ArticlePDF AvailableLiterature Review

Hemorrhoidectomy: Indications and risks

February 2004
European Journal of Medical Research 9(1):18-36

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PubMed

Authors:

Ludwig-Maximilians-University of Munich

Hemorrhoids are a common cause of perianal complaints and affect 1-10 million people in North-America and with similar incidence in Europe. Symptomatic hemorrhoids are associated with nutrition, inherited predisposition, retention of feces with or without chronic abuse of laxatives or diarrhea. Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even incontinence. The significance of hemorrhoids for anal continence (corpus cavernosum) is recognized. In most instances, hemorrhoids are treated conservatively; the surgeon is contacted when conservative measures have failed or complications, e.g., thrombosis, have occurred. 4 degrees prolapsed internal hemorrhoids are the main indication for hemorrhoidectomy: high (Parks) or low (Milligan-Morgan) ligation with excision, closed hemorrhoidectomy (Ferguson) or stapler hemorrhoidectomy. Thrombosed external hemorrhoids are primary treated by incision and secondary by excision. Complications after operative treatment of external thrombosed hemorrhoids are rare. After standard hemorrhoidectomy for internal hemorrhoids approximately 10% may have a complicated follow-up (bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, incontinence); there may be concomitant disease, e.g., perianal cryptoglandular infection, causing complex fistula/abscess, which is associated with an increased risk (30-80%) for complications, e.g., incontinence. Other treatment options, e.g., sphincterotomy, anal stretch, have been accused to cause more complications, e.g., incontinence in 30-50% of cases. However, incontinence is a complex phenomenon; it is evident that an isolated single injury is normally not a sufficient cause, e.g., injury of the internal sphincter. The majority of patients may present with prior obstetric injury, perianal infection or Crohn's disease and other comorbidity. Therefore all systemic and regional disorders, causing incontinence, should be excluded before starting manometric, neurophysiological and sonographic investigations. Variation and overlap in test results, patient-, instrument- or operator-dependent factors ask for cautious interpretation. There is vast evidence that the demonstration of muscle fibers in hemorrhoidectomy specimens is a normal feature. In conclusion, standard hemorrhoidectomy with proper indication is a safe procedure. If complications occur, it is in the interest of the patient and surgeon to perform a thorough investigation.

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EUROPEAN JOURNAL OF MEDICAL RESEARCH January 26, 2004

Abstract: Hemorrhoids are a common cause of

perianal complaints and affect 1-10 million people

in North-America and with similar incidence in

Europe. Symptomatic hemorrhoids are associated

with nutrition, inherited predisposition, retention

of feces with or without chronic abuse of laxatives

or diarrhea. Increased pressure and shearing force

in the anal canal may lead to severe changes in to-

pography with detachment of the hemorrhoids

from the internal sphincter and fibromuscular net-

work resulting in bleeding, itching, pain and dis-

ordered anorectal function, even incontinence.

The significance of hemorrhoids for anal conti-

nence (corpus cavernosum) is recognized. In most

instances, hemorrhoids are treated conservatively;

the surgeon is contacted when conservative meas-

ures have failed or complications, e.g., thrombo-

sis, have occurred. 4° prolapsed internal hemor-

rhoids are the main indication for hemorrhoidec-

tomy: high (Parks) or low (Milligan-Morgan) liga-

tion with excision, closed hemorrhoidectomy

(Ferguson) or stapler hemorrhoidectomy. Throm-

bosed external hemorrhoids are primary treated

by incision and secondary by excision. Complicati-

ons after operative treatment of external throm-

bosed hemorrhoids are rare. After standard he-

morrhoidectomy for internal hemorrhoids ap-

proximately 10% may have a complicated follow-

up (bleeding, fissure, fistula, abscess, stenosis, uri-

nary retention, soiling, incontinence); there may

be concomitant disease, e.g., perianal cryptoglan-

dular infection, causing complex fistula/abscess,

which is associated with an increased risk (30-80%)

for complications, e.g., incontinence. Other treat-

ment options, e.g., sphincterotomy, anal stretch,

have been accused to cause more complications,

e.g., incontinence in 30-50% of cases. However,

incontinence is a complex phenomenon; it is evi-

dent that an isolated single injury is normally not

a sufficient cause, e.g., injury of the internal

sphincter. The majority of patients may present

with prior obstetric injury, perianal infection or

Crohn’s disease and other comorbidity. Therefore

all systemic and regional disorders, causing incon-

tinence, should be excluded before starting mano-

metric, neurophysiological and sonographic inves-

tigations. Variation and overlap in test results, pa-

tient-, instrument- or operator-dependent factors

ask for cautious interpretation. There is vast evi-

dence that the demonstration of muscle fibers in

hemorrhoidectomy specimens is a normal feature.

In conclusion, standard hemorrhoidectomy with

proper indication is a safe procedure. If complica-

tions occur, it is in the interest of the patient and

surgeon to perform a thorough investigation.

Key words: hemorrhoids – hemorrhoidectomy –

fecal incontinence – external thrombosed hemor-

rhoids – anal fistula – complication – anal manom-

etry – endoanal sonography – internal anal

sphincter – ischiorectal abscess

Hemorrhoids affect many human beings in

North-America and Europe. It is estimated that

one to ten million Americans suffer from hemor-

rhoidal complaints per year. The incidence ranges

from 58 % to 86 % (Haas et al. 1983; Dennison et

al. 1988; Johanson and Sonnenberg 1990; Bleday

et al. 1992).

Hemorrhoids are classified into external and

internal hemorrhoids. Internal hemorrhoids are

further subclassified into first, second, third and

fourth degree internal hemorrhoids (Thomson

1981; Hulme-Moir and Bartolo 2001). Thickened

cushions of mucosa and submucosa appear to the

right anterior, right posterior, and left posterior

position with possible variations and secondary

cushions. Hemorrhoids consist of venous plexus

and arterial supply embedded in a stroma of con-

nective tissue, smooth muscle and nerves

(Thomson 1975; Mosley et al. 1980).

The epithelial lining of the anal canal has been

divided into three zones: cutaneous, middle, and

mucosa. The cutaneous zone consists of true skin

and squamous stratified epithelium. The transi-

tion zone from cutaneous to middle zones is

called mucocutaneous junction and contains the

anal crypts. The mucosal zone consists of true co-

lumnar epithelium and continues upward as rec-

tal mucosa. On palpation a depression is felt

between the internal and external sphincter,

which should not be confused with a dip formed

by the mucocutaneous junction. According to

Parks Milligan and others confused the visible de-

pression (the line of anal crypts) with the palpa-

ble groove lower in the anal canal (Parks 1956).

This intersphincteric groove may be misleading

in the diagnosis of sphincter defect (Sangwang

and Solla 1998).

Eur J Med Res (2004) 9: 18-36

I. Holzapfel Publishers 2004

Review

HEMORRHOIDECTOMY: INDICATIONS AND RISKS

R. G. Holzheimer

University Halle-Wittenberg, Germany

In relation to the anal canal, there are two ana-

tomical spaces that are of clinical importance: the

submucous space, lying between the mucous

membrane and the internal sphincter, including

the internal hemorrhoidal plexus, covered by

glandular rectal epithelium, and the perianal space

which contains the external hemorrhoid plexus

and the subcutaneous external sphincter (Milligan

et al. 1937).

The internal sphincter forms a wall of the

whole anal canal though the subcutaneous external

sphincter may occupy the terminal position.

Fibers of the conjoined longitudinal muscle, which

acts as supportive structure for the venous plexus

and the anal submucosa and mucosa penetrate the

internal and external sphincter forming a fibroelas-

tic network (Thomson 1975; Haas and Fox 1977;

Mosley et al. 1980). The longitudinal muscle is at-

tached to the anal skin and anal margin. Through

the gap between the two sphincter muscles passes

the most medial of the terminating strands of the

longitudinal muscle, which gains firm attachment

to the skin over the anal verge. The groove

between the hemorrhoidal plexuses is caused by

the adherence of a fibromuscular band to the mu-

cosa, which was called mucosal suspensory liga-

ment by Parks (1956). It consists of muscularis mu-

cosae, muscle-fibers from the internal sphincter, fi-

brous tissue from the fascia surrounding the inter-

nal sphincter, gains attachment to the mucosa of

the anal crypts and divides the subepithelial space

into the superior compartment containing the

internal hemorrhoidal plexus and the inferior

compartment, marginal or perianal space which

contains the external hemorrhoidal plexus (Parks

1956). Thomson (1975) noted that this smooth

muscle (corrugator cutis ani, musculus submucosae

ani, mucosal suspensory ligament, musculus canal-

is ani) was always present in normal cadavers and

hemorrhoidectomy specimens. The anatomical de-

scription of the conjoined longitudinal muscle

layer and the musculus canalis ani with its relation

to the sphincter muscles, rectal mucosa suggested a

role in normal defecation and internal sphincter

contraction (Fine and Lawes 1940; Shropshear

1960; Lawson 1974; Thomson 1975; Hansen 1976;

Haas and Fox 1977; Lunniss and Phillips 1992;

Loder et al. 1994). Stelzner (1992) emphasized that

with regard to the anorectal continence we are fo-

cused on the sphincter muscles not recognizing the

importance of the corpus cavernosum and the net-

work of the longitudinal muscle mesh. Stieve re-

ported that the internal sphincter might not com-

pletely close the anal canal (Stieve 1928; Stieve

1930). Stelzner has introduced the term corpus

cavenosum with his description of the arteriove-

nous shunts in the hemorrhoids (Stelzner 1962).

The importance of the cushions for the continence

has been elucidated in further studies and it is now

suggested that the vascular filling is contributing

15 to 20 % to the resting anal pressure (Stelzner et

al. 1966; Thomson 1975; Hansen 1977; Gibbons et

al. 1986; Lestar et al. 1989). This has been support-

ed by the finding that excision of the piles in he-

morrhoidectomy may impair continence to rectal

saline infusion (Read et al. 1982).

