e crypts were delineated and incised (Fig. 2); skin flap raised (Fig. 3); and the muscles identified and protected, clamp applied (Fig. 4); re- d u n d an t tissue was excised (Fig. 5); and pr imary closure (Figs. 6-8). Now, gent lemen; I have described my technique. Tell us how you would have done it.

f

!, iii~i !

!t

\1 V

FIG. 2. Crypts delineated and incised.

FIG. 3. Skin flap raised.

FIG. 4. Muscles identified and protected, clamp applied,

f

FIG. 5. Redundant tissue excised.

FIGS. 6-8 Primary closure.

Volume 23 Number 4 H E M O R R H O I D S U R G E R Y 217

DR. SALVATI

Tha t is exactly how I would have done it.

DR. MAZIER

I agree. This is basically the technique we have been using for the past 25 years.

DR. ~V[ORGAN

I would do a closed hemorrho idec tomy, but I believe that the only advantage is that it makes the pa- t ient Stop seelSing a little earlier. Perhaps there are fewer postoperative visits, but I don' t think it does anyth ing for his postoperat ive pain, and it does often lead to more anal skin tags. The trial that came f rom J o h n Goligher 's unit showed this.

DR. SMITH

I also do closed hemorrho idec tomies . T h e only point I might stress is that I tend to do a little more s u b m u c o s a l d i ssec t ion and maybe take o f f less mucosal tissue and skin until later in the operat ion when I see that everything is going to lie flat, at which point I can take more off.

DR. MORGAN

I wouldn' t sew them up with a cont inuous stitch like that. I would sew them very loosely and, like Lee, I would use skin hooks and unde rmine the tissues and get r id o f all t hose vessels and w o u l d m a k e a min imum number , certainly never any more than three cuts.

DR. SMITH

I don' t think that the number of cuts is as impor tan t as the amount of tissue that is removed.

DR. MAZIER

We are talking about the total technique and the most i m p o r t a n t th ing is not how m a n y incisions you've got, but how much tissue you remove, and it is the an ode rm that you cannot spare. A n o d e r m is the tissue you can't af ford to lose too much of. Th a t is what should be very carefully exposed, and that is where the surgeons' j u d g m e n t is very important . Per- sonally, I feel that if you use more than three elliptical incisions, then you stand a grea ter chance o f develop- ing an anal stenosis, especially if the p rocedu re is done when the pat ient has acute h e m o r r h o i d s or needs emergency hemorrho idec tomy; then I think you have to be more careful. However , if you do a

linear incision to supplement the opera t ion so that you can u n d e rm in e the a n o d e r m and excise excess hemorrhoida l tissue, I don ' t think it does the patient any harm. I think we tend to put ou r sutures a little bit fu r the r apart and maybe not quite so tightly.

DR. MARINO

Dr. Salvati, I'll bet you've used more than three linear incisions.

DR. SALVATI

No more than four. I don ' t think you should cross the dentate line with more than four longitudinal incisions because I think, no mat ter how carefully you do it, you are going to get a certain degree o f stenosis. I would handle the secondary groups by a circular incision in an amputat ive fashion between the primary groups.

DR. MARINO

Th e next patient is a 50-year-old gent leman c o m - ' plaining of itch, anal fullness, protrusion on evacuation which is self repositing, and bleeding on and of f for the past six to eight months, with recently increasing s y m p t o m s - - n o t h i n g a c u t e . S i g m o i d o s c o p y and bar ium enema with air contrast have been unreveal- ing o f disease proximal to what you see in this picture, which is the inspection of the anus (Fig. 9), and what you will see in the next two pictures. Figure 10 shows the patient straining; the elongated papilla, situated posteriorly, did not have an associated fissure or ulcer; the classically located internal hemor rho ids are seen here at the time o f opera t ion (Fig. 11). These were apparen t on anoscopy. Gent lemen, you know what I did; I p e r f o r m e d a hemorrho idec tomy. What would you do?

DR. MORGAN

I would opera te on him. I don ' t think there is any doubt that the first picture (Fig. 9) indicated that at that time, anyway, there was a significant external component , and I think you would do best with surgical t reatment.

DR. SMITH

I think that this man will ultimately come to hemorrhoidectomy. I f I were seeing him, I would carefully have to weigh his symptoms. I f he is not having much pain or bleeding with the prolapse, and if it does not in te r fe re with whatever he does such as dancing, work, or whatever else, I might do nothing more than to give him a bulk stool softener.

