Hemorrhoids Surgery / Piles

Hemorrhoids Surgery / Piles

Hemorrhoids Surgery / Piles

Hemorrhoids Surgery / Piles

Hemorrhoids (or commonly termed piles) consists of dilated blood vessels that are normally present in the anus. It is a common cause of Per Rectal bleeding or blood in stool. There are many factors that contribute to the development of piles. These include straining, constipation and lifestyle habits. Consequently, factors that predispose to these also contribute like the lack of fibre diet, lack of exercise and prolong siting.

From the dilated blood vessels, the thinned-out wall tends to break easily thus leading to bleeding. As the condition worsens, it can also lead to the lost of elasticity in the supporting ligaments and thereby prolapse out of the anus initially during defecation and eventually not being able to reduce causing severe pain.

Symptoms of piles

Most individuals are asymptomatic and only noted to have piles on examination or picked up on colonoscopy for other indications. The following symptoms are some of the more common symptoms patients present with:

  • 1. Per rectal bleeding or blood in stools
  • 2. Perianal itch or itch around the anus
  • 3. A Lump at the anus
  • 4. Pain around the anus
  • 5. Mucous in stools
Hemorrhoids Surgery / Piles

Surgery for piles

Most patients will benefit from conservative management for piles. Symptomatic piles are referred for intervention especially when symptoms persist after medical therapy. The options are broadly divided into 2 main categories: bedside procedures and day surgery procedures.

Bedside procedures include:

1. Rubber band ligation
2. Injection Sclerotherapy

Rubber band ligation is the recommended first option by international guidelines (quote ASCRS website) and widely used. This procedure can be done without any sedation. It is relatively painless and carries a very small risk of bleeding and infection. Most patients will feel some urge to defecate for about 3- 5 days after ligation and this feeling goes away the rubber band drops off.

Injection sclerotherapy has few reported severe complications due to the systemic dissemination of the sclerosant. Coupled with the similar efficacy compared to band ligation, this technique is not commonly performed and indicated only in small hemorrhoids. Day surgery procedures include: 1. Conventional hemorrhoidectomy 2. Ligasure or Energy-device hemorrhoidectomy 3. Stapler hemorrhoidopexy 4. Laser Ablation or HETTM Bipolar System ablation Conventional hemorrhoidectomy, Milligan-Morgan or Ferguson, including diathermy hemorrhoidectomy are variants of a similar procedure of excisional hemorrhoidectomy. Beyond minor technical differences, these procedures all involve the removal of the dilated hemorrhoids. The outcomes are largely similar as well and remains an effective method for the treatment of hemorrhoids.

Ligasure hemorrhoidectomy uses an energy sealing device to perform the hemorrhoidectomy. This allows for increase hemostasis for the surgery. The outcomes for this procedure

Stapler hemorrhoidopexy uses a unique device to remove a circular ring of tissue above the dentate line. This results in the interruption of blood flow into the hemorrhoids thereby leading to shrinkage and resolution of symptoms. As the surgery is performed above the line of tactile sensation, this procedure is proven to have lesser post-operative pain and faster recovery to work. Similar to other surgeries, this is performed under general anesthesia or spinal and patients can be discharged on the same day.

Ablation techniques involve using heat to ablate the hemorrhoids. These techniques avoid cutting the inner lining of the anal canal which has the possible benefit of lesser pain and less post-operative bleeding.

Frequently Asked Questions

  • What can cause hemorrhoids to worsen?

    Hemorrhoids can worsen due to the following factors:

    1. Constipation
    2. Prolonged straining during defecation
    3. Low Fiber diet intake and dehydration 
    4. Alcohol intake
    5. Lifting of heavy weights

    These factors lead to an increase in effort to defecate.  An increased pressure in the rectum will then lead to dilatation of the veins around the anal region and lead to the worsening of the hemorrhoids. It is advised to avoid these factors when the patient is having active symptoms from hemorrhoids as they can lead to prolongation of duration of symptoms.  

  • How long will hemorrhoids last?

    Typically, hemorrhoidal symptoms last for about 3-5 days. Most of the symptoms resolve by themself, but taking medication can shorten the duration of symptoms.  However, it can last up to 2 weeks also depending on the severity. For piles that are prolapsing, it may persist even when the pain is resolved and medication in such cases will usually not be as effective.

  • How long will a hemorrhoid surgery take?

    It is usually very fast, especially for small hemorrhoids and straightforward cases. The entire procedure excluding the anesthesia and recovery is approximately 10 to 20 mins. Different procedures may take different lengths of time especially if there are additional steps taken to treat both internal and external hemorrhoids.

  • When is hemorrhoid surgery recommended?

    The indications for hemorrhoid surgery are divided into elective and emergency types. Elective cases will include failure of conservative treatment, symptoms affecting quality of life and patient’s choice. Emergency indications include bleeding piles, thrombosed piles and painful thrombosed piles.

  • Are hemorrhoids permanent?

    Most hemorrhoids are not permanent. Hemorrhoid tissues are actually blood vessels. And these have the propensity to dilate and constrict over time. Thus even when it is very dilated or painful, most piles should go for a course of conservative treatment and allow them to shrink prior to consideration for the need for surgery. 

    However, some piles especially external piles upon resolution will end up with skin tags in around the anus. These are not the same as piles and usually do not require excision. These tend to be very common after pregnancy and tend to be mistaken for piles.

  • Are hemorrhoids cancerous?

    No. Hemorrhoids are never cancerous. They also do not become cancerous. The hemorrhoids themselves are blood vessels and cancer in the anus or lower rectum come from glandular cells in the inner lining of the intestine. Both conditions are clearly from different origins and hence should not be confused as the same disease.

  • Can I live with hemorrhoids?

    Yes. In fact many people live with hemorrhoids and do not need any treatment. A consultation with a doctor like a GP is necessary though to ensure that the symptoms are not caused by other conditions. In our experience, there were rare cases where patients had a lump at the anus and thought they had piles. 

    As it never went away and got bigger, which is a red flag, they sought medical treatment eventually which was then noted to be a tumor. As they were promptly removed, patients continued to be well after surgery. This highlights the importance of an initial consult prior to the dismissal of symptoms.

  • What happens if I have hemorrhoids for too long?

    In general, hemorrhoids progress with age. However, many patients still do not require surgery even when the hemorrhoids are bigger or of a higher degree. (There are 4 degrees of piles) Thus nothing serious usually happens for patients with hemorrhoids for a long time. However, they may present with an acute problem like thrombosis or prolapse which is often very painful and rarely requires an emergency surgery.