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Hemorrhoids

Peter Cataldo, MD
Associate Professor of Surgery
University of Vermont
College of Medicine
Burlington, VT
Disclosure: No Affiliation

Introduction

Hemorrhoids have plagued human beings throughout history, perhaps beginning when we first assumed upright posture. Beginning in Medieval times, hemorrhoids were known as St. Fiacre's curse, and today hemorrhoid sufferers from around the world visit St. Fiacre's stone in order to obtain a miracle cure. St. Fiacre, also known as the patron saint of gardeners, was told he could farm all the land he could cultivate in a single day. He was given a particularly small shovel by a less then benevolent bishop. After a particularly long day of spading his garden, in order to obtain the maximum amount of land, he developed a terrible case of prolapsed hemorrhoids. Seeking a solution, he sat on a stone and prayed for resolution of his problems. This resulted in a miraculous cure and, according to legend, the imprint of St. Fiacre's hemorrhoids remains on the stone today. Hemorrhoid sufferers from all over the world continue to sit on this stone and pray for relief.(1)

Nearly every patient visiting the general or colon and rectal surgeon with anal problems comes in complaining of "hemorrhoids". They are often assigned blame for pruritus ani, anal fissures, condylomata acuminata, fistula in ano and incontinence. Not surprisingly, only a minor percentage of these complaints are actually due to hemorrhoids. It is essential, therefore, that treatment for hemorrhoids is only undertaken if they are truly symptomatic. The mere presence of hemorrhoids is not an indication for any therapeutic intervention.

Hemorrhoids can be divided into those originating above the dentate line which are termed internal and those originating below the dentate line which are termed external. External hemorrhoids are rarely symptomatic unless thrombosed and will be discussed later in this chapter.

Many myths exist regarding the etiology and pathophysiology of internal hemorrhoids. The development of hemorrhoids has been attributed to prolonged periods of driving, sitting on cold seats or benches, eating spicy foods, and doing manual labor. These activities are rarely the cause of anal problems. In addition to misconceptions regarding their etiology among the lay members of our community, there are equally numerous misconceptions regarding the pathophysiology of hemorrhoids among the medical community. These misconceptions have been perpetuated throughout many surgical texts.

Internal hemorrhoids were originally thought to be a result of portal hypertension and were described as varicosities decompressing the portal system via a porta systemic connection in the distal anorectal region. This is clearly known not to be the case and although true anorectal varices do exist in cirrhotic individuals, rectal bleeding in these patients is much more common as a result of hemorrhoidal disease than it is secondary to variceal disease.(2)

Fibrovascular cushions (or hemorrhoids) are part of the normal anatomy within the anal canal and are believed to be important in maintaining continence. As an individual coughs, strains or sneezes, these fibrovascular cushions engorge and maintain closure of the anal canal in order to prevent leakage of stool in the presence of increased intrarectal pressure. They may also be important in sensation of the anal canal, specifically in differentiating liquid, solid and gas. It is therefore important to remember that while undertaking any treatment for hemorrhoidal disease that fibrovascular cushions are a part of normal anorectal anatomy and are important in the continence mechanism. Therefore, surgical removal may result in varying degrees of incontinence particularly in individuals with marginal preoperative control.

1. PATHOPHYSIOLOGY
Hemorrhoids are thought to represent engorgement or enlargement of the normal fibrovascular cushions lining the anal canal. It has been postulated that chronic straining secondary to constipation or occasionally diarrhea results in pathologic hemorrhoids. As an individual strains repeatedly over time, these fibrovascular cushions lose their attachment to the underlying rectal wall. This eventually leads to prolapse of internal hemorrhoidal tissue through the anal canal. In addition, as these hemorrhoids engorge, the overlying mucosa becomes more friable and the vasculature increases. Arterio-venous connections are known to normally exist within these cushions. With overlying thinning of the mucosa and vascular engorgement, subsequent rectal bleeding, in the form of bright red blood per rectum, occurs. Several authors have identified stretching and disruption of submucosal muscle in association with hemorrhoidal prolapse.(3) These microscopic abnormalities support the theory of straining and disruption of connections with the rectal wall as the etiology of hemorrhoids. Chronic straining either secondary to constipation, diarrhea and tenesmus, or prolonged attempts at defecation have been implicated in the etiology of hemorrhoids. Increased resting anal pressure has been found in association with hemorrhoids in various studies.(4) Reader's Digest has identified the bathroom as the number one site for reading for adults in the United States. Spending significant amounts of time reading on the commode is thought responsible for the development of hemorrhoids in many individuals.