ETIOLOGY

The pathogenesis of hemorrhoids is not yet finally

elucidated. It has been suggested by several authors

that there is a genetic link, which would explain

the association between hemorrhoids and hernia

and prolapse of the genitourinary system or vari-

cose veins (Stelzner 1962; Burkitt 1975; Loder et

al. 1994). Environmental factors, e.g., low-fiber

diet, constipation, repeated and prolonged strain-

ing, hard stool, chronic use of laxatives, have been

identified to support the development of hemor-

rhoids (Burkitt 1975; Haas et al. 1984). In fact,

straining associated with constipation, gynecolog-

ical prolapse and prolapse of the anal mucosa with

loose stools, diarrhea or ulcerative colitis can be

found in the patient history (Stern 1964). Chronic

abuse of laxatives has been observed in 22.2% of

males and 76.4% of females prior to hemorrhoidec-

tomy (Kouba 1980). In recent reports it has been

proposed that hemorrhoids are caused by patho-

logic slippage of the normal lining of the anal

canal together with changes in connective tissue,

e.g., loss of organization, muscular hypertrophy,

fragmentation of the muscle and elastin compo-

nents which may be aggravated by stress during

defecation (Gass and Adams 1950; Thomson 1975;

Haas and Fox 1980; Haas et al. 1983; Haas et al.

1984; Loder et al. 1994). Venous stasis, ischemia,

edema, clot formation may be responsible for com-

plications of the hemorrhoidal disease, e.g., super-

ficial ulceration, fissure formation, hemorrhagic

infarction, external thrombosed hemorrhoids

(Dayal and DeLellis 1989; Jongen et al. 2003).

SYMPTOMS

Patients with symptomatic hemorrhoids may

have bleeding, prolapse, pain, itching, mucous dis-

charge, leakage of anal contents, soiling, rectal

dysfunction, incontinence, feeling of a lump and

constipation (Stern 1964; Ganchrow et al. 1971;

Thomson 1994).

PATHOPHYSIOLOGY

The anal cushions resemble erectile tissue contain-

ing large blood spaced fed by arterioles (Thomson

1975). In normal subjects they may help to pre-

serve continence by forming an expansive seal

(Gibbons et al. 1986). Forty % of patients with

hemorrhoids, especially non-prolapsing hemor-

rhoids, complain of obstructed defecation and vig-

orous straining (Hancock 1977; Sun et al. 1990)

leading to increased anal pressure, lower rectal

compliance and more perineal descent (Arabi et

al. 1977; Hiltunen and Matikainen 1985; el-Gendi

and Abdel-Baky 1986; Lin 1989; Sun et al. 1990;

Ho et al. 1995). It has been assumed that the ab-

normal high anal pressures are caused by an in-

creased tonic activity of the internal and external

January 26, 2004 19EUROPEAN JOURNAL OF MEDICAL RESEARCH

sphincter (Hancock 1977; Teramoto et al. 1981;

Lane 1982), which may hinder defecation, and

cause expansion of the anal cushions by impairing

venous drainage (Sun et al. 1990). Teramoto dem-

onstrated by biopsies taken from anal sphincters

in patients with hemorrhoids that these were in a

state of increased tonic contraction, which causes

muscle hypertrophy and may contribute to in-

creased resting pressure (Teramoto et al. 1981).

More recently, the anal cushions were rediscov-

ered as main cause for the high resting and residu-

al pressures in the outer canal by demonstrating

abnormally high vascular pressure in anal cush-

ions themselves (Sun et al. 1990). Hancock (1976)

considered ultraslow waves to represent a syn-

chronous contraction of the whole internal

sphincter. Roe et al. (1987) observed that ultra-

slow waves were associated with high pressures

and often a pulse wave was superimposed indicat-

ing the vascularity of the hemorrhoidal tissue.

Ultraslow waves may represent some form of per-

istaltic action in the sphincters by the presence of

hemorrhoids (Roe et al. 1987). During defecation,

when sphincters are relaxed to facilitate expulsion

of stool, dilated anal cushions could cause anal re-

sistance, which could only be overcome by in-

creased abdominal pressure (straining). This pres-

sure may create a shearing force with detrimental

effect on venous drainage of the cushions, connec-

tive tissue supporting the anal lining finally lead-

ing to intermittent or permanent prolapse of hem-

orrhoids and influencing the continence (Hancock

1977; Hancock 1981; Shafik 1984; Gibbons et al.

1986; Sun et al. 1990). The external sphincter in

patients with hemorrhoids may remain in a state

of increased tonic contraction, inducing muscle

hypertrophy; the role of the internal sphincter for

the pressure in the anal canal when a bolus is

present may be overestimated (Teramoto et al.

1981). Especially females with a history of consti-

pation and preg-nancy were recognized to be

prone to develop spontaneous incontinence

(Stelzner 1992). Despite controversy on the occur-

rence of increased resting anal pressure in patients

with symptomatic hemorrhoids (Fantin et al.

2002) it is well accepted that there is distal dis-

placement of anal cushions with loosening and

fragmentation of the subepithelial connective tis-

sue (conjoined longitudinal muscle, musculus can-

alis ani, fibromuscular ligament) with a significant

change of the topography of the anal canal which

may affect continence (Parks 1956; Stelzner 1962;

Thomson 1975; Hansen 1976; Hansen 1977; Haas

et al. 1984; Stelzner 1992; Loder et al. 1994).

IAGNOSIS

For diagnosis of hemorrhoids a detailed history

with local and general examination may be neces-

sary. Inspection and proctoscopy may reveal acute

thrombosed external or internal hemorrhoids;

however, perianal abscess, submucous abscess, and

even ischio-rectal abscess should be ruled out.

Sigmoidoscopy, colonoscopy or further radiologic

examinations (barium enema, MRT) may be nec-

essary in individual cases. (Stern 1964). The

sphincter ani externus and internus can be palpat-

ed well and their functional status checked. The

inferior part of the sphincter ani internus has been

described by Stelzner as “hard as cartilage”

(Stelzner et al. 1966). Sensitivity of the anal canal,

which is also important for continence, is highest

in the lower part (Stelzner 1992).

TREATMENT

Evidence-based treatment modalities include injec-

tion sclerotherapy, photocoagulation, cryothera-

py, diathermy, banding, laser, open or closed he-

morrhoidectomy and stapled hemorrhoidectomy

(Holzheimer 2001). The indication for hemor-

rhoidectomy should be based on the patient’s

symptoms and the condition of rectal outlet

(Ferguson and Heaton 1959). Associated anorectal

disease may be present at least in 22 % of patients

(Bleday et al. 1992). Patients with long-standing

hemorrhoids may have impaired anal sphincter

pressures associated with perineal descent and pu-

dendal nerve injury (Hancock 1976; Read et al.

1982; Bruck et al. 1988; Ho et al. 1995). External

sphincters may be hypertrophied probably from

hyperactivity in response to an irritating anal

mass as well as the constant fear of soiling from

discharge associated with piles (Teramoto et al.

1981). Most patients with symptomatic hemor-

rhoids may be treated conservatively (45.2%) or

by rubber band ligation (44.8%) (Rudd 1970;

Bleday et al. 1992). The most common indication

for surgery are persistent grade IV hemorrhoids

after failure of conservative management with the

conventional excision-ligation (Milligan-Morgan)

hemorrhoidectomy being the most common tech-

nique in Britain and Ireland (Beattie et al. 2002),

but the best treatment for hemorrhoids is preven-

tion (Brisinda 2000). Patients seek surgical atten-

tion often after onset of complication or when

medical therapies have failed. Surgical interven-

tion is required when clear signs and significant

discomfort are present (Tajana 1989).

HIGH AND LOW LIGATION WITH EXCISION

VERSUS

CLOSED TECHNIQUE

The operation should aim at the removal of the

dilated veins, ligation of the hemorrhoidal arteries

and fixation of the anal mucosa to the underlying

muscle (internus) to prevent prolapse and to oblit-

erate the submucous space (Parks 1956). Ligation

of the hemorrhoidal artery may be done as high li-

gation (Parks 1956) or low ligation (Milligan et al.

1937). Closed hemorrhoidectomy is supposed to

be less painful and may preserve anal sensory

function better and lead to faster wound healing

(Ferguson and Heaton 1959; Khubchandani et al.

1972) but it has a reputation in Europe for dehis-

cence and infection (Turell 1952; Watts et al.

1964). However, Ferguson insisted that complicat-

ions such as abscess or para-anal cellulitis practi-

20 January 26, 2004EUROPEAN JOURNAL OF MEDICAL RESEARCH

cally never occur after closed hemorrhoidectomy

(Ferguson and Heaton 1959). In Europe the

Milligan-Morgan procedure is preferred whereas

in the United States the closed hemorrhoidectomy

as described by Ferguson is more popular

(Milligan et al. 1937; Ferguson and Heaton 1959;

Wolf et al. 1979; Arbman et al. 2000). However,

only few studies have compared closed and open

techniques (Gemsenjäger 1989; Ho et al. 1997;

Arbman et al. 2000); nevertheless, both operations

may have an impact on the maximum resting pres-

sure leaving the recto-anal inhibitory reflex un-

changed which would infer that the hemorrhoidal

tissue itself is responsible for the increased pres-

sure (Roe et al. 1987). In most descriptions of the

hemorrhoidectomy technique the dissection of

the mucosal ligament of the internal sphincter

opens up a plane between the superior hemor-

rhoidal plexus and the internal sphincter – the

plane of the M. canalis ani or M. corrugator ani

(Milligan et al. 1937; Parks 1956; Ferguson et al.

1971; Stelzner 1992). Stelzner has emphasized that

only hemorrhoids which have been disconnected

from the rectum and/or sphincter ani internus or

a fibrotic/thrombotic at the anal verge fixated seg-

ment of the hemorrhoids (external hemorrhoid)

may be securely resected (Stelzner 1992). Parks’

observations support this notion: adherent muco-

sa is difficult to rise from the underlying muscle

unless continued prolapse has resulted in attenua-

tion of the mucosal ligament. In third degree piles

the mucosal ligament has disappeared and the

mucosa flaps have to be fixed to the muscle be-

cause otherwise the slipping down of rectal muco-

sa may cause discharge and irritation (Parks 1956).