Dis. CoL & Rect. 218 svMpostu~I May-june 1980

Votume 23 Number 4 HEMORRHOID SURGERY 2 1 9

FIGS. 9-13 (facing page) 9 (top left). Hemorrhoids in 50-year-old man complain-

ing of itch, anal fullness, protrusion on evacuation which is self repositing, and occasional bleeding. 10 (center left). Same patient, straining. Note elongated papilla situated posteriorly. 11 (bottom left). Same patient. Hemorrhoids seen at operat, ion. 12 (upper right). Anal appearance of 33-year-old physically active man with a two-week history of discomfort and

a lump at the antis noticeable on straining. 13 (lower right). Patient with delayed healing: anal appearance one year after hemorrhoidectomy. Healing took four months and was followed by chronic fissure and stenosis.

DR. MARINO

You are t reat ing him for his symptoms, as well as for his disease?

DR. SMITH

Yes, his symptoms and how they affect him. Basi- cally you are t reat ing symptoms, not how the anus looks.

DR. MAZIER

I think Lee answered all the questions well. We have all seen pat ients with horr ible- looking bot toms and no symptoms, and we have seen them the o ther way a round , where there isn't much to look at and they are in terrible pain. O f course, these people usually have fissures. So, give the pat ient the opt ion of having it done electively. In the meant ime, have t hem use any kind of o in tment that you like; I don ' t think any o f t h e m real ly work. Also, r e g a r d i n g bulk- p r o d u c i n g diet, I 've become increasingly fond of bran, any kind of bran. I prescribe it frequently.

DR. SALVATI

I would r e c o m m e n d opera t ing on this patient. One of the p r imary reasons is that he has what I call a shor t anal c a n a l - - a fiat a n u s - - a n d l igature technique is not effective, except on a palliative basis, in this type o f anatomic anal canal.

DR. MARINO

Now suppose this gen t leman wanted relief o f his symptomatology, but refused opera t ion. Dr. Salvati? What would you do?

DR. SALVATI

I wouldn ' t hesitate to ligate him.

DR. MAZIER

I think he would be a good candidate for ligation. Somet imes Surfacaine | o intment , or one of the topi- cal o in tments will help, and of tent imes I r e c o m m e n d the use of an ice pack, too.

DR. ~,IORGAN

I would certainly consider ligation, but we must emphasize the impor t ance of diet. T h e incidence of hemor rho idec tomy in ou r count ry is going down each year; and one observes, in this country, that there is a very substantial d i f ference in the diets available here. T h e a m o u n t o f v e g e t a b l e f ibe r in the o r d i n a r y d o u g h n u t is very, very low, and the availability of bran-conta in ing b r ead and o ther types o f food ap- pears to be equally low. I guess that if we could get all our patients to eat enough fiber in their diets, most hemor rho ids , except those that have a significant in ternal -external componen t , wouldn ' t require much t r e a t m e n t at all.

DR. SMITH

I would rubbe r band them.

DR. MARINO

I have a question f r o m the audience for your consideration, gent lemen. Is it advisable to do partial sph inc te ro tomy as an adjunct to s t andard external and in ternal h e m o r r h o i d e c t o m y ?

DR. SALVATI

We use an ext ra large, 35 -mm Hil l -Ferguson re- t ractor. I f that re t rac tor can be placed into the anal canal and pulled ou t with ease, and there is no tight- en ing of the distal por t ion of the internal sphincter , then we will not do a lateral in ternal sphinctero tomy. I f there is any t igh ten ing of the distal por t ion of the in terna l sphincter , then we will always do an internal sphinc tero tomy.

DR. MAZIER

During the course of a s t andard hemor rho idec - tomy one usually cuts a few of the sphincter fibers, so I think you do it inadvertent ly . I don ' t think you need to do it on pu rpose and I don ' t think it has to be very deep. We, too, use the ex t ra large, Hi l l -Ferguson re- t ractor for ou r hemor rho idec tomy ; however , I think we close the wound a r o u n d the s tandard or m e d i u m - sized Hi l l -Ferguson retractor . I f you can do it a r o u n d that, I don ' t think you will have any prob lems with

Dis. Col. & Rect. 2 2 0 SYMPOSIUM May-June 19S0

stenosis afterwards, unless the patient has a chronic problem such as diarrhea or an occult disease such as Crohn's.