2. ANORECTAL VARICES
Portosystemic communications exist at multiple intra-abdominal sites, most notably at the esophagogastric junction but also through the falciform ligament at the umbilicus, in the retroperitoneum via the veins of Retzius, and in the anorectal region. Portosystemic communications in the anorectal area exist as the superior hemorrhoidal veins are decompressed via the middle and inferior hemorrhoidal veins of the systemic circulation. These varices are not responsible for hemorrhoidal bleeding, but may rarely cause lower gastrointestinal hemorrhage. Hoskins identified anorectal varices in 44% of cirrhotics with portal hypertension, while Johnson identified only 5 cases of anorectal varices in 1100 cirrhotic patients.(5) Chawla and Dilawari, in a study from India, found 78% of their cirrhotics had anorectal varices identified by flexible sigmoidoscopy.(6) They noted 89% of patients with extrahepatic portal obstruction had varices compared with only 56% of cirrhotic patients.(6)

Importantly, patients with anorectal varices rarely develop symptoms. Chawla and Dilawari identified only 1 of 72 patients with bleeding anorectal varices.(6) Similarly, Wilson identified bleeding anorectal varices in 2 of 309 cirrhotic patients(7), while Hoskin found bleeding in 2 of 100 similar patients.(2)

In summary, anorectal varices occur with varying frequency in patients with portal hypertension depending upon the etiology and the method of detection. However, these varices, unlike esophagogastric varices, rarely bleed. The majority of painless outlet bleeding, even in cirrhotic patients, is due to internal hemorrhoids. In the rare case of symptomatic, bleeding anorectal varices, portal decompression via transhepatic portosystemic shunting (TIPS) has been successful.(8)

3. ANATOMY AND CLASSIFICATION
Internal hemorrhoids are found in the right anterior, right posterior and left lateral positions within the anal canal. This was originally thought to be due to the terminal branching of the superior mesenteric artery, however recent studies have refuted this. The position of hemorrhoids within the anal canal however remains remarkably consistent.

Internal hemorrhoids are classified by history and not by physical examination. They are graded as follows:

  • Grade I - bleeding without prolapse.
  • Grade II - prolapse with spontaneous reduction.
  • Grade III - prolapse with manual reduction.
  • Grade IV - incarcerated, irreducible prolapse.

This system has been in place for many years and correlates relatively well with treatment algorithms (ie Grade I and II hemorrhoids are often successfully treated by non operative means while Grade III and Grade IV hemorrhoids are more likely to require surgery).

4. SYMPTOMS
As previously mentioned, individuals with varying rectal complaints seek medical attention complaining of "hemorrhoids". True hemorrhoidal symptoms, however, are relatively specific. Patients either present with bright red blood per rectum or a prolapsing anal mass. Bleeding associated with hemorrhoids generally occurs with, or following, bowel movements, is almost universally bright red, and very commonly drips into the toilet water. Blood may also be seen while wiping after defecation. Occasionally blood may stain the underclothes if hemorrhoidal prolapse is present. Bleeding associated with hemorrhoids is rarely mixed with the stool, dark, or melanotic in nature. Rarely individuals with large chronic hemorrhoids may present with anemia secondary to chronic blood loss.(9)

Hemorrhoidal prolapse usually occurs in association with a bowel movement, particularly when straining is present. Hemorrhoids may also prolapse during walking or heavy lifting as a result of increased intra-abdominal pressure. The prolapse is associated with a full, uncomfortable feeling which resolves when the prolapse reduces. If incarcerated prolapse occurs then strangulation may develop. In this circumstance, patients present with extreme pain, bleeding and occasionally signs of systemic illness. These individuals may require urgent hemorrhoidectomy.

5. HEMORRHOIDS IN PREGNANCY
Many women experience hemorrhoids for the first time during pregnancy, particularly during the last trimester. Hormonal changes, obstruction of venous return by the gravid uterus, and chronic straining secondary to constipation, commonly associated with pregnancy, have been suggested as potential causes.(10) The true etiology is unknown but often treating the constipation associated with pregnancy alleviates symptoms and once the baby has been delivered, the vast majority of hemorrhoidal symptoms resolve.