SPHINCTEROTOMY AND STAPLER

PROCEDURE

Some authors have recommended an additional

sphincterotomy for surgical treatment of hemor-

rhoids, although this may be associated with a risk

for incontinence (Tajana 1989; Arbman et al.

2000). Baradnay (1974) stated that the high recur-

rence rate after the Langenbeck (1852) operation,

and the frequent incontinence, stricture and mu-

cosal prolapse after the Whitehead (1887) opera-

tion, has been a stimulus for the surgeons to look

for better procedures (Milligan et al. 1937, Parks

1956; Ferguson and Heaton 1959; Baradnay 1974),

but neither closed nor open techniques are per-

fect. Postoperative pain, a frequent nuisance to

the patient, led to the introduction of the stapler

procedure as described by Longo for the treat-

ment of third and fourth degree hemorrhoids

(Longo 1998; Kohlstadt 1999; Rowsell et al. 2000;

Fazio 2000).

REATMENT OF THROMBOSED EXTERNAL

HEMORRHOIDS

Thrombosed external hemorrhoid, located in the

marginal or perianal space, is probably one of the

most frequently diagnosed anorectal emergencies

and as a result excision is a frequently performed

anorectal operation (Jongen et al. 2003).

Symptomatic isolated thrombosed external hem-

orrhoids may ask for a much higher excision rate

(84 %) than internal disease, which may be due to

the increased occurrence and recurrence of exter-

nal thrombosed hemorrhoids (Bleday 1992).

Although acute thrombosed external hemorrhoids

are usually obvious, according to Stern (1964)

they should be differentiated from perianal ab-

scess, submucous abscess or even ischiorectal ab-

scess. The treatment strategy from that performed

in internal non-thrombosed hemorrhoids differs:

in acute thrombosed hemorrhoids it is not neces-

sary to perform a standard three-position hemor-

rhoidectomy but rather just to remove sympto-

matic tissue (Hayssen et al. 1999; Hulme-Moir and

Bartolo 2001).

COMPLICATIONS

“Poor results of hemorrhoidectomy have nearly al-

ways been reported by surgeons among cases referred

to them in which the initial treatment was given

elsewhere. Those who have attempted to follow-up

their own cases have all reported satisfactory results”

Parks (1965) was quite aware that it is difficult to

evaluate postoperative complications due to flaws

in subjective – there is a group of patients with he-

morrhoidal symptoms who have either weak anal

sphincters or whose muscle relax easily when they

strain is leading to a descent of the perineum and a

shallow anal canal – and objective factors – assess-

ing the results of operations performed elsewhere

may be difficult as one never can be sure what

procedure was carried out (Parks 1965). 13-18 %

of treated patients had preoperative incontinence,

soiling was reported in 82-84 %, bleeding in 95-97

% and prolapse in 79-82 % of patients (Arbman et

al. 2000). Even histological examination may not

be reliable as the fixed tissue lost its elasticity. The

interpretation of the actual topography is finally

left to the attentive surgeon (Stelzner 1992). On

the other hand, surgical hemorrhoidectomy is

known to have an impact on continence – conti-

nence to saline infusion and anal canal pressures

are reduced – which may be due to anal dilatation

(Read et al. 1982; Ho and Tan 1997; Shalaby and

Desoky 2001). Hemorrhoidectomy is the most de-

finitive way of treating prolapsing piles.

Postoperative pain is a major concern, and surgery

itself is not without complications, including not-

ably bleeding and anal stricture (Golighten et al.

1969; Milsom and Mazier 1986; MacRae and

McLeod 1995). Recurrence of hemorrhoids after

hemorrhoidectomy has been observed in 0.5 % to

26 % of cases (Bennett et al. 1963; Tajana 1989;

Konsten and Baeten 2000).

Complications occurring within the first two

postoperative days include urinary retention,

bleeding, soft fecal impaction, and itching. Later

complications include urinary tract infection, sec-

ondary bleeding, wound infection, fissure and in-

continence. Up to 50% of patients complain of

January 26, 2004 21EUROPEAN JOURNAL OF MEDICAL RESEARCH

soiling in the early postoperative period (Roe et

al. 1987; Isler 1999).

COMPLICATIONS AND EMERGENCY SURGERY

Emergency surgery, usually performed by junior

doctors, did not result in a higher incontinence

rate when compared to elective operation (4.4 %

versus 5.2 %) (Eu et al. 1994).

COMPLICATIONS AND SPECIFIC SURGICAL

TECHNIQUE

Some types of techniques seem to be associated

with a higher complication rate. Four piles he-

morrhoidectomy may have an increased risk of in-

continence when compared to modified radical

hemorrhoidectomy (Seow-Choen and Low 1995).

There is some controversy with regard to addi-

tional sphincterotomy. When anal stretch was

used in the treatment of hemorrhoids 57.3 % of

patients suffered from fecal soiling for ten weeks

postoperatively when compared to 6.4 % of pa-

tients with additional subcutaneous external

sphincterotomy (Asfar et al. 1988; Arbman et al.

2000) whereas Goligher observed impairment of

anal control for 6-12 months postoperatively

(Goligher et al. 1969). It seems fair to say that in

general anal dilatation and lateral sphincterotomy

in combination with open hemorrhoidectomy

may not offer an advantage and carries the risk of

incontinence; however, the interpretation of the

studies remains open as different techniques, e.g.,

open partial sphincterotomy, subcutaneous exter-

nal sphincterotomy, partial lateral internal

sphincterotomy (LIS), were used (Goligher et al.

1965; Mortensen et al. 1987; Asfar et al. 1988;

Bleday et al. 1992; Mathai et al. 1996; Arbman et

al. 2000), and some investigators saw no inconti-

nence in patients treated with excision-ligation

procedure, anal dilatation and open partial sphinc-

terotomy (Arbman et al. 2000). Chung et al.

(2002) found no difference in postoperative com-

plications after harmonic scalpel, bipolar scissors

hemorrhoidectomy or scissors excision (Chung et

al. 2002).

GENERAL COMPLICATIONS AFTER HIGH/

LOW LIGATION HEMORRHOIDECTOMY

In a survey among the members of the American

Society of Colon and Rectal surgeons (ASCRS)

comparing open and closed techniques inconti-

nence has been observed after both procedures

(0.18 % – 14.6 %) (Wolf et al. 1979). A high inci-

dence of temporary soiling and leakage was pro-

duced by both procedures, with half of the pa-

tients in each group (submucosal hemorrhoidecto-

my; excision/ligation hemorrhoidectomy) affect-

ed (Roe et al. 1987). These figures are supported

by Arbman et al. who reported that six weeks

after closed and open hemorrhoidectomy 28-52 %

had soiling, 9-15 % incontinence. More than one

year after hemorrhoidectomy 24-30 % had soiling

and 8-15 % incontinence (Arbman et al. 2000).

Urinary retention may occur in 4-12 %, early

hemorrhage in 1-3 %, late hemorrhage in 1 %, fis-

sure in 2-4 %, inflammatory complications in 3-6

% of patients treated with the excision/ligation

technique. Pain may be severe in 4-8 %, mild in

55-65 %. Disturbances of continence can be

present even a long time after operation and is

usually due to muscular strains, diarrhea, imper-

fect closure of the anus or change in sphincter

pressure (Baradnay 1974; Tajana 1989; Argov

1999). It became obvious that a definite assessment

of the surgical results cannot be done prior to the

end of a year (Kouba 1980).

COMPLICATIONS AFTER CLOSED

HEMORRHOIDECTOMY

The introduction of the closed hemorrhoidecto-

my by Ferguson as opposed to the open technique

by Milligan-Morgan did not eliminate the risk of

delayed bleeding. Obviously, both the classical

open and the closed hemorrhoidectomy tech-

niques are far from optimal: both operations seem

to be followed by protracted convalescence period

and significant prevalence of complications al-

though the fear of infection caused by primary

closure of hemorrhoidectomy incisions is un-

founded (Ganchrow et al. 1971; Buls and

Goldberg 1978; Sayfan 2001).

PAIN AFTER HEMORRHOIDECTOMY

In the period immediately following operation

not only retention of urine, hemorrhage, occa-

sionally incontinence but also pain may occur

(Parks 1956). Pain sometimes increases a few days

after hemorrhoidectomy and should be differen-

tiated from infection (Carapeti et al. 1998). Watts

et al. (1964) have compared five different forms of

hemorrhoidectomy (excision with high ligation,

excision with low ligation, excision with primary

suture, submucosal excision, excision with clamp

and cautery). Despite the extensive intra-anal

wounds, healing of the mucosal part of the anal

canal proceeded rapidly. There was no difference

in pain following the different types of operation,

with the exception of excision with primary su-

ture, which was more painful (Watts et al. 1964).

Recognition of postoperative pain has been a pow-

erful stimulus to surgeons in introducing various

modifications of technique for this operation

(Watts et al. 1964). Diathermy excision of hemor-

rhoids has not been shown to reduce postopera-

tive pain compared with scissors excision (Seow-

Choen et al. 1992; Andrews et al. 1993).

COMPLICATIONS AFTER STAPLER

EMORRHOIDECTOMY

Stapler hemorrhoidectomy has been compared in

several studies against standard hemorrhoidecto-

my techniques. Data from randomized studies

showed that continence score, anorectal mano-

22 January 26, 2004EUROPEAN JOURNAL OF MEDICAL RESEARCH

metric and endoanal ultrasonographic findings

were not different after stapler hemorrhoidecto-

my from those after open hemorrhoidectomy (Ho

et al. 2000). Complications observed were urinary

retention, hemorrhage in up to 50% of cases, anal

fissure, anal stenosis and incontinence (Mehigan et

al. 2000; Ho et al. 2001). The development of

postoperative pain after stapler hemorrhoidecto-

my has been a matter of controversy recently.

