Haemorrhoids
Grading of Haemorrhoids (piles)
Grade1:
Piles which bleed, no prolapse
Grade2:
Piles which prolapse, reduce on its own
Grade3:
Piles which have to be manually reduced by patients, stays in
Grade4:
After reduction, they prolapse again
Grade5:
Permanently prolapsed
Treatment
Medical therapy- 60% reassure, diet.
Non-operative techniques
- Sclerotherapy
- Band Ligation
- Photocoagulation
- Cryofreeze therapy
Operative techniques
- Stapled haemorrhoidopexy
- Closed haemorrhoidectomy
- Open haemorrhoidectomy
- H.A.L.O therapy
* Please see power point presentation on haemorrhoids.
Stapled haemorrhoidopexy was introduced by Antonio Longo. It is advocated preferably for grade 2-5 piles. They are normal anal cushions consisting of engorged blood vessels. Indicated for grade 2-5 piles.
Aru introduced this technique at the Royal Cornwall hospital since 2005 and has performed over 100 procedures both on the NHS and privately at the Duchy hospital.
See presentation(*powerpoint) on stapled haemorrhoidopexy.
Haemorrhoidectomy
What are haemorrhoids?
Haemorrhoids also known as piles, are soft fleshy lumps just inside the back passage (anus). They have a rich blood supply and bleed easily, usually causing fresh bright-red bleeding when a motion is passed. They do not usually cause pain but can cause itching around the anus. When large, they can pass through the anus (prolapsed pile), felling like a lump when you clean yourself (see figure 1).
Figure 1 Back passage showing a prolapsed, bleeding & clotted pile
Your doctor has recommended a haemorrhoidectomy. However, it is your decision to go ahead with the operation or not. This leaflet will give you information about the benefits and risks to help you make an informed decision.
How do haemorrhoids form ?
Haemorrhoids develop gradually, often over a long period of time. They are associated with constipation, particularly if you need to strain to open your bowels. They often run in families and can be made worse by pregnancy.
Are there any alternatives to surgery?
Haemorrhoids can often be successfully treated by simple measures such as making sure your motions are bulky and soft, and that you do not strain while opening your bowels. Eating more fibre and drinking more fluid usually improves the way your bowels work.
If these simple measures are unsuccessful, the haemorrhoids can usually be treated successfully in a clinic. Local treatments aimed at shrinking the haemorrhoids include ‘banding’ or ‘injecting’ the haemorrhoids. In 6 out of 10 people, these treatments are successful. However they may need to be repeated. The treatment is usually painless but can cause discomfort for up to a day.
Only when the surgeon has tried these treatments and ruled out other causes of your symptoms will they recommend a haemorrhoidectomy or surgery may be the only choice in grade 3 and 4 haemorrhoids.
What will happen if I decide not to have the operation?
You will continue to bleed at times but you may accept this. You can decide to continue with simple measures or local treatments. As long as the bleeding is only caused by your haemorrhoids and you are not anaemic (not enough red blood cells) it should be safe to continue as you are. However, it is important that you are examined by a specialist to make sure that the bleeding is coming from your piles and nowhere else.
What does the operation involve?
A open haemorrhoidectomy is usually performed under a general anaesthetic and takes about twenty minutes. However, a variety of anaesthetic techniques are possible. Your anaesthetist will discuss the options with you and will recommend the best form of anaesthesia for you.
When you are asleep, your surgeon will carefully examine your back passage and lower bowel. The haemorrhoids can be removed by either cutting them away or using a staple gun. Your surgeon will make sure that the blood vessels that supplied the haemorrhoids have stopped bleeding. They may inject local anaesthetic near the back passage. This is effective at reducing pain after the operation.
What should I do about my medication?
You should continue your normal medication unless you are told otherwise. Let your surgeon know if you are on Warfarin or Clopidogrel. Follow your surgeon’s advise about stopping this medication before the operation.
What complications can happen?
The healthcare team will try to make your operation as safe as possible. However, complications can happen. Some of these can be serious and can even cause death. You should ask the surgeon if there is anything you do not understand. Any numbers which relate to risk are from studies of people who have had this operation. Your doctor may be able to tell you if the risk of a complication is higher or lower for you.
The complications fall into three categories.
- Complications of anaesthesia
- General complications of any operation
- Specific complications of this operation
1. Complications of anaesthesia
Your anaesthetist will be able to discuss with you the complications of having an anaesthetic.
2. General complications of any operation
• Pain – A haemorrhoidectomy can be painful. The local anaesthetic and painkilling medication will help to keep you comfortable. The pain can continue for two to three weeks while the raw areas in your back passage heal. The pain may be less if a staple gun is used. You will need medicationto keep your motions soft.
• Bleeding after surgery. If the blood vessels start to bleed again soon after surgery. You may need another operation to stop the bleeding (risk: less than 1 in 100). If your haemorrhoids were cut away, bleeding may happen one to two weeks after surgery. However, this usually settles on its own. If you do not get bleeding, let your doctor know as you may need to have antibiotics to reduce the risk of infection.
• Infection in the surgical wound. The wounds are usually left open to reduce this risk but occasionally a course of antibiotics is needed.
• Blood clots in the legs (deep vein thrombosis) which can occasionally move through the bloodstream to the lungs (pulmonary embolus), making it difficult for you to
breathe. Nurses will encourage you to get out of bed soon after surgery and may give you injections to reduce the risk of blood clots.
3. Specific complications of this operation
• Incomplete haemorrhoidectomy, which sometimes happens if the haemorrhoids are so widespread that it would not be safe to remove them all during the operation. Some tissue may be left so you may still feel a lump.
• Difficulty passing urine, which may need a catheter (tube) in your bladder for a day or two (risk: 1 in 5). The risk of needing a catheter is higher if you had difficulty passing urine before the operation.
• Anal stenosis, where the back passage narrows due to scarring. This may need further surgery.
• Developing skin tags, where small pieces of skin are left at the edge of the anus after the wounds have healed
• Developing an anal fissure, which is a tear in the skin around the back passage caused by a wound not healing properly. There are simple treatments to treat an anal fissure but sometimes surgery is needed.
• Incontinence, which can happen to a minor degree soon after surgery but should settle. If it does not settle, you may need further treatment.
How soon will I recover?
In Hospital
After the operation you will be the operation you will be transferred to the recovery area and then to the day-case ward. You should be able to go home later on the same day. A responsible adult should take you home in a car or taxi, and stay with you for at least 24 hours. You will need support for a few days.
At home
You should drink plenty of fluid and increase the amount of fibre in your diet to avoid constipation. This is important for the first few days after your operation. You may be prescribed laxatives to help to prevent you from becoming constipated. If you are worried about anything once you are at home, contact Duchy Hospital on 01872 226100.
Returning to normal activities
You should be able to return to work within 3 to 4 weeks depending on your type of work. The wounds often take several weeks to heal completely and you may need to wear pads until then. There are no open wounds with the stapled technique. Slight bleeding or discharge is common until your wounds have healed. A nurse should check the wounds after about a week. You will normally be seen in the clinic to make sure everything has settled.
Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, you should ask a member of the healthcare team or your GP for advice.
Do not drive until you are confident about controlling your vehicle and always check with your doctor and insurance company first.
The future
You should make a full recovery and the symptoms should clear completely. However, occasionally haemorrhoids come back. If your symptoms continue, particularly bleeding, you should let your doctor know.
Summary
Haemorrhoids are a common problem, if non-surgical treatments fail, surgery is usually recommended. Surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early.