Much of the literature regarding treatment of hemorrhoidal disease associated with pregnancy is anecdotal. Gravid women improve after delivery regardless of the treatment prescribed therefore it is difficult to determine the efficacy of any given regimen. Wijayanegara et al however did a placebo controlled trial of rutosides (a plant extract used to decrease capillary fragility) in 97 pregnant women.(11) They found that rutosides 500 mg. orally, twice daily, significantly improved pain, protrusion, and bleeding when compared with placebo.

O'Connor reported on the effectiveness of the Lord procedure (anal dilatation) in 119 women with hemorrhoids or fissures following delivery.(12) He reported 100% symptom relief and no complications with short follow-up. This, however, has not been subject to a controlled trial or repeated by other authors. Saleebly et al reported on 25 emergency hemorrhoidectomies performed on a 0.2% (25 of 12,455) pregnant women between 1983 and 1989, indicating that the need for operative treatment of hemorrhoids complicating pregnancy is a rare event.(13) Eighty-four percent of women were in their third trimester, and all hemorrhoidectomies were performed under local anesthesia. No major complications developed and all babies were born without incident. However, 24% of operated women needed further treatment for their hemorrhoids on long term follow-up. In summary, most pregnant women develop hemorrhoidal symptoms during their third trimester, but can be treated with conservative measures. In rare cases, hemorrhoidectomy may be necessary and can be done with minimal morbidity and little risk to the fetus.

6. PHYSICAL EXAMINATION
Nearly every person who visits the colon and rectal surgeon with an anal complaints dreads the physical examination. They have often had repeated rectal examination and anoscopies, often by inexperienced examiners. It is essential to quell the fears of these individuals prior to performing any examination if any meaningful information is to be obtained.

Patients should be examined in the left lateral decubitus position as this is better tolerated, more comfortable and less demeaning than the prone jackknife or lithotomy position. When using the Sims, or left lateral decubitus position, it is important to position the patient properly in order to obtain a good view of the anal canal. The patient should be placed with the left side down with the buttocks slightly off the edge of the examining table with the left shoulder back and the right shoulder rolled forward so that the patient is more on his or her belly than on his back. Both knees should be brought up towards the chest and the feet pushed forward away from the examining area. This position will allow good exposure of the anal canal with minimal discomfort to the patient.

The buttocks should be gently spread and the external perineal area examined for any rashes, condylomata, or eczematous lesions. Satellite lesions associated with a candidal rash should be noted if present. Any gaping of the anal aperture should also be noted. The patient should then be asked to contract his or her external sphincter and the function of this noted. Any abscesses, fissures or fistulae should be carefully inspected for as should areas of tenderness. Once this has been done, a lubricated finger should be gently inserted into the anal canal while asking the patient to bear down as if he were pushing out a bowel movement. During the digital exam, the resting tone of the anal canal should be ascertained as well as the voluntary contraction of the puborectalis and external anal sphincter. Any rectal or perirectal masses should be noted as well as any areas of tenderness. It should be noted that internal hemorrhoids are generally not palpable on digital examination. Any palpable anorectal lesions need to be clearly identified.

After completing the digital examination, anoscopy is performed. A side viewing anoscope is ideal as end viewing anoscopes provide a view of the rectum not of the anal canal. The side viewing anoscope should be inserted with the open portion in the right anterior then right posterior and finally the left lateral position to look for hemorrhoidal bundles. Hemorrhoidal bundles will appear as bulging mucosa and anoderm within the open portion of the anoscope. Once this is completed, the patient should be asked to strain to determine if there is any hemorrhoidal prolapse.

7. EVALUATION OF RECTAL BLEEDING
Anal outlet bleeding is most commonly associated with hemorrhoids but may certainly be a harbinger of colorectal cancer. Any individual with rectal bleeding should undergo an appropriate, thoughtful workup to rule out rectal cancer. In a young individual with bleeding associated with hemorrhoidal disease and no other systemic symptoms, and no family history, perhaps anoscopy and rigid sigmoidoscopy are all that is warranted. However, in an older individual, with either a family history of colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule out proximal neoplasia.

8. TREATMENT
Treatment for symptomatic internal hemorrhoids varies from simple reassurance to operative hemorrhoidectomy. Treatments are classified into three categories: 1) Dietary and lifestyle modification. 2) Non operative/office procedures. 3) Operative hemorrhoidectomy. In general, less symptomatic hemorrhoids, such as those that cause only minor bleeding, can be treated with simple measures such as dietary modification, change in defecatory habits, or office procedures. More symptomatic hemorrhoids such as Grade III or Grade IV are more likely to require operative intervention.