Cheetham et al. reported that patients had severe

rectal pain and fecal urgency after stapler hemor-

rhoidectomy (2000), whereas Fantin et al. (2002)

observed only mild rectal pain in 68% and inter-

mittent anal bleeding in 50% of patients. Also oth-

ers have reported less pain and less urinary reten-

tion after stapler operation (Longo 1998;

Kohlstadt et al. 1999; Mehigan et al. 2000; Rowsell

et al. 2000; Cheetham et al. 2001; Ebert and Meyer

2002; Fantin et al. 2002). Ebert and Meyer were

concerned about the high rate of incontinence in

their patients treated with stapler hemorrhoidec-

tomy, although they admitted that these were sub-

jective complaints and preoperative incontinence

was not recorded (Ebert and Meyer 2002). Rarely,

septic complications after stapler hemorrhoidecto-

my were observed (Molloy and Kingsmore 2000).

COMPLICATIONS AFTER EXCISION OF

EXTERNAL HEMORRHOIDS

External hemorrhoids represent distended vascu-

lar tissue distal to the dentate line. They may re-

sult from straining with stools, childbirth, long

car trips or prolonged sitting, constipation or di-

arrhea. 50% of patients treated for acute throm-

bosed external hemorrhoids had previous bleed-

ing/prolapse of hemorrhoids and diarrhea in 54%

of cases (Turell 1952; Sakulsky et al. 1970; Oh

1989). A prior history of hemorrhoids was nearly

always obtained (Stern 1964). Previous anal symp-

toms (wet anus, itching, bleeding at defecation,

prolapsing hemorrhoids) were recorded in 74-88%

of patients (Nieves et al. 1977; Saleeby et al. 1991).

External hemorrhoids are covered by anoderm

and perianal skin richly innervated with somatic

pain fibers, which explains why thrombosis may

cause intensive pain (Zuber 2002). Perianal throm-

bosis results from thrombosis within the rich ex-

ternal venous plexus constituting the most distal

part of the hemorrhoidal mechanism, mostly

caused by stasis and local trauma (Ganchrow et al.

1971; Thomson 1982; Brearly and Brearly 1988;

Oh 1989). Pain will often prevent a full assess-

ment of other local conditions (Stern 1964).

“Traditionally, it has been taught, for safety’s sake,

hemorrhoidal crisis should be treated with heat or

ice, bed rest, ointments, analgesics, suppositories,

antibiotics, and in some countries, with prayers to

St. Fiacre, patron saint of proctologists and hemor-

rhoid sufferers” (Nieves et al. 1977). However, a re-

view of the literature has failed to substantiate the

widely held belief that operation at this time car-

ries with it a risk of infection and subsequent por-

tal pyemia (Smith 1967). Usually a simple evacua-

tion of the blood clot through a small incision is

performed (Stern 1964). In up to 70% of cases,

however, a secondary hemorrhoidectomy may be

necessary (Grace and Creed 1975). Hemor-

rhoidectomy is performed through an elliptic or

circumferential incision over the site of the

thrombosis with removal of the entire diseased he-

morrhoidal plexus. Infection after suture closure

is rare secondary to the rich vascular network in

the anal area (Turell 1952; Sakulsky et al. 1970;

Mazier 1973; Hansen and Jorgensen 1975; Grosz

1990; Zuber 2002). Possible complications include

bleeding, excessive scarring, stenosis, fissure and

fistula – incontinence has not been reported as

complication after hemorrhoidectomy of external

thrombosed hemorrhoids (Blessing et al. 1992;

Zuber 2002). Infectious complications of the exci-

sion procedure may relate to unrecognized infec-

tious processes, such as perianal abscess (Zuber

2002; Jongen et al. 2003). Ulceration of the overly-

ing mucosa and not the presence of thrombosis

seemed to be the determinating factor in degree of

inflammatory change. By histological examination

of a segment of the subcutaneous portion of the

external sphincter it has been demonstrated that

thrombosis did not increase the occurrence of

postoperative infection (Laurence and Murray

1962). In conclusion, thrombosed external hemor-

rhoid can be safely performed as outpatient proce-

dure with a low complication rate (Jongen et al.

2003). (Table I)

PREVALENCE OF FECAL INCONTINENCE

Fecal incontinence is said to affect at least 2 % of

the adults in the United States (Nelson et al.

1995). The prevalence may be much higher in spe-

cific groups, e.g., multiple sclerosis (51 %), irrita-

ble bowel syndrome (20 %) and diabetes (20 %)

(Feldman and Schiller 1983; Okamoto et al. 1983;

Drossman et al. 1986; Hinds et al. 1990; Harari et

al. 1997; Krogh et al. 1997; Menter et al. 1997).

However, “reluctance to disclose incontinence is

recognized to be an impediment to obtain accurate

estimates of the prevalence of fecal incontinence;

only one-third of individuals with fecal inconti-

nence have discussed this with a physician”

(Johanson and Lafferty 1996). The majority of pa-

tients seen in specialized units have incontinence

resulting from trauma, especially obstetrical inju-

ry, from a cryptogenic abscess/fistula, or from a

sphincter disruption due to Crohn’s disease

(Kodner 1990).

DEFINITION OF FECAL INCONTINENCE

Despite the definition of incontinence – recurrent

uncontrolled passage of fecal material for at least

one month – the difficulty has been recognized to

articulate a definition of fecal incontinence that re-

liably separates health from disease (Whitehead et

al. 1999; Whitehead et al. 2001). There may be dif-

ferent forms of incontinence which may be asso-

ciated with specific pathology: passive inconti-

January 26, 2004 23EUROPEAN JOURNAL OF MEDICAL RESEARCH

24 January 26, 2004EUROPEAN JOURNAL OF MEDICAL RESEARCH

Table I. Complications after surgical treatment of thrombosed hemorrhoids.

Author Patients Type of Operation Fecal Fistula Stenosis Hemorrhage Infection Ulcer Incontinence

hemorrhoid impaction stricture fissure

Laurence and 12 Prolapsed Dissection and Yes No Yes No No No No

Murray 1962 ligation; White-

head

Tinckler and 39 External Excision No No 3 No No No No

Baratham 1964 prolapsed

Smith 1967 15 Internal St. Marks No No No No No No No

Howard and 25 External Whitehead No No No No No No No

Pingree 1968

Sakulsky et al. 50 Mostly Excision No No No 1 No 1 No

1970 external

Ganchrow A) 100 A) 87 Ferguson No No 1 3 No No No

et al. 1971 B) 30 external

B) 23

external

Hansen and 25 Prolapsed Milligan- Morgan No No 1 2 No No No

Jorgensen 1975

Nieves et al. 85 Prolapsed St. Marks No No No 1 No 1 No

1977

Saleeby et al. 25 Thrombosed Closed hemor- No No No 1 No No No

1991 or gangrenous rhoidectomy

Jongen et al. 340 External Excision No 7 (2.1%) No 1 (0.3%) See fistula No No

2003

nence (unwanted stool without patient awareness),

urge incontinence (unwanted stool despite active

attempts to inhibit defecation), post-defecation

soiling (stool postvoiding with normal conti-

nence), nocturnal fecal incontinence or inconti-

nence associated with increased bowel frequency;

80% of patients with rectal prolapse report some

degree of incontinence (Talley et al. 1992; Engel et

al. 1995; Buchanan et al. 2001).

PATHOGENESIS OF FECAL INCONTINENCE

“Fecal continence is maintained by the integrated ac-

tion of anal sphincteric function, the puborectalis, the

levator plate, and intact sensory pathways. It is de-

pendent on rectal reservoir function, colonic motil-

ity, the volume and consistency of stool, anorectal

sensation, the anorectal angle, normal resting anal

tone and resistance to opening. As continence depends

on several factors, some mechanisms may be able to

compensate and maintain clinical continence when

one element is abnormal. Therefore, objective knowl-

edge of the continence state and of the function of all

components is fundamental to an adequate estimate

of the clinical situation”. In view of the heterogene-

ous etiology of anal incontinence, a uniform defect

in anorectal function should not be expected.

(Felt-Bersma et al. 1990; Felt-Bersma et al. 1992;

Penninckx et al. 1992; Mavrantonis and Wexner

1998; Francombe et al. 2001; Whitehead et al.

2001). True fecal incontinence must be distin-

guished from soiling, which may be caused by def-

ormation of the anal canal, fecal mass in the rec-

tum, mucosal prolapse, and from urgency – pa-

tients are unable to withhold the stool -, which

may be related to impaired rectal compliance due

to inflammatory disease of the rectum.

Incontinence may be due to a sensory loss in the

anal canal, which is characterized by the passage of

feces without the patient being aware of it, as in

rectal prolapse and in patients with neuropathic

incontinence or diabetes (Felt-Bersma et al. 1989;

Mavrantonnis and Wexner 1998). Incontinence

may be associated with perineal descent or de-

scending perineum syndrome which occurs more

often in women, not only because of obstetric in-

jury, but also because of the higher incidence of

straining during defecation, constipation, and out-

let obstruction (Moore-Gillon 1984; Pinho et al.

1990). A thorough history, which includes the pos-

sibility of steatorrhea, neurologic information, ob-

stetric and gynecological surgical history in female

patients, all previous operations upon the anus,

rectum, colon and operations for fistulae and hem-

orrhoids is mandatory (Mavrantonis and Wexner

1998). Causes of incontinence could be simple

structural defects, weak sphincters, idiopathic in-

continence, rectal prolapse, diabetes mellitus, pro-

gressive systemic sclerosis, multiple sclerosis, de-

scending perineum syndrome, perianal infection

(Penninckx et al. 1992; Vaizey et al. 1998). The

cause of incontinence may be classified according

to functional aspects, sphincter weakness, sensory

loss (Whitehead et al. 2001), sphincter complex,

neurological disorders, sensory, alterations of

compliance, congenital, psychological, and miscel-

laneous disorders (Francombe et al. 2001) or trau-

ma, congenital, myopathy, neurological, colorectal

disease, and miscellaneous disorders (Buchanan et

al. 2001). Whitehead et al. (2001) stated that diar-

rhea and constipation are the most common cause

of incontinence. Several compounds may decrease

the anal basal pressure, which may affect conti-

nence, e.g., diltiazem, ketanserin, encephalin, glu-

cagon, somatostatin (Pennickx et al. 1992;

Carapeti et al. 1999; Whitehead et al. 2001). (Table

II)

DIAGNOSIS OF FECAL INCONTINENCE

Before specific investigations are performed, all in-

testinal and systemic disorders must be excluded as

causative factors (Mavrantonis and Wexner 1998).

