Introduction

Haemorrhoids (piles) are a common condition affecting the majority of patients who go to see their doctors with rectal bleeding. Up to 50% of the population will suffer from problems with haemorrhoids at some point in their lives of which 5-25% will require surgical intervention. The vast majority of the time this will be painless rectal bleeding. Other ymptoms can involve itching and irritation, bleeding, persistent rectal discharge, swelling, prolapse  and rarely incontinence. Haemorrhoids are only ever painful when they are thrombosed and stuck outside the anus. Haemorrhoids can be ‘uncomfortable’ if they prolapse, but that discomfort is relieved when they are pushed back into the anus. 

 

 haemorrhoids    
 Cross sectional view of haemorrhoids in the anal canal    Internal haemorrhoids seen
with an endoscope looking
backwards

Why do we have haemorrhoids?

Haemorrhoids are normal; we all have them. When they work normally they form a neat ‘plug’ at the bottom of the anal canal helping us maintain continence. They have further function in helping us decide whether what is in our rectum is gas, liquid or solid. Some people’s haemorrhoids are bigger than others, some prolapse and some bleed. Often in these cases the haemorrhoids get displaced from their normal position to lower in the anal canal making them more prone to bleeding and prolapse. If you have very hard, constipated stool or persistent loose stool then enlarged haemorrhoids are more likely to bleed.

Treating haemorrhoids

There are many ways of treating haemorrhoids as listed below:

  • Dietary manipulation
  • Injection sclerotherapy
  • Banding
  • Cryotherapy or Infrared treatment
  • Haemorrhoidectomy (open surgery)
  • Stapled haemorrhoidectomy (aka PPH)
  • Haemorrhoidal artery ligation (aka HALO & Hemorpex)

Many patients can find relief by altering their diet; increasing the amount of fibre and fluid (see here for details) will soften the faeces and make it less traumatic to the haemorrhoids when they have their bowels open. Unfortunately for some these simple measures are not enough to relieve the bleeding and treatment is required from a colorectal surgeon.

If the simple measures above are not sufficient most surgeons move on to injecting the tissue above the haemorrhoids with a mixture of 5% phenol in almond oil. This can be performed in the outpatient department. The injection causes a ‘scarring’ type reaction above the haemorrhoids, decreasing the bleeding from them. It is important that you tell your surgeon if you are allergic to nuts before this treatment is given.

Those patients with ‘prolapsing’ type haemorrhoids are often more suitable for the banding procedure. This again can be performed in the outpatient department where a tiny rubber band is placed around the excess loose tissue above the haemorrhoid. This interrupts the blood supply causing the haemorrhoid to shrink over a period of time. This happens with the injection technique as well, but to a lesser extent. Banding can be very uncomfortable in some patients and for this reason I do not advocate its use.

Until recently when these treatments have failed the only option left is for an operation to remove the haemorrhoids – open haemorrhoidectomy. The operation involves excising the haemorrhoidal tissue and the necessary associated skin to remove the problem area directly. This operation is known to be quite painful as raw areas of skin are left around the anus. Often patients are required to stay in hospital for 3-5 days, mainly for pain relief and it can take 4-6 weeks for the area to fully heal with some residual discomfort for many weeks afterwards. The operation however is very successful at curing the condition, albeit with consequences!

 

Surgical Haemorrhoidectomy

 

Surgical haemorrhoidectomy involves excision of the haemorrhoidal cushions, and is the traditional surgical approach used for treating haemorrhoids. It is usually performed under general anaesthesia. The technique has been demonstrated to have successful long term results. However, it  has a reputation of being rather painful post-procedure. Complications can involve bleeding, infections in the surgical wound, difficulty passing urine, developing skin tags anal stenosis (narrowing of the anal opening) and rarely, incontinence.

