HEMORRHOIDS & SURGERY
This week’s topic is a very sensitive one, indeed! Hemorrhoids have, presumably, afflicted mankind ever since we began walking upright. Hemorrhoids are, basically, dilated (varicose) veins that normally line the anorectal canal. As these hemorrhoidal veins enlarge, inflammation can develop, causing the characteristic symptoms of swelling, itching, burning, pain, and frequently, the passage of bright red blood with bowel movements. As hemorrhoids dilate further, the blood flow within these veins can become so sluggish that blood clots can arise. When external hemorrhoids become acutely clotted (thrombosed), they can cause exquisite anorectal pain and swelling (internal hemorrhoids are generally painless, because they are located within the lower rectal canal, which does not contain pain-sensing nerve fibers).
When internal hemorrhoids become significantly dilated and inflamed, they may protrude (prolapse) from the anus, requiring the patient to manually push them back into the anorectal canal (in some cases, internal hemorrhoids may prolapsed so severely that the patient may be unable to “reduce” them back into the anorectal canal, thus requiring semi-urgent surgical treatment).
Bright red blood on the toilet paper, blood in one’s underwear, and the passage of excessive mucus from the rectum may all occur with significant internal or (and) external hemorrhoidal disease.
Unfortunately, hemorrhoids are a very common and vexing health problem. By the age of 50, at least half of all people will have symptomatic hemorrhoids. (Women also often experience the unpleasant symptoms of hemorrhoids during pregnancy, when the changes of pregnancy cause hemorrhoidal veins to enlarge and protrude, although, in most cases, these pregnancy-associated hemorrhoids will resolve following delivery.)
The precise causes of hemorrhoids continue to be debated, but most experts agree that a combination of anatomy and lifestyle factors probably account for the vast majority of cases. Due to our upright posture, blood tends to pool in the thin-walled veins that line the anorectal canal. Standing, and especially sitting, for prolonged periods of time, encourages this gravity-related pooling of blood in the anorectal veins, as well as the progressive dilation of these veins over time. Other important factors in the development of hemorrhoids include a low fiber diet, a lack of exercise, and poor toilet habits.
In general, the longer we spend sitting on the toilet to do our “business,” the more likely we are to develop hemorrhoids. Sitting on the toilet with our derričres hanging flaccidly in mid-air for prolonged periods of time encourages the pooling of blood in the anorectal veins, and the relaxation of our anal sphincters that occurs while we are engaged in passing stool further encourages the dilated internal hemorrhoidal veins to prolapse out of the anorectal canal, which further encourages swelling and dilation of these delicate structures. Chronic constipation (which is often associated with inadequate dietary fiber and inadequate physical activity) further complicates matters, as constipated people spend more time sitting on the pot. Straining to defecate is particularly bad, as it forces blood, under pressure, back into hemorrhoidal veins, causing them to balloon out, and to dilate further.
Good bowel habits cannot be overemphasized when it comes to living a hemorrhoid-free life (or, at least, a life that is not unduly influenced by hemorrhoidal symptoms). So, forget about reading your favorite magazine or novel while you are doing your “business.” The longer you sit on the toilet, the more likely you are to develop symptomatic hemorrhoids. So, get rid of the reading rack next to the toilet! Also, when you feel the urge to strain, resist it! (Finally, don’t delay when the urge to defecate occurs, as this will contribute to constipation, as well.)
Because of the particular etiologic factors associated with the development of symptomatic hemorrhoids, most cases will respond well to some fairly simple lifestyle modifications. First and foremost, a diet rich in fiber and water will help you to more easily pass your stools, allowing you to spend less time on the potty, and alleviating the urge to strain when defecating. Likewise, getting enough exercise to stimulate normal bowel function is important (and regular exercise is not beneficial only for your GI tract, alone, of course!). Avoiding overly aggressive anal hygiene is also important, as excessively vigorous or frequent washing of the anal skin can cause irritation of this sensitive area and the underlying anorectal veins.