Due to the multifactorial and complex etiology

the investigation should include anorectal manom-

etry, electromyography, pudendal nerve terminal

January 26, 2004 25EUROPEAN JOURNAL OF MEDICAL RESEARCH

Table II. Common causes for fecal incontinence.

Fecal impaction Pelvic floor dyssynergia, drug-side effect, idiopathic, spinal cord injury

Diarrhea Irritable bowel syndrome, infections, metabolic diseases

Cognitive/psychological Dementia, psychosis, willful soiling

Sphincter injury Obstetrical trauma, motor vehicle accident, foreign body trauma, complex fistula

and/or abscess, fistula surgery, hemorrhoidectomy

Pudendal nerve injury Obstetrical trauma, diabetic neuropathy, multiple sclerosis, idiopathic, straining

CNS injury Spina bifida, spinal cord injury, cerebrovascular accident, multiple sclerosis

Sensory loss Diabetic neuropathy, spinal cord injury, multiple sclerosis, surgery

Congenital Hirschsprungs disease, atresia, spina bifida

Colorectal disease Rectal prolapse, rectocele, hemorrhoids, tumors, inflammatory bowel disease

Miscellaneous Laxative abuse, constipation, straining, drugs decreasing anal pressure

Myopathy Primary internal sphincter degeneration, systemic sclerosis

Modified according to Buchanan et al. 2001, Francombe et al. 2001, Whitehead et al. 2001

motor latency, cinedefecography, and anal ultra-

sound. While some authors reported that an expe-

rienced colorectal surgeon is capable of assessing

the resting and squeeze pressures with physical ex-

aminations, others disagree. To make things even

more difficult, the usefulness and practicality of

anorectal neurophysiologic evaluation is a matter

of controversy (Hallan et al. 1989; Wexner et al.

1991; Buchanan et al. 2001). The investigation nor-

mally starts with perianal inspection, which may

reveal scarring from previous surgery, childbirth

damage or episiotomy, hemorrhoids, skin tags or

rectal prolapse, and digital rectal examination for

assessment of anal sphincter tone, impaction, ab-

normalities of stool. Proctosigmoidoscopy is man-

datory to view mucosal abnormality, hemor-

rhoids, fissure, or fistula (Hallan et al. 1989;

Buchanan et al. 2001).

ANAL MANOMETRY, RECTAL CAPACITY,

ALINE-INFUSION AND PNTML

Anorectal manometry is most commonly used to

assess anal sphincter function. Maximum basal

pressure (MBP) was thought for measurement of

the internal sphincter and maximum squeeze pres-

sure (MSP) for evaluation of the external sphincter

(Felt-Bersma et al. 1990). Early study results falsely

gave the impression that the maximum basal pres-

sure is generated for 85 % by the internal sphincter

and for 15 % by the external sphincter (Frenckner

and von Euler 1975). This, however, is no longer

accepted as more recent studies came up with dif-

ferent figures: the MBP is generated for 30 % by

the external sphincter, for 55 % by the internal

sphincter and for 15 % by expansion of the hemor-

rhoidal plexus (Lestar et al. 1989; Felt-Bersma et

al. 1992). Furthermore, the anal manometry may

be influenced by sex, age, prolapsing or non-pro-

lapsing hemorrhoids, rectocele or rectal tumor

presence and repair (Loening-Baucke and Anuras

1985; McHugh and Diamond 1987; Arnold et al.

1990; Felt-Bersma et al. 1990; Sun et al. 1990; Keck

et al. 1995; Ho et al. 1998). “There is no accepted

standardized method of performing or interpreting

this test, thus comparison of data between institutions

has been problematic” (Mavrantonis and Wexner

1998). This and the limited value of anal manome-

try in patients with soiling were repeatedly dem-

onstrated (Felt-Bersma et al. 1989; Diamant et al.

1999). Several studies have analyzed differences

between incontinent and continent patients with

basic anorectal function investigations including

anal manometry, rectal capacity, and the saline-in-

fusion test with controversial results (Read et al.

1979; Read et al. 1984; Felt-Bersma et al. 1988). In

a more recent study Felt-Bersma et al. found no

significant difference in MBP between incontinent

patients and normal controls. Differentiation

between incontinent and continent patients was

not possible with a single test (anal manometry,

rectal capacity, saline-infusion), because there was

complete overlap. “Therefore, in the individual pa-

tient, an abnormal result in one test must be inter-

preted with caution.” (Felt-Bersma et al. 1990). The

saline-infusion test has been developed for demon-

stration of fluid incontinence (Read et al. 1979),

but Felt-Bersma et al. (1990) found no absolute dis-

crimination between incontinent and continent

patients, even when corrected for stool consisten-

cy. Rectal capacity may be influenced by concomi-

tant diseases, e.g., proctitis, Crohn’s disease

(Buchman et al. 1980). Anal sensation has been rec-

ognized as important factor for the continence

(Read et al. 1982; Read and Read 1982). If impaired

it may indicate neurological or postsurgical nerve

impairment (Miller et al. 1989; Kamm and

Lennard-Jones 1990). However, both methods,

anal manometry and determination of anal sensa-

tion, are largely dependent on the patient’s coop-

eration (Read et al. 1982; Felt-Bersma et al. 1990)

and on the absence of certain compounds which

are known to influence anal pressure, e.g., diltia-

zem, etc. (Penninckx et al. 1992) or lignocaine.

Lignocaine is known to double the electrosensitiv-

ity threshold (Roe et al. 1987). The rectoanal in-

hibitory reflex has been proposed as a measure of

the internal sphincter function, but the interpreta-

tion of levels in continent and incontinent patients

is difficult (Buchanan et al. 2001; Zbar et al. 2001).

Pudendal nerve terminal motor latency (PNTML)

is often used to provide additional information on

the innervation of the external anal sphincter.

While some authors report it may reveal unsus-

pected neuropathy in traumatic fecal incontinence

or correlate with outcome from sphincteroplasty

(Felt-Bersma et al. 1992; Engel et al. 1994; Ternent

et al. 1997), the test has been criticized by others

for its lack of sensitivity and specificity (Laurberg

et al. 1988; Wexner et al. 1991; Vernava et al. 1993;

Cheong et al. 1995; Ho and Goh 1995; Gilliland et

al. 1998; Buchanan et al. 2001).

ENDOANAL ULTRASONOGRAPHY, MRT AND

EVACUATION DEFECOGRAPHY

Anal ultrasonography may be used for mapping

internal and external sphincter defects (Yang et al.

1993). Different structures of the upper part, mida-

nal canal or lower part may be identified

(Mavrantonis and Wexner 1998). It is primarily

used for identifying morphologic anomalies

(Whitehead et al. 2001). Interpretation of the ultra-

sonographic investigation may be difficult after

hemorrhoidectomy: Ho et al. (2001) demonstrated

new internal sphincter defects after hemorrhoidec-

tomy, but none of the patients had symptoms of

incontinence. “It is conceded that operator dependen-

cy and possible false identification of anal sphincter

injury at endoanal ultra-sonography is possible” (Ho

et al. 2001). Variability in manometric measure-

ment (Ho et al. 2001) and the use of a 7 MHz

probe instead of a 10 MHz probe (Buchanan et al.

2001) will make the job more difficult.

Unfortunately magnetic resonance imaging, which

is complimentary to endoanal ultrasonography,

has shown lower inter-observer reproducibility for

detecting sphincter defects (Buchanan et al. 2001;

26 January 26, 2004EUROPEAN JOURNAL OF MEDICAL RESEARCH

Malouf et al. 2001). Evacuation proctography (de-

fecography) is not of established value in patients

with fecal incontinence (Diamant et al. 1999). In

conclusion, “although anorectal investigations are in

widespread use, their clinical value has sometimes

been doubted” and results of tests should be inter-

preted with caution (Buchanan et al. 2001).

OBSTETRIC INJURY AND FECAL

INCONTINENCE

The majority of patients referred to a colorectal

clinic may have incontinence as a result of obstet-

ric injury to the sphincter complex (uncontrolled

second stage delivery, epidural anesthesia, instru-

mental delivery, episiotomy) or as results of pro-

longed labor with damage to the innervation (Nn.

Levatorii, Ganglion pelvinum, Nn. Pudendales)

(Snooks et al. 1985; Stelzner 1991; Sultan et al.

1993; Sultan et al. 1994; Kamm 1994; Poen et al.

1998; Sultan et al. 1998). Occult injuries to the

sphincter are more common than previous thought

and may present many years later (Sultan et al.

1998; Francombe et al. 2001). The occult denerva-

tion of the pudendal innervation is a gradually pro-

gressive phenomenon in that functional effects of

the original injury together with other factors, e.g.,

abnormal straining patterns of defecation with pel-

vic floor descent, are leading to stretch-induced

damage to the pelvic floor during defecation (Parks

et al. 1977; Snooks et al. 1984; Swash et al. 1985;

Snooks et al. 1985b; Snooks et al. 1986; Snooks et

al. 1990). There may be extensive reinervation,

which may explain why in some patients the exter-

nal sphincter seems to be intact despite obstetric

trauma in the past (Wunderlich and Swash 1983).

Childbirth causing damage to the pelvic floor in-

nervation is considered to be a precursor of stress

incontinence (Snooks et al. 1986). After first vagi-

nal delivery endoanal ultrasonography has demon-

strated sphincter defects in 30 % of women (Sultan

et al. 1993). In a study by Jacobs et al. (1990) 19 %

were incontinent without signs of obstetric injury

(Jacobs et al. 1990). This has been supposed to be

an early manifestation of idiopathic (neurogenic)

incontinence, which has been associated with pro-

longed or difficult labor (Neill et al. 1981; Kiff and

Swash 1984). There is evidence gained in recent

studies that 25% of primiparous women and about

33% of multiparous women with a history of vagi-

nal delivery have an anal sphincter defect. The

probability that postpartum fecal incontinence is

associated with an anal sphincter defect is 76.8-82.8

% (Oberwalder et al. 2003).