 

 

The stapled haemorrhoidectomy procedure

This procedure is known by several names: PPH (Procedure for Prolapse and Haemorrhoids), Stapled Anopexy and Stapled Haemorrhoidectomy. It was introduced in Italy in 1997; 4-years later it was introduced into the United States, and shortly afterwards in the United Kingdom.

The procedure works by reducing the size of the haemorrhoids by removing the redundant (excess) lining of the bowel, lifting up the haemorrhoidal tissue back to its normal position and reducing their blood supply causing them to shrink.

 PPH Procedure    PPH completed
 Stapled Haemorrhoidectomy
being performed
   Stapled Haemorrhoidectomy
Completed

The main advantage over the open procedure described above is that all of the ‘work’ of the operation is performed inside the anal canal, which is considerably less sensitive than the skin bearing area around the anus where the open procedure is performed. The other advantage of the operation is that it leaves the haemorrhoids behind, but in the correct position and much smaller. As mentioned at the beginning of this article, haemorrhoids are important in our bowel function when they work normally, and the operation aims to restore haemorrhoids to their normal size and position.

As the procedure is almost pain free it can be performed as a day-case operation in most cases and you can return to work considerably quicker than after an open procedure.

Is the procedure safe?

One of the reasons the procedure was delayed in this country was that it had to be evaluated by NICE (National Institute for Clinical Excellence). Guidance was published in December 2003 where NICE concluded that based on current evidence the procedure is safe and effective. NICE also concluded that surgeons should be specially trained, mentored and monitored in the procedure.

Where can I have this procedure?

The operation is available on the NHS, as it has been approved by NICE. However, at the moment not all colorectal surgeons are trained in the procedure, which limits the availability.

The procedure can be performed at private hospitals with the same restrictions as above. I perform this operation both on the NHS and privately and am a recognised trainer for the procedure.

Hemorpex Procedure and HALO

Both of these procedures are similar in that they use a stitching technique within the anal canl to deal with the haemorrhoids. No cutting or stapling is done with either procedure and as such is generally afer than above and has been approved by NICE. There are differences between the 2 procedures though as detailed below:

 

The HemorPex System (HPS) is a new technique for haemorrhoid treatment consisting of the repositioning of haemorrhoidal cushions by means of sutures repositioning the anorectal mucosa, and the ligature of the branches of the superior haemorrhoidal artery. The procedure is performed without and cutting or stapling or excision of tissue and is therefore relatively pain free. Procedure time ranges between 15 to 25 minutes with either local anaesthesia or even with mild sedation. 97% of patients are discharged within 6 hours of the operation. The procedure is simple, quick, highly effective, pain free surgical treatment of haemorrhoidal disease giving a 94% success rate.

HPS in use

 

The HALO procedure is similar to HPS. It involves suturing of the haemorrhoidal artery only as it comes into the top of the haemorrhoid. There is no repositioning of the anorectal mucosa and no immediate shrinkage of the haemorrhoids as with HPS. The procedure requires the use of special Doppler equipment to locate the artery so a single suture can be placed around it. The procedure is almost painless and can be performed under mild sedation or a general anaesthetic. 

 

 

 

What are the worrying bowel symptoms?

Haemorrhoids usually produce symptoms of either a soft lump(s) coming out of the anus or bright red painless rectal bleeding. Any of these symptoms can be produced by a number of other bowel conditions including bowel cancers. If these symptoms persist for more than 6-weeks you should seek the opinion of a qualified doctor as soon as possible. Other bowel symptoms that warrant an opinion of your doctor as soon as possible include:

All Ages:
  • Rectal bleeding WITH a change in your normal bowel habit to looser stool and/or increased frequency of defecation that is persistent for more than 6-weeks
Over 45-yrs of age:
  • Rectal bleeding persistently WITHOUT anal symptoms (pain itching etc
  • Change of bowel habit to looser stool and/or increased frequency of defecation WITHOUT rectal bleeding persistent for more than 6-weeks

Jason Smith MD DMI FRCS(Gen.Surg)
Consultant General, Colorectal & Laparoscopic Surgeon

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