DR. MORGAN

I don ' t think it should be done. T h e r e is some evi- dence, if you cut the internal sphincter , however small the incision, that there will be some leakage sub- sequently. I think that one should avoid doing so for that reason. It has been done historically because it was thought to diminish postoperat ive pain. We can't overcome pain completely, but I believe the best way of making the first bowel action as pain-free as possible is to get it to happen as quickly as possible by initiating a high-fiber diet quickly and prescribing Normacol or Isogel, or whatever you use here, immediately after the operation.

DR, SMITH

I do not use sphincterotomy rout inely with hemorrhoidectomy. T h e only time I might is if there were some additional abnormality. I will put in a bid for the Fansler opera t ing anoscope. It has a large d iameter and, if you can close the wounds with it in place, it gives a very adequate lumen, avoiding stenosis.

DR. MORGAN

Can I put in a bid for an even cheaper ins t rument which is two fingers? I f you can get them in at the end o f the operat ion, it's okay.

DR. MARINO

Now here's ano the r patient for your consideration, gent lemen. This is a 33-year-old physically active man with a two-week history of discomfort and a lump at the anus, no t i ceab le on s t r a in ing (Fig. 12). He thought that he had had hemorrho ids for the past one to two years, but he only bled once and that was a week before this lump appeared. He does not have any great deal of pain; he just knows that it is there. This hemor rho id is covered by anal skin and is soft and compressible. Anoscopy is unreveal ing except for what you see here. Sigmoidoscopy did not reveal any ulcerat ion or tumors . Dr. Smith, what would you advise?

DR. SMITH

Again, as I ment ioned a few moments ago, I think the decision for therapy is based upon symptoms.

This man, as you describe him, doesn ' t have a great deal of symptoms. I f he doesn ' t have symptoms, then I don ' t do anything. Again, I would r e c o m m e n d that he go on a bulk stool sof tener o f some kind.

DR. MORGAN

I think you can see, in this picture, the point f rom where he has been bleeding. It looks as though this thing is almost coming th rough the skin. It is a pret ty unusual slide. When I first saw it, I thought it was a t h rombosed p i l e - - an acute th rombosed pile that had been bleeding; but our Cha i rman assures that it is soft and not tender. That ' s going to bleed again nex t week and you may as well cut your losses and do a relatively minor surgical p rocedure to fix it.

DR. MARINO

You would do that as an outpat ient then? It is within the anal canal.

DR. MORGAN

I would probably do it as an overnight hospital ad- mission, I think.

DR. MAZIER

I think the patient is probably just scared and really doesn' t know what's going on; and he needs a doctor 's reassurance that it is no th ing serious. As long as he's getting bet ter and feeling better, I think it could be left alone. However, he should be told about the nat- ural history of hemor rho ida l disease and that he will, more than likely, develop the problem with increasing frequency. Maybe, then he wouldn ' t be so scared as to what's going on. I f he continues to have problems, then he should come back and be checked out again. He will probably come to h em o r rh o id ec to m y some time in the future, but I don ' t know when.

DR. SALVATI

I f this is not a th rombosed externa l hemor rho id , and you assure me that it isn't, then I would tell this patient not to worry. He doesn ' t have anything that is going to lead to cancer, but he eventual ly will requi re hemorrho idec tomy. This will get progressively worse; it will be u n c o m f o r t a b l e fo r him. You ce r t a in ly couldn ' t ligate this, and he should have a hemorrho idec tomy done; and he eventual ly will, in the future.

Volume 23 Number 4 HEMORRHOID SURGERY 221

DR. MARINO

Tha nk you; now let's proceed to some questions f rom the audience. Dr. Smith, please discuss why you have given up c r y o h e m o r r h o i d e c t o m y . S o m e o n e didn ' t read your paper.

DR. SMITH

For the few who weren' t at this meeting last year, I took a series o f 26 patients whom I used as their own control. I used cryotherapy on half of the anus and operative hemor rho idec tomy (closed type) on the op- posite side; then I followed them carefully for up to three years. I found that, indeed, the patients re- quired anesthesia to have the cryotherapy per formed . I had initially been assured by the manufac ture rs that it was painless; it is not painless. I was also assured that this would make them disappear; but, at the end o f one year's time, fully 50 per cent of the patients had persistent hemorrho ids at the site of cryotherapy. Also, at the site of the cryotherapy, the external tags, external hemorrhoids , what have you, that were there previously, were there as bad, or worse, and the patients didn' t like it. T h a t is, they had a side that was smooth and nice f rom operat ion and they had a side to compare with it which was ragged and ugly; when they had a choice, they did not like it. At the end of the year, when I asked the patients how they rated the two means o f therapy, 65 per cent said if they had their choice, they would opt for operation, and 35 per cent would opt for cryotherapy.