ONSTIPATION AND FECAL INCONTINENCE

Many incontinent patients were women with

chronic constipation and a descending perineum.

Incontinence is believed to be caused by chronic

stretch injury of the pudendal nerve and the sacral

branches causing a low anal pressure and an ob-

tuse puborectalis angle (Neill et al. 1981; Bartolo

et al. 1983; Read et al. 1984; Felt-Bersma et al.

1990). Anorectal incontinence due to sphincter

denervation has been demonstrated in patients

with rectal prolapse and fecal impaction (Parks et

al. 1977). Stelzner (1991) has seen an association of

the abuse of laxatives causing toxic damage to the

innervation of the bowel and the consecutive in-

continence.

NEUROLOGICAL DISEASE AND FECAL

INCONTINENCE

In patients with neurological disease other factors

than childbirth need to be identified, e.g., side ef-

fects of drugs or coexistent behavioral disorders

(Hinds et al. 1990). Fecal incontinence may be ob-

served in patients with multiple sclerosis (50%),

spinal injury (61%), spina bifida (90%), or in pa-

tients with long-standing neuropathy secondary to

diabetes mellitus (Hinds et al. 1990; Malone et al.

1994; Glickman and Kamm 1996). Isolated degen-

eration of the smooth muscle of the internal anal

sphincter may affect both men and women often

in the middle age and is a common cause of soiling

(Vaizey et al. 1997). The resting anal pressure is

usually low and endosonography shows a thin and

fibrotic internal sphincter (Francombe et al. 2001).

Degeneration and fibrosis of the internal anal

sphincter and sensory receptors, leading to passive

fecal incontinence may occur in patients with pro-

gressive systemic sclerosis, idiopathic intestinal

pseudoobstruction and diarrhea may aggravate the

clinical situation (Engel et al. 1994). Incontinence

is seen in patients treated for anal atresia or

Hirschsprung’s disease (Catto-Smith et al. 1995;

Mulder et al. 1995; Hassink et al. 1996). Sphincter

function may also be impaired by radiation injury

(Varma et al. 1985; Varma et al. 1986).

ANAL STRETCH, SPHINCTEROTOMY AND

FECAL INCONTINENCE

Manual dilatation (Lord procedure) for treatment

of hemorrhoids has not gained widespread accep-

tance since it relies on uncontrolled damage to the

anal sphincter with high incontinence rates (20%

and more) at long-term follow-up (Lord 1969;

MacIntyre and Balfour 1977; Buls and Goldberg

1978; Konsten and Baeten 2000). Fecal inconti-

nence after sphincterotomy may range from 1% to

5%, but 35% of patients may have a lack of control

for flatus and 22% complain of soiling (Buls and

Goldberg 1978; Khubchandani and Reed 1989;

Lund and Scholefield 1996). However, others have

performed sphincterotomy without observing any

case of incontinence (Bleday et al. 1992). Arbman

et al. (2000) used anal dilatation in the Milligan-

Morgan group, but they found no patient with

fecal incontinence after six weeks of follow-up.

ANAL FISTULA/ABSCESS AND FECAL

INCONTINENCE

Anal abscess and fistula are parts of a spectrum of

the same disease process (Eisenhammer 1954). The

January 26, 2004 27EUROPEAN JOURNAL OF MEDICAL RESEARCH

incidence for men has been estimated to be 12.3

per 100.000 and for women 5.6 per 100.000 (Sainio

1984). Anorectal suppuration is usually caused by

cryptoglandular infection. The anal glands, arising

at the level of the crypts, penetrate through the

internal sphincter muscle into the transphincteric

plane (Johnson 1914; Morgan and Thomson 1956;

Shropshear 1960; Schouten and van Vroonhoven

1991). Anal fistula is caused by infected anal glands

in the vast majority of cases (Eisenhammer 1956;

Eisenhammer 1961; Parks 1963). Anal abscess or

fistula may be idiopathic or non-specific. Specific

causes of anorectal sepsis include Crohn’s disease,

tuberculosis, actinomycosis, various malignancies,

gut duplication, foreign bodies, as well as intraab-

dominal or pelvic disease (Seow-Choen and

Nicholls 1992). The site of the internal opening is

relevant for the development of incontinence as is

the type of fistula (high or complex fistula)

(Milligan and Morgan 1934; Belliveau et al. 1983;

Garcia-Aguilar et al. 1996). Most of the ducts have

their orifices in the posterior portion of the anal

canal, which may explain the predominance of

posterior anal fistulae (6 O’clock in lithotomy po-

sition) (Morgan 1936; Burke et al. 1951; Kuster

1965; Cirocco and Reilly 1992). Intersphincteric,

transsphincteric and extrasphincteric fistula were

identified by Stelzner (1959). The most widely

used system of classification is that of Parks: inter-

sphincteric, transsphincteric, suprasphincteric and

extrasphincteric fistula (Parks et al. 1976). The

prevalence of supralevator fistulous abscess varies

from 2-22 % (Eisenhammer 1966; Bevans et al.

1973; Parks et al. 1976; Hanley 1978; Read and

Abcarian 1979; Prasad et al. 1981; Terranova et al.

1989), the prevalence of infralevator or ischiorectal

abscess ranges from 9-38% (Hamilton 1975; Hanley

et al. 1976; Parks and Stitz 1976; Aluwihare 1983;

Ustynoski et al. 1990). Ischiorectal abscess, which

is the second most common anatomic site, is prone

to cause incontinence (Cox et al. 1997). The esti-

mated amount of internal sphincter involved by

the fistula has been identified as an independent

factor for the development of incontinence by

multivariate analysis (Garcia-Aguilar et al. 1996).

Soiling (20.6%) and incontinence (21.8 %) was

present already in one fifth of patients before sur-

gical treat-ment (Schouten and van Vroohoven

1991) and they may have already a poor resting

tone and/or voluntary contraction before opera-

tion, which indicates an already compromised

internal or external anal sphincter function

(Pescatori et al. 1989). Affected patients may have

quite subtle signs despite the development of mas-

sive anorectal suppuration (Seow-Choen and

Nicholls 1992). Problematic fistula and/or abscess-

es may be missed or misdiagnosed even in special-

ized units. Endoanal ultrasonography was not con-

sidered to be as useful as digital examination

(Seow-Choen and Phillips 1991). Management of

anal fistula may be done by classical laying open

(fistulotomy), by excision (fistulectomy) or by in-

cision and drainage. Several studies have shown

continence disturbance in 44 to 67 % of patients

(Parks and Stitz 1976; Hanley 1978; Oh 1983;

Ramanujam et al. 1983; Culp 1984; Kuypers 1984;

Aguilar et al. 1985; Mann and Clifton 1985;

Parkash et al. 1985; Christensen et al. 1986; Wedell

et al. 1987; Reznick and Bailey 1988; Shemesh et al.

1988; Thomson and Ross 1989; Kennedy and

Zegarra 1990; Ustynoski et al. 1990; Schouten et al.

1991; Williams et al. 1991; Seow-Choen and

Nicholls 1992; Kodner et al. 1993; Matos et al.

1993; Pearl et al. 1993; Lunniss et al. 1994; van Tets

and Kuijpers 1994; Graf et al. 1995; Garcia-Aguilar

et al. 1996; Ozuner et al. 1996; Golup et al. 1997;

Hamalainen and Sainio 1997; Ho et al. 1997;

Garcia-Aquilar et al. 2000; Gustafsson and Graf

2002). Early studies have demonstrated a higher in-

cidence of complications with ischiorectal and

intersphincteric abscesses (Chrabot et al. 1983;

Ramanujam et al. 1984; Vasilevsky and Gordon

1984). Major incontinence will follow with drain-

age of transsphincteric fistula with translevator su-

pralevator extension (Parks et al. 1976). Women

are particularly prone to sphincter damage during

surgery for anal fistula (Goldberg 1976; Seow-

Choen and Nicholls 1992). In a more recent study

incontinence was associated with female sex, high

anal fistula, type of surgery, and previous fistula

surgery. “Surgical treatment of fistula-in-ano is asso-

ciated with a significant risk of recurrence and a high

risk of incontinence“(Garcia-Aguilar et al. 1996).

Certain types of fistula may be associated with an

even higher rate of incontinence: transphincteric

54%, suprasphincteric 80%, extrasphincteric 83%

(Garcia-Aguilar et al. 1996). In certain cases it may

be difficult to find the internal openings and the

production of false openings or passages may result

in complex supralevator or infralevator abscesses

(Kratzer 1950; Scoma et al. 1974; Lockart-

Mummery 1975; Hanley 1978; Hanley 1979; Fazio

1987) enbloc resection of the scarred tissue may

cause incontinence (Stelzner 1992). In conclusion,

surgical treatment of fistula-in-ano frequently re-

sults in postoperative incontinence (Garcia-Aguilar

et al. 2000). Even a simple division of an acceptable

portion of the sphincter muscle in low anal fistula

may cause varying degrees of impairment of anal

control (Sainio and Husa 1985; Shoulder 1986).

The risk for incontinence after treatment of ischio-

rectal abscess is higher than after perianal abscess

(Ho et al. 1997). The higher risk of incontinence

after fistula surgery in female patients is probably

attributable in part to partial anal disruption

and/or traction injury to the pudendal nerve dur-

ing vaginal delivery (Garcia-Aguilar et al. 1996).

HEMORRHOIDECTOMY AND INCONTINENCE

Hemorrhoidectomy is not generally regarded as

cause of incontinence, but may be a predisposing

factor when the patient has diarrhea (Read et al.