Despite adopting a bowel-healthy lifestyle, however, some people will still develop symptomatic hemorrhoids, unfortunately. In addition to the lifestyle modifications that I’ve already discussed, warm baths (especially after bowel movements) can ease the burning and itching of hemorrhoids. The sparing use of anti-inflammatory creams or suppositories can also help to reduce the annoying symptoms of mild-to-moderate hemorrhoidal disease. Occasionally, chronic constipation that does not improve with increased dietary fiber and liquids (and increased exercise) may require the use of non-laxative stool softeners, such as docusate sodium (the frequent or regular use of laxative-type medications will only worsen constipation over the long run).
Despite taking all of these recommended steps, however, persistently symptomatic hemorrhoids may require various interventions by a physician, however. Once again, less radical approaches to symptomatic hemorrhoids should be attempted prior to more radical measures. There are several different interventional approaches to bothersome hemorrhoids that are currently available, and these approaches often differ depending upon whether the offending hemorrhoids are internal or external (or both).
For acutely thrombosed (clotted) external hemorrhoids, your doctor can extract the blood clot from inflamed external hemorrhoids under local anesthesia in his or her office. Generally speaking, this approach is most beneficial within the first 2 or 3 days after the onset of thrombosis and pain, and will expedite resolution of the exquisite pain that usually accompanies the formation of a blood clot in external hemorrhoids. However, several clinical studies have shown that performing a “thrombectomy” of thrombosed external hemorrhoids more than 2 or 3 days after the acute onset of symptoms is generally of little benefit to patients as, by this time, the acute inflammatory response to the blood clot generally begins to subside (instead of surgical clot extraction, most patients will, at this point, do better with warm baths and the temporary use of anti-inflammatory hemorrhoidal creams).
Especially severe itching, burning, swelling, and bleeding from non-thrombosed external hemorrhoids may, in some cases, require invasive surgical intervention (hemorrhoidectomy)l, although this more aggressive approach is necessary only in the minority of patients, fortunately.
Prolapsing or bleeding internal hemorrhoids can also fail to respond to the conservative measures that I have described. Because the tissues in and around internal hemorrhoids are not capable of sensing pain, there are several different “minimally-invasive” therapies available, short of surgical resection (hemorrhoidectomy). These treatments include rubber-band ligation (“banding”), sclerotherapy, and infra-red coagulation. (Although other, newer approaches to the management of internal hemorrhoids have been used recently, we don’t yet have the same long-term experience and documented outcomes available with these treatments, like we have with the more established procedures that I’ve listed.)
Rubber-band ligation involves the use of as simple device that places a constricting rubber-band around the base of symptomatic internal hemorrhoids. The blood supply to the hemorrhoids is strangulated by the rubber-band, causing the hemorrhoids to, essentially, die and slough-off after a couple of days. The rubber-band must be carefully placed by the physician, such that the entire thickness of the rectal wall is not included in the rubber-band, lest a full-thickness injury to the rectal wall occur. Also, occasionally, significant bleeding can occur when the hemorrhoid begins to slough-off. Placement of the rubber-band around the area of transition between the internal anorectal canal (which cannot sense pain) and the external anal canal (which is exquisitely sensitive to pain) can lead to severe anorectal pain. In the vast majority of cases, however, the use of rubber-band ligation of internal hemorrhoids, by an experienced physician, is a well-tolerated and effective treatment for symptomatic internal hemorrhoids that are refractory to more conservative treatments.
Sclerotherapy of internal hemorrhoids involves the injection of irritating substances (sclerosants) into the tissues around symptomatic hemorrhoids, which leads to scarring and shrinkage of the offending hemorrhoid or hemorrhoids. This method of treatment is less effective, however, for very large internal hemorrhoids.
Infrared coagulation of internal hemorrhoids uses heat that is painlessly generated by a special infrared probe to shrink symptomatic hemorrhoids, primarily by causing the blood within the dilated hemorrhoid to form a blot clot. As with acutely thrombosed external hemorrhoids, the blood clots formed within internal hemorrhoids by the infrared coagulator initiates an inflammatory response which, in most cases, leads to the eventual scarring and shrinkage of the hemorrhoid. Because the application of high temperatures to external hemorrhoids would be terrifically painful, infrared coagulation can only be used on internal hemorrhoids. As is the case with sclerotherapy, very large internal hemorrhoids may not be effectively or completely treated using infrared coagulation alone.