9. DIETARY AND LIFESTYLE MODIFICATIONS
Since prolonged attempts at defecation, either secondary to constipation or diarrhea, have been implicated in the development of hemorrhoids, the main goal of this treatment is to minimize straining at stool. In most circumstances, this means minimizing constipation. This is usually achieved by increasing fluid and fiber in the diet, recommending exercise, and perhaps adding fiber agents to the diet such as psyllium. Psyllium works in concert with water to add moisture to the stool and subsequently decreases constipation. Additionally, if necessary, stool softeners may be added. To many people's surprise, psyllium may also be therapeutic in treating diarrhea. It may add bulk to liquid stools therefore increasing their consistency and decreasing their number.

Many times a change in defecatory habits is all that is required. People often use the bathroom as a "sanctuary" and Reader's Digest, in response to a national poll, identified the bathroom as the most common site of reading in the United States. Often times simply asking an individual to curtail reading on the commode resolves the hemorrhoidal problem. Perhaps these simple words of advice are appropriate, "you don't defecate in the library so you shouldn't read in the bathroom". Lifestyle and dietary modifications along with ruling out proximal sources of bleeding are all that is required for the majority of patients complaining of hemorrhoidal disease.

Perez-Miranda et al. randomized patients with bleeding internal hemorrhoids to fiber vs placebo. They identified significant reduction in bleeding in the treatment group, but no difference in hemorrhoidal prolapse.(14) Micronized flavonoids (agents which decrease capillary fragility) have also been effective in decreasing hemorrhoidal bleeding. Ho et al. in a randomized, prospective trial, found flavonoids more effective in reducing bleeding when compared to fiber alone or hemorrhoid banding.(15) Misra and Parshad compared flavonoids to placebo for acute hemorrhoidal bleeding. They identified 40% cessation of bleeding in the treatment group versus 19% in the control group and recommended flavonoids for acute hemorrhoidal bleeding prior to initiating office treatments.(16)

Office Treatments

Office treatments consist of various methods short of surgical intervention. The most commonly used methods today are rubber band ligation, infrared photocoagulation, bicap. coagulation, sclerotherapy and rarely cryotherapy. Cryotherapy is rarely used today as it is difficult to identify the true extent of the "ice ball" created in this method and it often leads to a foul smelling discharge which is undesirable. In a series of 1000 "cryohemorroidectomies, Oh reported 67% of patients experienced pain, 12% had severe pain, and an average post procedure disability of 5 days.(17)

1. RUBBER BAND LIGATION
The most common method currently in use for the outpatient treatment for hemorrhoids was originally described by Barron in 1963(18). He reported satisfactory results in 150 patients; the majority of which were treated in the outpatient setting. Rubber band ligation is commonly recommended for individuals suffering from Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids.

In preparation, patients are asked to take a prepackaged phosphate enema. After anal examination, a slightly larger anoscope is inserted and the hemorrhoid to be banded is identified (generally the largest hemorrhoid is banded first). The hemorrhoid can either be grasped with a modified Allis forceps, or alternatively sucked into the banding instrument with wall suction. Once this has been accomplished, the patient is asked if he or she feels any pain. If pain is perceived when the hemorrhoid is grasped or suction is applied, a band should not be placed in that location. Pain indicates somatic, not autonomic, innervation of the mucosa at that level. If a band is placed in that location, the patient will experience significant pain following the procedure. Instead the instrument should be advanced proximally farther into the anal canal until an asensate spot is identified. If the patient does not experience any pain or discomfort then the rubber band is applied by depressing the trigger on the hemorrhoid ligator. This treatment is only applicable, to asensate, internal hemorrhoids above the dentate line. Some individuals prefer to band all three hemorrhoids at one setting, however this often results in significant discomfort. It is my practice to band one hemorrhoid at the first setting. If the patient tolerates this well, then at the second setting (three weeks later) the second and third hemorrhoids will be banded. If the first banding, however, had been difficult, then the remaining hemorrhoids will be banded one at a time.