1979; Read et al. 1982). The evaluation is compli-

cated by preexisting comorbidity. Bennett report-

ed that 63% of patients with symptomatic hemor-

rhoids admitted that they have experienced peri-

anal trouble for more than five years before opera-

28 January 26, 2004EUROPEAN JOURNAL OF MEDICAL RESEARCH

tion. 86% complained of pain and discomfort prior

to the hemorrhoidectomy (Bennett et al. 1963).

The details of studies on the incidence of inconti-

nence after hemorrhoidectomy are often unclear.

Read has reported an incidence of less than 10 % of

frank incontinence following hemorrhoidectomy

(Read et al. 1982). Bennett is often quoted to re-

port an incidence of 26% of incontinence after he-

morrhoidectomy. However, he indicates that these

were minor defects of anal control and “certainly

do not amount to frank incontinence” (Bennett et al.

1963). Minor defects in anal control do also occur

in normal people, according to Bennett: 10% expe-

rience inadvertent passage of flatus, 3% occasional

unexpected leakage of feces and 2% frequent soil-

ing. He concluded, that as none of the sphincters

are divided in a standard hemorrhoidectomy –

though the possibility of slight inadvertent damage

to superficial layers of the internal sphincter can-

not be entirely excluded – it might be assumed that

the functional imperfections are related to removal

of sensitive anal skin (Duthie and Gairus 1960;

Bennett et al. 1963). “Whether an insensitive anal-

canal scar, weakened sphincter action, or yet uneluci-

dated factors are responsible, it is apparent that

minor imperfections of continence do sometimes

occur after hemorrhoidectomy as well as after other

anorectal operations” (Bennett et al. 1963). The true

incidence of symptomatic soiling after hemorrhoi-

dectomy is unknown which may be due to no or

short follow-up (Bennett et al. 1963; Zbar et al.

2001). Patients have been reported to present with

symptoms of incontinence after hemorrhoidecto-

my 11 months (inter-quartile range 8-16 months)

after hemorrhoidectomy (Zbar et al. 2001). Mano-

metry or sphincter morphology has been studied

only rarely in incontinent patients before and/or

after hemorrhoidectomy and results are conflict-

ing (Read et al. 1992; Abbasakoor et al. 1998; Zbar

et al. 2001). It is well recognized that patients with

long-standing hemorrhoids can have impaired anal

sphincter pressures at rest before surgery (Bruck et

al. 1988; Ho et al. 1995; Zbar et al. 2001) and after

hemorrhoidectomy (Ho and Tan 1997). Several

other factors may influence anal pressure. The

function of the internal anal sphincter may be al-

tered by endoanal retraction during hemorrhoi-

dectomy (Zbar et al. 2001). Increased sphincter

tone is maintained by the presence of hemor-

rhoids, possibly because of reflex tonic contrac-

tion of the internal and external anal sphincter

caused by prolonged stimulation of the anal canal

(Hancock and Smith 1975; Hancock 1976;

Teramoto et al. 1981; Read et al. 1982). The fact

that postoperative squeeze pressures were lower in

patients who soiled after hemorrhoidectomy com-

pared to those who did not suggests that conscious

contraction of the external sphincter may be of

importance in preventing leakage through a dis-

torted anal canal (Read et al. 1982). Hemorrhoi-

dectomy is known to result in the abolition of

ultra-slow waves together with a reduction in basal

and squeeze pressures. An association was found

between soiling following surgery and abnormally

low postoperative squeeze pressure (Read et al.

1982), but manometry failed to correlate with clin-

ical function after operation (Melange et al. 1992).

It also has been stated that morphologic assess-

ment of anal sphincters after surgery may not be

helpful for assessment. “The causes of incontinence

after these types of surgery (lateral sphincterotomy, he-

morrhoidectomy) are probably multifactorial and do

not seem to rely entirely on the presence either of an

occult preexisting sphincter injury or an advertent

intraoperative sphincter injury”(Zbar et al. 2001),

although it has been conceded that individual

patients’ variations in the length and tone of the

anal sphincter, preexisting sphincter injuries unde-

tected by diagnostic modalities and differences in

other anatomic and functional elements may con-

tribute to anal incontinence (Garcia-Aguilar 2001).

“Continence is a more complex phenomenon than

mere preexisting or inadvertent intraoperative

sphincter injury. This of course has considerable me-

diolegal significance” (Zbar et al. 2001).

INTERNAL SPHINCTER DEFECT AND FECAL

INCONTINENCE

Internal sphincter defect does not necessarily lead

to a state of incontinence. There may be transient

incontinence and/or internal sphincter fragmenta-

tion found on endoanal ultrasound 6-8 weeks after

operation, which may not be present at later con-

trols (Ho et al. 2000). Internal anal sphincter de-

fects seen on the endoanal ultrasound are not nec-

essarily associated with clinical incontinence (Ho

et al. 2000; Brown et al. 2001; Ho et al. 2001).

Complete fecal incontinence does not usually

occur with internal sphincterotomy (Mavrantonis

and Wexner 1998); it is the interaction between

the internal anal sphincter and anal cushions,

which is essential for perfect anal control

(Sanwang and Solla 1998). The anatomic topogra-

phy may also be relevant for the interpretation of

a possible sphincter injury: while internal hemor-

rhoids are in close contact with the internal

sphincter, the external thrombosed hemorrhoid is

located more distally in the anal canal and sphinc-

ter injury does occur less likely, actually there is

none reported in the literature “The pathologist

can tell by looking at the lining of protruding hemor-

rhoids, if they are internal (mucosa lining) or exter-

nal (anoderm)” (Haas et al. 1984).

MUSCLE FIBERS IN HEMORRHOIDECTOMY

SPECIMEN AND FECAL INCONTINENCE

Smooth muscle fibers are normally present in nor-

mal hemorrhoids (Haas et al. 1984). Their pres-

ence does not indicate injury to the sphincter.

Hemorrhoids consist of a stroma with blood ves-

sels, smooth muscles and supporting connective

tissue; and there is the anchoring connective tissue

system, which connects hemorrhoids to the inter-

nal sphincter and the conjoined longitudinal coat,

all consisting of muscle fibers (Haas et al. 1984).

Teramoto et al. reported that biopsies of sphinc-

January 26, 2004 29EUROPEAN JOURNAL OF MEDICAL RESEARCH

ters were taken in patients with hemorrhoids but

no case of incontinence has been reported

(Teramoto et al. 1981). Khalil et al. (2000) found

skeletal muscle fibers and smooth muscles fibers

in histological specimens after sutured hemorrhoi-

dectomy and stapler hemorrhoidectomy. They

concluded that the histological presence of muscle

fibers in excised hemorrhoidal tissue neither

means sphincter injury nor incontinence (Khalil

et al. 2000).

In summary, in most instances, hemorrhoids

are treated conservatively; the surgeon is contact-

ed when conservative measures have failed or

complications, e.g., thrombosis, have occurred. 4°

prolapsed internal hemorrhoids are the main indi-

cation for hemorrhoidectomy: high (Parks) or

low (Milligan-Morgan) ligation with excision,

closed hemorrhoidectomy (Ferguson) or stapler

hemorrhoidectomy. Thrombosed external hemor-

rhoids are primary treated by incision and secon-

dary by excision. Complications after operative

treatment of external thrombosed hemorrhoids

are rare. After standard hemorrhoidectomy for

internal hemorrhoids approximately 10% may

have a complicated follow-up (bleeding, fissure,

fistula, abscess, stenosis, urinary retention, soil-

ing, incontinence); there may be concomitant dis-

ease, e.g., perianal cryptoglandular infection, caus-

ing complex fistula/abscess, which is associated

with an increased risk (30-80%) for complica-

tions, e.g., incontinence. Other treatment op-

tions, e.g., sphincterotomy, anal stretch, have

been accused to cause more complications, e.g., in-

continence in 30-50% of cases. However, inconti-

nence is a complex phenomenon; it is evident that

an isolated single injury is normally not a suffi-

cient cause, e.g., injury of the internal sphincter.

The majority of patients may present with prior

obstetric injury, perianal infection or Crohn’s dis-

ease and other comorbidity. Therefore all system-

ic and regional disorders, causing incontinence,

should be excluded before starting manometric,

neurophysiological and sonographic investiga-

tions. Variations and overlap in test results, pa-

tient-, instrument- or operator-dependent factors

ask for cautious interpretation. There is vast evi-

dence that the demonstration of muscle fibers in

hemorrhoidectomy specimens is a normal feature.

In conclusion, standard hemorrhoidectomy with

proper indication is a safe procedure. If complica-

tions occur, it is in the interest of the patient and

surgeon to perform a thorough investigation.

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Address for correspondence:

René Gordon Holzheimer MD PhD

Praxisklinik Sauerlach (Center for Daycase Surgery)

Tegernseer Landstr. 8

D-82054 Sauerlach

Tel. +49-8104-887822

Fax +49-8104-887824

E-mail info@praxisklinik-sauerlach.de

EUROPEAN JOURNAL OF MEDICAL RESEARCH

Epidemiological and Therapeutic Aspects of Proctological Pathologies in Pregnant and Postpartum Women at the Reference Health Center of Commune IV of Bamako District

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Sep 2021

Hemorrhoid, is one of the most common anal pathologies. It is considered as a big issue in our society, surgical treatment is one of the valid ways to treat hemorrhoids. Pain after surgery is the most important complication beside other complications. Piles are removed with overlying skin removed with hemorrhoidectomy. Pain intensity varies, depending on the patient's pain threshold. This research attempts to see if open hemorrhoidectomy by itself or hemorrhoidectomy and internal sphinctorotomy were effective in treating post-operative pain.

