So you think you need . . .a haemorrhoidectomy

Haemorrhoids (piles) are common – about half the population will have them at some point in life. They are like varicose veins, but of the tissue that lines the anal canal. If these veins become dilated and swollen, they can project into the anal canal and sometimes even from out of the rectum (called ‘prolapse’), forming swellings (‘piles’) visible to the naked eye.

Piles can cause a variety of problems, including skin irritation, discomfort and, occasionally, severe bleeding.

No one knows precisely what causes haemorrhoids, but contributing factors include straining to pass stools, chronic constipation, diarrhoea, prolonged sitting, pregnancy, advancing age and pelvic tumours.

Haemorrhoids are classified into four grades:
* Grade I haemorrhoids bulge into the anal canal, but don’t protrude past the anus
* Grade II haemorrhoids protrude through the anus while passing stools, but retract into the anal canal without intervention
* Grade III haemorrhoids protrude through the anus with defecation or straining and don’t retract spontaneously, but need to be gently pushed back into place with a finger after defecation
* Grade IV haemorrhoids are ‘irreducible’ – they can’t be pushed back into place once they protrude from the anus.

Patients who continue to experience symptoms despite conservative or less-invasive therapies are usually told that they require a haemorrhoidectomy to surgically remove their haemorrhoids.

What doctors tell you
Diagnosis is based on patient history and clinical evaluation. The physician examines the rectum and anus by inserting a gloved finger to feel for any abnormalities.

To test for ‘occult bleeding’ (not visible to the naked eye), the physician obtains a small stool sample during the rectal examination. The sample is placed onto chemically coated paper, and another chemical is dropped onto the sample. If blood is indeed present, the paper will turn blue.

To exclude other anorectal disorders and other possible causes of bleeding, endoscopy is required. This uses a flexible or rigid scope with a lighted tip to examine the inner surfaces of the digestive tract. Other ‘oscopies’ include anoscopy or sigmoidoscopy in younger patients, or a colonoscopy, often recommended for older patients to exclude more serious causes of gastrointestinal bleeding such as colorectal cancer. Before these procedures, a laxative may be prescribed to ensure that the rectum and large intestine are clear of faeces.

A haemorrhoidectomy involves removing any excess, haemorrhoidal tissue from the anal canal while under spinal or general anaesthesia. An anoscope (an instrument for examining the lower rectum and anal canal) is used to find the haemorrhoids that are to be removed. During the procedure, the doctor may also remove excess tissue from the rectum, and any wounds will be either sewn closed or left to heal on their own.

Your surgeon may perform a ‘stapled’ haemorrhoidectomy instead. This ‘procedure for prolapse and haemorrhoids’ (PPH) was developed in the early 1990s, and excises the prolapsed haemorrhoidal anal tissue using a circular stapling device. While cutting away the excess tissue, the device staples the remaining haemorrhoidal tissue back into its original position.

After either procedure, patients may be allowed to go home the same day or, at worst, stay in hospital for up to three days, depending on recovery. Sitz baths – warm-water baths taken in a sitting position that cover only the hips and buttocks – are encouraged. Stool softeners and the application of ointments to the affected areas are also recommended.

In general, patients are able to return to work within a few days or weeks, depending on their type of work. There may be difficulty in passing urine, and in controlling gas and bowel movements for a few days immediately after the operation.

What doctors don’t tell you
Physicians tend to downplay the risks of new procedures like stapled surgery, and may even offer it when it’s not suitable for the given patient.

* PPH is not suitable for all types of haemorrhoids – in particular, grade IV types (Eur J Surg, 2002; 168: 621-5). In some patients, gaining access to the anal canal can be difficult, and the amount of tissue to be removed may be too bulky for the stapling device to handle properly.

* PPH may lead to pelvic sepsis. Reports of serious infection following stapled haemorrhoidectomy have raised concerns as to whether this is an appropriate treatment for haemorrhoidal disease.

* Just-in-case antibiotics, even with flawless PPH technique, may be necessary to avoid postoperative infection (Lancet, 2000; 355: 810).

* PPH may not work. A Belgian study found that some stapled patients continued to suffer haemorrhoids and/or prolapse, and some patients needed to undergo repeat surgery (Acta Chir Belg, 2005; 105: 44-52).

But even conventional haemorrhoidectomy is not without its complications, which include:

* longer postoperative pain and recovery time. Studies have clearly shown that patients undergoing standard haemorrhoidectomy suffered more postoperative pain than patients who had undergone stapled haemorrhoidectomy (Lancet, 2000; 355: 782-5). Hospital stays were lengthier – and the time required to return to normal activities significantly longer – with conventional haemorrhoidectomy (Lancet, 2000; 355: 779-81)

* a 10 per cent rate of postsurgical complications such as bleeding, fissures, fistulas, abscesses, urinary retention, soiling, and other conditions such as perianal cryptoglandular infection, which can cause complex fistulas/abscesses that are associated with an increased risk (30-80 per cent) of even further complications such as incontinence (Eur J Med Res, 2004; 9: 18-36).

Isabel Atherton

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Written by What Doctors Don't Tell You

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