Lee et al. and Chaleoykitti both compared individual ligation (one hemorrhoid per session) to triple ligation (three hemorrhoids in a single session) and identified minor increases in pain and vagal symptoms as well as a higher recurrence rate associated with triple ligation.(19,20) Wai-lun Law added local injections of anesthetic in association with multiple bandings, but did not find this decreased post procedure pain.(21) Armstrong created a modified anoscopic allowing all three hemorrhoids to be banded with a single insertion (of the anoscope) and reported excellent patient satisfaction in a randomized comparison with traditional multiple hemorrhoid ligation.(22)

Complications of hemorrhoid banding include bleeding, pain, thrombosis and life threatening perineal sepsis. Bleeding generally occurs immediately after banding or 7-10 days later when the band falls off. This is a rare occurrence but occasionally operative intervention is required to control persistent hemorrhage. A dull persistent ache is common for the first one to two days following banding. Significant anal pain is rare but is often secondary to a rubber band placed too close to the dentate line. If the pain is experienced immediately following the banding, then the rubber band can be removed with a beaver blade, although this is a difficult procedure. If the patient develops pain later this is generally treated with sitz baths, analgesics and occasionally antispasmodics. It is important to avoid constipation during this period as well. Rarely, hemorrhoid banding can result in thrombosis of internal and external hemorrhoids resulting in significant pain. There have been several anecdotal cases of life threatening perianal sepsis following hemorrhoid banding.(23) Patients are therefore asked to watch for the cardinal signs of this phenomenon which would be significant pain, fever, and difficulty urinating. Although there is only anecdotal evidence, some authors recommend avoiding hemorrhoidal banding in individuals with immune compromised states because of the potential risk of perianal sepsis.

Hemorrhoidal banding is successful in two thirds to three quarters of all individuals with first and second degree hemorrhoids. Most individuals respond to banding of the three common hemorrhoidal bundles although this may need to be repeated in the future. Rarely individuals fail to respond whatsoever or cannot tolerate banding and may require formal hemorrhoidectomy.

DiGiorgio et al reported experience banding 304 hemorrhoids over an 18 month period.(24) They found that nearly all patients required multiple sessions with an average of 3.4 bandings per patient. Ninety percent of patients experienced relief of symptoms without further treatment. Twenty percent complained of a dull ache after the procedure, but all others were asymptomatic. No major complications were encountered.

As previously mentioned, all hemorrhoids can be banded at a single session or at multiple sessions. Lee, Spencer, and Beart compared multiple vs. single bandings retrospectively.(19) They identified greater discomfort (29% vs. 4.5%) and more vasovagal symptoms (12.3% vs. 0%) with multiple hemorrhoids being banded at a single session. They encountered no major complications and felt multiple bandings to be well tolerated.

Bat et al prospectively studied complications in 512 patients undergoing hemorrhoid banding.(25) Minor complications developed in 4.6% of patients including pain, band slippage, mucosal ulcer, and priapism. Hospitalization for major complications was necessary in 2.5%, and included massive hemorrhage, severe pain, urinary retention and perianal sepsis.

Savior et al investigated relapse rates following banding in 92 individuals.(26) They found 23% of patients required repeat banding over 5 years and 32% at 10 years, and felt hemorrhoid banding to be a durable procedure.

In one of the largest studies of hemorrhoid banding, Bayer, Myslovaty, and Picovsky followed 2,934 patients banded over a 12 year period.(27) Seventy-nine percent required no further therapy, while eighteen percent required repeat banding due to recurrence. Hemorrhoidectomy was necessary in 2.1% related to persistent symptoms.

Iyer, Shrier, and Gordon followed 805 patients for a median of 3 years and identified a 70% success rate. Complications included bleeding (2.8%) external thrombosis (1.5%), and bacteremia (0.9%)(28)

Recently a new device has been developed for hemorrhoid banding.(29) An anoscope/ligator which can be attached to suction is reported as an alternative to traditional banding methods. The anoscope is inserted and directed at the appropriate hemorrhoid and suction applied. Prior to firing, the instrument is rotated tenting the mucosa to insure that it is asensate. The band is then discharged in a blind manner. O'Regan reported a 97% success rate with 2 major complications (one episode of bleeding and one of perianal sepsis) in 480 patients.(29)