Comparison of the effects of methylene blue with adrenaline and Marcaine with adrenaline on pain control after hemorrhoidectomy

Preprint

Full-text available

Sep 2023

Background Hemorrhoidectomy is still considered the mainstay of treatment for advanced and/or complicated hemorrhoids, although post-hemorrhoidectomy pain remains a challenging problem. Objectives This study aimed to comparison the effect of intradermal methylene blue with adrenaline and Marcaine with adrenaline injection in pain relief after hemorrhoidectomy. Matherial and methods In this single-center prospective double-blind randomized trial, Patients aged 18-60 years with the diagnosis of hemorrhoids with grade three or four candidate for open hemorrhoidectomy were enrolled. Patients were randomly divided into two groups. Intradermal injection during hemorrhoidectomy of 4 ml 1% methylene blue with adrenaline and 16 ml 0.5% Marcaine for patients in methylene blue group and 16 ml 0.5% Marcaine with adrenaline and 4 ml saline without methylene blue in control group was used. Patients’ information were recorded prospectively. Results Ninety seven patients were enrolled. Postoperative pain in patients in methylene group between the 1st and 7th days after surgery was significantly lower than patients in control group. However, no significant difference was detected in pain scores between the two groups from 8th to the 14th days after surgery. Also, patients in methylene blue group received analgesic drugs were significantly less than control group between days 1 and 7 after the surgery. Conclusion An intradermal application of 1 % methylene blue with adrenaline solution is associated with a positive effect on pain relief with low side effects related to sensory cutaneous innervation in all patients. It can achieve a long-acting analgesic effect with few complications.

Hemorrhoidal Disease: How to Proceed After Unsuccessful Medical Treatment?

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Mar 2023

Maria Isabel Gomez Coral

Picking Up the Threads: Long-Term Outcomes of the Sutured Haemorrhoidopexy: A Retrospective Single-Centre Cohort Study

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Jan 2023

Background: This study aimed to assess the short- and long-term safety and efficacy of the sutured haemorrhoidopexy (SH) in patients with haemorrhoidal disease (HD). Methods: A retrospective study was performed, assessing the following treatment characteristics: number of sutures needed; operation time; perioperative complications; postoperative pain; hospital stay. The short- and long-term postoperative complications, HD recurrence and data on current HD symptoms were assessed according to the Core Outcome Set for HD. Results: Between January 2009 and December 2021, 149 patients with HD underwent a SH. One-hundred and forty-five patients were included, with a mean age of 61 years (±12.8), of which 70 were women (48.3%). Patients were predominantly diagnosed with grade III (37.2%) HD and the median follow-up was nine years (5-11). Perioperative complications occurred in four cases (2.8%). In two patients (1.4%), short-term postoperative complications were reported, and in seven patients (6.2%), long-term complications were reported. The cumulative efficacy in terms of freedom of recurrence was 88.3% (95% CI, 83.1-93.5) at six months, 80.0% (95% CI, 73.5-86.5) at one year, and 67.7% (95% CI, 59.7-75.7) at five years. Conclusions: Sutured haemorrhoidopexy is a safe treatment for patients with HD and can be proposed as a minimally invasive surgical treatment if basic and outpatient procedures fail.

Surgical Outcomes of LigaSure Hemorrhoidectomy in the Elderly Population: A retrospective cohort study

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Oct 2021
BMC GASTROENTEROL

Background This study aims to assess the association between age and outcomes in patients undergoing hemorrhoidectomy. Methods This is a population-based cohort study. A retrospectively collected database with consecutive patients whose symptomatic prolapsed hemorrhoids managed by the LigaSure hemorrhoidectomy between Jan. 2015 and May 2017 was reviewed. Among 1238 patients, 1075 were under 65 years old (group 1), and 163 were 65 years old or older (group 2). Both groups were compared regarding baseline characteristics and surgical outcomes. Results All patients tolerated the whole course of the operation in the prone jackknife position without anesthetic-associated complications. There was no significant difference between these two groups regarding sex, hemorrhoids grade, operation time, duration of hospital stays, postoperative pain score, analgesic consumption, total postoperative complications, re-admission rate, reoperation rate and follow-up times. The multivariate logistic regression analysis that may contribute to postoperative complications revealed no significant difference for all complications between both groups. Conclusion The LigaSure hemorrhoidectomy for elderly patients is safe and effective without significant difference in short-term operative outcomes and all complication rates, compared with younger patients.

Colour Doppler-guided Haemorrhoidal Artery Ligation: a possible evolution of Transanal Haemorrhoidal Dearterialisation

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Jul 2021

Introduction: Haemorrhoids are a very common disease, with a great economic burden. Many treatments have been developed for trying to solve the problem, being the standard not yet found. In 1995, Doppler-guided haemorrhoidal artery ligation was introduced, aiming to reduce postoperative pain and complications. In this work, an evolu-tion of the aforementioned surgical technique was described. Materials and methods: 183 patients treated with standard Doppler-Guided Haemorrhoidal Artery Ligation were statistically compared with 225 patients dealt with Colour Doppler-Guided Haemorrhoidal Artery Ligation. The procedures were performed under local anaes-thesia with patients in lithotomy position. A special proctoscope and a dedicated Colourdoppler US probe were employed in the second group. Superior haemorrhoidal artery terminal branches were con-secutively ligated according to provided technique in the first group and under vision in the second. In all cases, each ligation was followed by mucopexy. Results: No significant differences between the two groups, in terms of post-operative pain, early complications (bleeding, urinary retention, incontinence) or patient satisfaction, were demonstrated. Recurrence rate was significantly higher in patients treated with stan-dard DG-HAL. No late complications (after one-year follow-up) were registered in both groups. Conclusions: Colour Doppler-Guided Haemorrhoidal Artery Li-gation represents an ideal management for 1-day surgery, and fulfils the requirements of minimally invasive surgery in patients with III-IV grade haemorrhoids. The absence of complications and the evidence of significant wellness of patients are the best advantages. Colour Doppler-Guided Haemorrhoidal Artery Ligation is a safe and easy procedure with good results and a very short-time training. It could be considered an easy and reliable method to treat symptomatic haemorrhoids.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review

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Jan 2023

Background: Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise. Aim: To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities. Methods: We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons. Results: Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients. Conclusion: Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

The role of 10 % Sucralfate Ointment in the Reduction of acute postoperative pain after haemorhoidectomy

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Aug 2022

Abdul JABBAR Mirani

Background: Th e purpose of the study was to evaluate the use of 10 % sucralfate ointment in the reduction of acute postoperative pain aft er open hemorrhoidectomy. Design: Th is study was a prospective, randomized, placebo-controlled trial. Sett ing and Duration: Th is study was carried out at the Department of General Surgery, Civil Hospital Karachi between January 2014 to December 2014. Methodology: A total of 48 patients (24 men and 24 women) between 20 and 70 years of age who underwent open hemorrhoidectomy were included in this prospective, randomized, controlled trial and were randomly divided into two groups (24 in each group), receiving either sucralfate ointment or placebo immediately aft er surgery and then every 12 h for 14 days. Th e primary outcome measure was pain intensity measured by a visual analogue scale at diff erent time points aft er hemorrhoidectomy. Results: Th e sucralfate group had signifi cantly less pain than the placebo group at 24th h and the 48th h aft er hemorrhoidectomy (4 ± 1.14 vs 5.08 ± 0.97; P = 0.001 and 3 ± 0.72 vs 4.41 ± 0.8; P\0.001, respectively), andthey consumed lower amounts of analgesics at the same time intervals (12.50 ± 16.48 vs 21.87 ± 15.30 mg of pethidine; P = 0.047 and 152 ± 23 vs 172 ± 29 mg of diclofenac; P = 0.009, respectively). Th e same trend continued until the end of the trial. Conclusions: Th e study showed that Sucralfate ointment reduced the acute postoperative pain aft er hemorrhoidectomy.

A PROSPECTIVE RANDOMIZED TRIAL OF COMPARISON BETWEEN SIMULTANEOUS APPLICATION OF SCLEROTHERAPY AND RUBBER BAND LIGATION VERSUS SCLEROTHERAPY AND RUBBER BAND LIGATION APPLIED SEPARATELY FOR THE TREATMENT OF HAEMORRHOID (1 ST AND 2 ND DEGREE INTERNAL HAEMORRHOID)

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Jul 2021

Ramanuj Mukherjee

A non randomised trial of combination of injection sclerotherapy and banding together in treatment of hemorroid

Surgical Treatment Evidence-Based and Problem-Oriented A liations

Book

Full-text available

Oct 2020

Excerpt "Surgical Treatment-Evidence-Based and Problem-Oriented" is based upon a concept which the editors believe will become increasingly important in the preparation of clinical textbooks in the 21st century, namely the quality of the evidence upon which currently accepted clinical practice is based needs to be assessed frankly and taken into account when recommendations for patient treatment are made. As is apparent in many of the chapters in this volume, the authors are frequently forced to conclude that a higher level of evidence than is currently available would be necessary in order establish the validity of the currently accepted management of a wide variety of common surgical problems. The editors believe this is a fact of which both students and surgical practitioners need to be aware, so that they may be prepared to update and alter their clinical decision making on the basis of higher levels of evidence when these become available. The editors also hope that increasing awareness of the low level of evidence upon which much present day surgical practice is based will prompt surgeons from many countries to plan or at least participate in clinical trials to achieve a higher quality of evidence upon which to base a more rational clinical practice.

The prevalence of hemorrhoids and chronic constipation (Reply)

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Feb 1990
GASTROENTEROLOGY

Hemorrhoids are a frequently occurring disorder widely believed to be caused by chronic constipation. In the present study, the epidemiology of hemorrhoids was evaluated and compared with the epidemiology of constipation. The analysis was based on 4 data sources: from the United States, the National Health Interview Survey, the National Hospital Discharge Survey, and the National Disease and Therapeutic Index; from England and Wales, the Morbidity Statistics from General Practice. Results showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, a peak in prevalence was noted from age 45–65 yr, with a subsequent decrease after age 65 yr. The development of hemorrhoids before age 20 yr was unusual. Whites were affected more frequently than blacks, and increased prevalence rates were associated with higher socioeconomic status. This was in contrast to the epidemiology of constipation, which demonstrated an exponential increase in prevalence after age 65 yr and was more common in blacks and in families with low incomes or low social status. The data presented illustrate differences in the epidemiologic behavior of hemorrhoids and constipation, calling the presumption of causality between constipation and hemorrhoids into question.

Die anorectalen Fisteln

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