Abstract
Only 30 years ago, hemorrhoids were assumed to be an abnormal structure caused by varicose vein. Also, after the sliding anal lining theory introduced by Thompson from United Kingdom in 1975, many other studies were presented to support this theory that is now accepted worldwide. However, the vascular hyperplasia theory deserves reconsideration. According to the sliding anal lining theory, the hemorrhoids are regarded as normal structure that closes the anal canal. Therefore, the treatment of hemorrhoids should not simply remove or destroy the hemorrhoid structure but rather focus on relieving the symptoms that patients claim.
Only 30 years ago, hemorrhoids were assumed to be an abnormal structure caused by varicose vein. Also, after the sliding anal lining theory introduced by Thompson from United Kingdom in 1975, many other studies were presented to support this theory that is now accepted worldwide. However, the vascular hyperplasia theory deserves reconsideration. According to the sliding anal lining theory, the hemorrhoids are regarded as normal structure that closes the anal canal. Therefore, the treatment of hemorrhoids should not simply remove or destroy the hemorrhoid structure but rather focus on relieving the symptoms that patients claim.
The level of dissection in hemorrhoid surgery has been always controversial. While some would advocate 2 cm proximal to the dentate line, others advocate dissecting up to the dentate line level; historically, low ligation, high ligation, and other issues were also debatable. The level of dissection depends on the condition of each hemorrhoid, where dissecting level is sufficient as long as the hemorrhoid does not prolapse out of the anus.
5.1 Classification of Hemorrhoids
The hemorrhoid can be divided into internal, external, or mixed type based on the dentate line. The internal hemorrhoid is covered by the transitional epithelium (or the columnar epithelium), whereas the external hemorrhoid is covered by the squamous epithelium. A skin tag can be a result of a thrombosed hemorrhoid, or it can be a complication of an inflammatory bowel disease that has nothing to do with hemorrhoids. More than 80 % of hemorrhoids are internal, approximately 5 % are purely external, and the rest are mixed.
Internal hemorrhoids can be divided from first to fourth degree depending on the severity of their prolapse (Fig. 5.1):
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First degree: The state of venous engorgement during bowel movement that does not protrude out of the anus but may bleed sometimes.
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Second degree: The hemorrhoid that prolapses out of the anus during bowel movement but goes back inside spontaneously into the anal canal after defecation.
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Third degree: The prolapsed hemorrhoid which is reducible into the anal canal by manual reduction:
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Third degree hemorrhoids can be divided into third degree A and third degree B.
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Third degree A: Hemorrhoid prolapses on defecation only and is reduced with manual reduction.
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Third degree B: Prolapse of the hemorrhoid occurs not only during bowel movement but also on usual time, which must be pushed back in manually.
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Fourth degree: The hemorrhoid protrudes from the anal canal all the time and is irreducible.
The pitfalls of this classification is that the third degree of hemorrhoid is sometimes more harder than that of the fourth degree to operate, and some scholars say that this is not a helpful classification for surgery. Therefore, I suggest that it should be reclassified according to the length of the prolapse measured after anesthesia during surgery. Hemorrhoids with mucosal prolapse are also thought to be the stage prior to rectal prolapse. Hemorrhoid and rectal prolapse are not two different diseases; the hemorrhoid seems to be a prolapse where Treitz’s ligament is destroyed, whereas the rectal prolapse seems to be caused by the weakness of the pelvic floor.
Since it is hard to classify the hemorrhoids after checking the length of prolapse at office, there is no choice but to use the Goligher classification.
The Goligher classification only considers the status of prolapse, omitting symptoms such as anal discomfort, incontinence, or the skin conditions. Other method of classification according to the anatomical standardization is suggested. A hemorrhoid can be classified into a primary hemorrhoid (a hemorrhoid that occurs at the anal cushion), a secondary hemorrhoid (a hemorrhoid that occurs between the anal cushions), and a circumferential hemorrhoid. The degree of prolapse can also be classified into “no prolapse, prolapse distal to the dentate line on rest, distal to the dentate line on straining, prolapse visible at the anal verge on rest, and visible at the anal verge on straining.” The condition of the anal verge (skin tag, congestion of external hemorrhoid, etc.), anal pressure, and severity of the perineal descent also needs to be described (Table 5.1).