DR. MARINO

Well, of course, cryosurgery is tissue loss, which is just another way of excision. Is tissue actually lost when you do cryosurgery?

DR. SMITH

Yes, a slough occurs, but the problem is that you can't predict how much is going to slough. Sometimes there is very little; sometimes there is a lot. Sometimes it will slough right down to the sphincter and sometimes you will get just a superficial skin loss. At the time of the procedure , all look the same- - the re ' s a nice white ball of ice, and it's obviously very cold because the probe is stuck to it, but you cannot predict how much is going to come off. Some sloughs off, but it's usually not enough to really do a good job. Yet, sometimes it's too much. I have, in fact, gone th rough the internal sphincter without knowing it.

DR. MARINO

I know that the panelists don ' t have any difficulty with delayed wound healing after anorectal operat ion or postoperat ive anal ulcer, or fissure, or stenosis, so they really might not recognize the problem that I have run into in Figure 13. This gent leman had a hemor rho idec tomy p e r fo rm ed one year previously. Heal ing took four months . He did not have any Crohn ' s disease or ulcerat ive colitis. T h e heal ing process left him with a chronic, recurr ing, poster ior ulcer or fissure, and narrowing o f the anal canal so that only the small f inger could be admitted. I shall ask our panelists how they prevent delayed healing, chronic postoperative fissure, and stenosis.

DR. I~IORGAN

I think this pat ient has almost certainly had some s loughing o f one o f the m u c o c u t a n e o u s br idges, perhaps more than one. The re fo re , the way to avoid this is to make no more than three cuts.

DR. SMITH

I agree. I think that the way to prevent that is to avoid loss of tissue and to preserve wide mucosal bridges between incisions.

DR. MAZIER

I agree with what Dr. Smith says, that d u r i n g h e m o r r h o i d e c t o m y you do not r e m o v e excessive anoderm. I think you can take more of the perianal skin or rectal mucosa, but you must sacrifice too much anoderm. If you do, then it will require a plastic procedure for correction.

DR. SALVATI

We use a 35-mm extra large Hil l-Ferguson retractor and we want to insert it with ease at the comple- tion of the operat ion. I f you can do that, and you combine it with a closed h e m o r r h o i d e c t o m y , it is highly unlikely that you will have problems. Occa- sionally you will get a slough, but it is highly unlikely.

DR. MARINO

I think this gent leman had three or four wounds. I would like to summarize this port ion of the discussion. I don' t think that the panelists would disagree with the s tatement that there are two separate groups

Dis. Col. & Rect. 222 S Y I V l P O S I U M May-June 1980

of factors in delayed h e a l i n g - - t h e local or mechanical factors and the systemic factors, colitis and enteritis. Both groups must be considered in any difficult post- opera t ive situation.

De. Mo~cAy

May I add one thing? Every patient that has any anal o p e r a t i o n should be careful ly ins t ruc ted on diet. Many o f these people do have pain and their way o f ove rcoming it is to pu rge themselves, and if they cont inue to pass fluid motions for weeks or months af ter an operat ion, they can get anal stenosis f r o m that alone. So it is worthwhile e i ther to take the time one 's self, or to get the dietitian to instruct t h e m on a high-f iber diet.

DR. SALVATI

I would agree, and we instruct ou r patients to eat a high-residue diet postoperat ively and, o f course, we place them on a bulk psyll ium seed p repa ra t ion such as LA formula , for example , three times daily, and we keep it up for at least four to six weeks subsequent to operat ion.

DR. MARINO

I would like to thank the panelists for shar ing their expertise. Perhaps the most impor t an t conclusions of this sympos ium are 1) do not t reat anal symptoms in the absence o f physical f indings and 2) do not t reat physical f indings in the absence of symptoms.

A n n o u n c e m e n t

ST. MARK'S HOSPITAL SURGICAL TRAINING PROGRAM

Postgraduate surgeons are invited to attend one of the 8-week terms of organized teaching. Each term will consist of a formal program of lec- tures, clinical meetings, and attendance at operation sessions, ward rounds, and outpatients. FEE PER TERM: s

Winter Term - - October/November Spring Term --January/March Summer T e r m - - May/June.

For further details, please write to: Secretary of Dean of Postgraduate Studies, St. Mark's Hospital, City Road, London EC 1V 2PS, England. Telephone: 01-253 1050, ext. 225.

anorectal surgery—hemorrhoids

Documents