2. INFRARED COAGULATION
The infrared photocoagulator generates infrared radiation which coagulates tissue protein and evaporates water from cells. The amount of destruction depends upon the intensity and the duration of application. It is recommended that a duration of 1.5 seconds be used and that each hemorrhoid be coagulated three times. Infrared coagulation, like banding, is performed in the office after administration of a phosphate enema. An anoscopic examination is performed and the infrared coagulator is applied to the apex of each hemorrhoid at the top of the anal canal. The infrared coagulator is not particularly effective in treating large amounts of prolapsing tissue, therefore is most beneficial in Grade I and small Grade II hemorrhoids. It has been described to be slightly less painful than rubber banding.(30) In a meta-analysis of 6 randomized, controlled infra-red coagulation was found to be significantly less painful than rubber band ligation, but required significantly more sessions to relieve symptoms.(31)

3. BICAP ELECTROCOAGULATION
Bipolar coagulation is commonly used in the operating room when precise coagulation is required as its' penetration is less than the standard monopolar cautery. It has been used in the office treatment of hemorrhoids as well. It works, in theory, similar to photocoagulation or to rubber banding, by decreasing tissue, decreasing vascularity, and increasing fixation to the anal musculature. The bicap probe is applied to the apex of the hemorrhoid and current applied. The procedure is generally painless and may be repeated at 3 week intervals until symptoms have resolved. Bicap coagulation was compared to monopolar heater probe coagulation in a randomized trial of 81 patients. The heater probe was associated with more procedure related pain, but higher success rates and a lower incidence of complications.(32)

4. SCLEROTHERAPY
Sclerotherapy was commonly used in the past but with the advent of rubber band ligation is less commonly used today. It involves the injection of an irritating material into the submucosa in order to decrease vascularity and increase fibrosis. This, in theory, decreases the blood entering the hemorrhoidal bundle, also fixes the hemorrhoidal bundle to the rectal wall and therefore decreases bleeding and prolapse. Injecting agents have traditionally been phenol in oil, sodium morrhuate, or quinine urea. Similar to the other office procedures, the hemorrhoids are identified in the anoscope and the injecting agent is infiltrated at the apex of the hemorrhoid at the proximal anal rectal ring. This occasionally results in a dull ache lasting 24-48 hours but rarely results in significant bleeding or other complications. There have been rare reports of misplacement of the sclerosing agent resulting in significant perianal infection and fibrosis.(33)

5. ANAL STRETCH
Manual anal dilatation was first described by Lord in 1968 and has been used mainly in Great Britain for the treatment of hemorrhoidal disease. This is based on the fact that individuals with hemorrhoidal disease have higher resting pressures in the anal canal and that outlet obstruction leads to straining and subsequent hemorrhoidal disease. Traditionally this procedure has been performed under intravenous sedation or general anesthesia. The anal canal is stretched until four fingers of each hand are can be inserted. Patients are then asked to intermittently insert an anal dilator once at home. This has been reported to be effective in the treatment of hemorrhoids although is not commonly used today due to subsequent incontinence. Long term follow-up identified alterations in continence in 52% of patients undergoing Lord’s dilatation for hemorrhoids.(34)

6. CRYOTHERAPY
Cryotherapy too has fallen into disfavor. It was used in the past with the belief that freezing the apex of the anal canal could result in decreased vascularity and fibrosis of the anal cushions. Unfortunately, this procedure resulted in a profuse foul smelling discharge secondary to necrosis. The procedure was also found to be painful and associated with slow healing times. For these reasons, it is all but abandoned today.

Surgical Treatment of Hemorrhoids

1. HEMORRHOIDECTOMY
Various types of hemorrhoidectomies have developed throughout the years but they are all associated with the same basic principle. This is decreasing blood flow to the anorectal ring and removing redundant hemorrhoidal tissue. In the United Kingdom, the Milligan and Morgan hemorrhoidectomy is most commonly used. This technique involves ligation and excision of the hemorrhoids while leaving the wound open. In this technique, the anus is gently dilated and the hemorrhoidal tissue and perianal skin are everted just outside the anorectal ring. The triangular shaped hemorrhoid is excised down to the underlying sphincter muscle. The pedicle is then ligated with suture. The wound is left open and a light dressing applied. One, two or three hemorrhoids may be treated in this manner.