For patients in whom all of the above methods fail, hemorrhoidectomy may be an option to consider for severely symptomatic external or (and) internal hemorrhoids. The classic and time-tested approach to persistently symptomatic hemorrhoidal disease has been to surgically excise the offending hemorrhoids, in addition to the skin overlying external hemorrhoids and the mucus membranes overlying internal hemorrhoids. For carefully selected patients with severe hemorrhoidal symptoms that are refractory to less invasive treatments, hemorrhoidectomy can dramatically improve the patient’s quality of life, but only after what is, unfortunately, a typically painful recovery from this most radical of approaches to hemorrhoids.
Because of the typically unpleasant postoperative recovery from traditional hemorrhoid surgery, clinical researchers have long sought a less painful method of dealing with severe hemorrhoidal disease that is refractory to less invasive treatment methods. One recent and promising innovation has been the adaptation of circular surgical stapling devices to allow for hemorrhoid excisions, thus eliminating the need to make large and painful surgical incisions within the anorectal canal. Preliminary research data has suggested that the use of these circular staples, to perform a so-called stapled hemorrhoidectomy, may be associated with less pain, and a more rapid recovery, than conventional surgical hemorrhoidectomy. Now, a new prospective, randomized clinical surgical research trial adds additional useful data regarding the relative risks and benefits of traditional versus stapled hemorrhoidectomy.
This new study, just published in the journal Gut, randomly assigned 182 adult patients with symptomatic hemorrhoids to undergo either traditional “excisional” hemorrhoidectomy or stapled hemorrhoidectomy. All of these patients were then closely followed, at regular predefined intervals, for an average of one year following hemorrhoidectomy.
The results of this study were similar, with regards to postoperative pain, as have been reported in previous non-randomized studies. While there were no significant differences between the two groups of patients in terms of residual or recurrent hemorrhoidal symptoms at one year following hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy reported, on average, significantly less pain in the early postoperative period when compared to the patients who underwent conventional hemorrhoidectomy. At the same time, while the overall rate of complications appeared to be equivalent between the two different procedures, the patients who underwent stapled hemorrhoidectomy reported a greater sense of urgency to have a bowel movement when compared to the “excisional” hemorrhoidectomy patients. Also, despite comparable overall relief of hemorrhoidal symptoms at one year following hemorrhoidectomy, the patients who had undergone conventional “excisional” hemorrhoidectomy reported fewer episodes of persistent or recurrent prolapsing internal hemorrhoids when compared to the stapled hemorrhoidectomy patients. Thus, at one year following hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy more frequently required retreatment for recurrent prolapsing hemorrhoids than did the patients who were treated with conventional hemorrhoidectomy.
Despite the significant long-term differences in outcomes between these two approaches to hemorrhoidectomy, including the higher rate of recurrence of symptomatic prolapsing hemorrhoids following stapled hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy were significantly more satisfied with the stapled approach to hemorrhoidectomy, and particularly the early outcomes of their operations (at 6 weeks and 12 weeks following hemorrhoidectomy), when compared to the patients who had been randomized to undergo conventional hemorrhoidectomy. Thus, the reduction in early postoperative pain achieved with stapled hemorrhoidectomy (when compared to conventional hemorrhoidectomy) was substantial enough to override patient concerns about the subsequent increased risk of hemorrhoidal relapse, as well as an increased sense of fecal urgency.
Before my tens of thousands of readers with symptomatic hemorrhoids run to their local neighborhood proctologists to ask for a stapled hemorrhoidectomy, I want to emphasize, once again, that both of these approaches to hemorrhoidectomy constitute major surgical operations, and both are associated with a small (but not insignificant) risk of complications, including bleeding, infection, recurrence of hemorrhoids, and a temporary or permanent compromise in the ability to control the passage of flatus or bowel movements (incontinence). Thus, hemorrhoidectomy, by any method, should be reserved for the minority of patients with severe hemorrhoidal symptoms that have been refractory to all other forms of treatment.
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity
is an oncologic surgeon, a professor
of surgery, a widely published author, and the
Physician-in-Chief for Surgical
Oncology at the Kaiser Permanente healthcare system in Orange County,
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Robert A. Wascher, MD, FACS.
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