The closed, or Ferguson hemorrhoidectomy, is most commonly performed in the United States. This technique involves exposure of the hemorrhoid with the anal retractor. Once this has been performed, local anesthetic is infiltrated first under the anoderm and extending into the anal canal. The hemorrhoidal bundle is gathered within the tines of a forceps, and the anoderm is sharply excised with a knife. The hemorrhoid is then elevated off the external and internal sphincter and excised to the proximal anal canal. The pedicle is then sutured with a single or double suture ligature. The wound is then closed with a running suture beginning at the apex and extending to the anoderm. As with the Milligan Morgan hemorrhoidectomy, one, two or three hemorrhoidal bundles may be excised in this fashion. It is essential in this type of hemorrhoidectomy that only minimal amounts of anoderm are excised. If large amounts of anoderm are excised, closing the anal wounds can result in significant postoperative pain and perhaps even long term anal stenosis.

The Whitehead hemorrhoidectomy was first described in 1882.(35) This technique involves circumferential excision of hemorrhoidal veins and mucosa beginning at the dentate line and proceeding proximally. It is still used occasionally in Great Britain but rarely employed in the United States due to technical difficulties and the potential for ectropion. This technique is relatively similar to the Delorme which has been described for rectal prolapse. It also bears significant resemblance to the newly developed "stapled hemorrhoidectomy" which will be described in the following paragraphs.

ALTERNATE ENERGY SOURCES

Hemorrhoidectomy (Ferguson or Milligan-Morgan) may be accomplished by a variety of methods. Alternative energy sources may be used for cutting tissue and for coagulation. Scalpel, electrocautery, harmonic scalpel, and Ligasure have all been advocated by their respective enthusiasts. Multiple comparison studies have been done, but no consensus exists identifying superiority of one technique over any other.(36-41)

2. STAPLED HEMORRHOIDECTOMY
Over the past 10 years, stapled hemorrhoidectomy has been developed as an alternative to standard Ferguson or Milligan-Morgan hemorrhoidectomy mainly because of the pain associated with traditional hemorrhoid surgery. It was first described by Pescatori et al (42) and refined by Longo.(43) Since then, it has been written about by many authors and subjected to several randomized controlled trials.(44-46)

Stapled hemorrhoidectomy involves transanal, circular stapling of redundant anorectal mucosa with a standard circular stapling instrument. There is continued debate about the mechanism by which it relieves symptoms. As hemorrhoids are thought to be redundant fibrovascular cushions, most treatments reduce blood flow and remove redundant tissue. Stapled hemorrhoidectomy is thought to work by a similar mechanism. Redundant mucosa is drawn into the instruction and excised within the "stapled doughnut". Additionally, mucosal and submucosal blood flow is interrupted by the circular staple line. No incisions are made in the somatically innervated, highly sensitive anoderm theoretically resulting in significantly less postoperative pain.

3. TECHNIQUE
Patients are prepared as they would be for a standard hemorrhoidectomy with partial or complete mechanical bowel preparation. General and spinal anesthesia have both been described, but local anesthesia can also be used. Patients may be positioned prone, in lithotomy, or in the Sim's position depending upon the surgeon's preference. After thorough examination of the anal canal and perianal tissues, a pursestring suture is placed. The pursestring should be 3-4 centimeters proximal to the dentate line and include only mucosa and submucosa. Suture "bites" should be close together as large gaps will allow redundant mucosa to evade the stapler resulting in persistent hemorrhoids. The pursestring can be placed by standard suture technique or alternatively a pursestring instrument can be used. A modified circular stapling instrument is then introduced, fully opened, into the anal canal, and the suture tightened between the anvil and shaft of the instrument. This should draw distal redundant mucosal proximally into the jaws of the stapler. After tightening the stapler, a finger is placed transvaginally in female to assure that the anovaginal septum has not been included within the stapler. The stapler is then fired and removed. Following this, the staple line is inspected for gaps and particularly for bleeding points, which should then be oversewn.

To date, several randomized, prospective trials have compared stapled hemorrhoidectomy to traditional surgery. Mehigan, Monson, and Hartley at the University of Hull randomized 40 patients with third or fourth degree hemorrhoids to stapled hemorrhoidectomy or Milligan- Morgan hemorrhoidectomy.(45) All procedures were performed under general anesthesia. Complications were minor and rare in both groups. Hospital stay and return of bowel function were similar in both groups. The stapled group, however, experienced significantly less pain (average 2.1 vs. 6.5 on a pain scale of 1 to 10) and returned to normal activity sooner (17 vs. 34 days).

Rowsell, Bello, and Hemingway at the Leicester Royal Infirmary, UK included 22 patients in a prospective randomized trial comparing conventional (excision with partial closure) hemorrhoidectomy to stapled hemorrhoidectomy.(45) Again both groups were without major complications. These authors found stapled hemorrhoidectomy to be associated with a shorter postoperative hospital stay (1.09 vs. 2.82 nights), less postoperative pain (total pain score 20 vs. 44) and quicker return to normal function (8.1 to 16.9 days).(45) Finally, Ho et al at Singapore General Hospital randomized 119 patients to stapled hemorrhoidectomy vs. Milligan-Morgan hemorrhoidectomy.(46) All their patients were described as having Grade IV or irreducibly prolapsed hemorrhoids. In addition, they followed all patients with endoanal ultrasound and anal manometry for three months postoperatively. Manometric and ultrasound results were similar in both groups. Open hemorrhoidectomy was associated with a higher likelihood of slowly healing perineal wounds, postoperative bleeding and pruritus. Hospital stay was similar for both groups, but traditional hemorrhoidectomy was associated with more pain on defecation and total analgesic requirements at 6 weeks.(46)

More recently several larger single center and multicenter trials have compared stapled hemorrhoidectomy to traditional surgical techniques. All have reached relatively similar conclusions. Wilson found stapled hemorrhoidectomy to be associated with a shorter convalescence when compared to open hemorrhoidectomy.(47) Palimento et al. in a multicenter, randomized, prospective trial compared PPH to Ferguson Hemorrhoidectomy. They concluded PPH was as effective as Ferguson in relieving hemorrhoidal symptoms, but found stapled hemorrhoidectomy to cause less postoperative pain, and result in less complications requiring reoperation. In addition patients undergoing PPH required fewer additional procedures in the first postoperative year to relieve persistent symptoms.(48) Senagore et al., in a multicenter, prospective randomized trial, compared PPH to Ferguson hemorrhoidectomy. They concluded PPH was associated with less postoperative pain, less total analgesic requirement, and less pain at first bowel movement. In addition, recurrent symptoms requiring intervention were similar in both groups.(49) Nisar et al. performed a meta-analysis of all randomized, prospective trials comparing PPH to traditional hemorrhoid surgery. They concluded PPH was associated with less postoperative pain and shorter hospitalization. However, at 6 month follow-up recurrence was significantly higher (OR 3.64).(50)

In summary, stapled hemorrhoidectomy is a promising new technique available to patients otherwise requiring surgical hemorrhoidectomy. In limited studies, it is associated with significantly less pain and similar complication rates when compared to conventional treatment. Considering the technique, however, the potential for disastrous complications may be higher (rectovaginal or rectourethral fistula due to including too much tissue within the pursestring). It is also important to note stapled hemorrhoidectomy has not been compared to office treatments for grade I and II hemorrhoids and should not replace these techniques for minimally symptomatic hemorrhoid disease.

Conclusions

The majority of patients with anal complaints visiting a colon and rectal surgeon will ascribe all their problems to hemorrhoids. A thorough history and physical examination will often determine that these complaints are secondary to other common anorectal problems such as fissures, fistulae, condylomata or pruritus ani. For the majority of patients who do truly have symptomatic hemorrhoids, treatment can often be performed in the office with minimum morbidity and discomfort. In patients with family histories of colorectal cancer, change in bowel habits or other systemic symptoms, proximal evaluation of the GI tract to rule out neoplasia is mandatory.

In the majority of individuals, reassurance, treatment of underlying constipation and change in defecatory habits will resolve hemorrhoidal symptoms. In other individuals, office treatment such as banding, sclerotherapy or photocoagulation may be necessary.

In the rare individuals not responding or not appropriate for office treatments surgical hemorrhoidectomy will be necessary. Traditional Ferguson or Milligan-Morgan hemorrhoidectomy is associated with significant postoperative discomfort but relieves symptoms with low recurrence in over 90% of individuals.

The newest innovation in the surgical treatment of hemorrhoids is the "stapled hemorrhoidectomy". This has been popularized over the past 10 years and has been touted to be as successful as standard hemorrhoidectomy for relieving symptoms in Grade II, III and IV hemorrhoids. Several randomized trials show it to be associated with less postoperative pain and earlier return to normal function. However, short term recurrence rates seem to be higher. If long-term follow identifies success rates equivalent to traditional techniques, stapled hemorrhoidectomy may be a new tool in the colon and rectal surgeons armamentarium for dealing with refractory hemorrhoidal disease.

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