Graham Stewart divided hemorrhoids into vascular and mucosal forms. Vascular hemorrhoids occur frequently among young and muscular people. Even without straining, engorgement in the anal cushion can be easily formed. In inspection, a large lump of hemorrhoid can be found and even minor trauma can cause bleeding. However, it rarely protrudes out of the anus. Mucosal hemorrhoids are found more often in women than men and occur more frequently among older and thinner person. The main symptom is the prolapse of the hemorrhoid, composed of vascular cushion and stretched rectal mucosa. Sometimes, these two kinds of hemorrhoids are said to appear in mixed type, regardless of sex or age.
5.1.1 An Attempt of New Classification
5.1.1.1 PEC Classification
Masuda et al. from Masuda Hospital in Japan presented the PEC classification at the Japanese coloproctology congress in 2005.
According to the degree of prolapse of the internal hemorrhoid:
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P0: No prolapse
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P1: Reducible prolapse
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P2: Irreducible prolapse
According to the condition of the external hemorrhoids:
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E0: No external hemorrhoid
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E1: Less than half circle of the anus
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E2: More than half circle of the anus
According to the involved anal circumference:
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C0: Individual hemorrhoids are independent.
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C1: Individual hemorrhoids are connected partly.
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C2: The hemorrhoids are connected to each other to the full circumference of the anus.
(Journal of Japan Coloproctology. 2008 p. 666; 2005 p. 491)
For example, it is categorized as P1E1C2 if a hemorrhoid presents reducible prolapse, the external hemorrhoid involves less than 50 % of the anus, and the hemorrhoids are connected to each other to the full anal circumference. This would be useful in deciding operative method and comparing objectively pre- and postoperative results.
Jung Moo Lee et al. of Hanlim University divided hemorrhoids into island form and sliding form. In the island form, internal hemorrhoids are separated from external ones with dentate line as a landmark with the pectin existing normally, and this form is prevalent in the young age group. The sliding form, so-called mixed hemorrhoid, appears mostly in the middle-aged group, in which the dentate line is shifted outside the anus with frequent rectal mucosal prolapse. He proposed operative method for internal and external hemorrhoids separately in the former type and suture-ligation method for the internal hemorrhoid only in the latter type (Fig. 5.2).
5.2 Indications of Hemorrhoid Surgery
5.2.1 Bleeding Hemorrhoids
Bleeding is one of the most common symptoms of hemorrhoids. Bleeding had been described in the Chap. 4.
Although most bleeding is due to anal diseases such as hemorrhoids or fissures, it is sometimes caused by colorectal cancer, ulcerative colitis, polyps, or other diseases, so colon or upper gastrointestinal tract examination is mandatory prior to the treatment. A digital rectal examination should be performed in all cases, and it is also recommended to conduct a colonoscopy or barium enema. Sigmoidoscopy must be performed at least.
For female patients, menstruation, pregnancy, and delivery worsen hemorrhoids and are especially related with bleeding. Hormones (mostly estrogen) and the mechanical factor worsen the bleeding, namely, (1) decreased coagulability, (2) weakening of the anal sphincter pressure, (3) increased pelvic blood flow, (4) descent of pelvic diaphragm by the pregnant uterus, and (5) tendency of constipation—straining during defecation, complicated environment during pregnancy and birth, dietary problem, and lack of exercise are special factors for constipation. The hard stool passing by and straining can increase the tendency of bleeding. Because the pregnancy and delivery induces or aggravates hemorrhoids, it is not advisable to recommend surgery for those who are pregnant or planning to have pregnancy soon.
Bleeding hemorrhoids without prolapse, first degree hemorrhoids, can be sufficiently treated with a conservative treatment. A sclerosing agent injection or IRC can also be used. For prolapsed hemorrhoids with bleeding, the bleeding would subside spontaneously after the treatment of prolapse. The second degree internal hemorrhoids can be treated using RBL or sclerosing agent injection, and third-, fourth degree hemorrhoids are best treated with surgery.
5.2.2 Prolapsed Hemorrhoids
Prolapse with no symptom does not need treatment. However, if patients are troubled with symptoms such as combined bleeding or manual reduction on defecation of hemorrhoids, it needs to be treated. Second degree hemorrhoids are also recommended to treat with RBL or a sclerosing agent injection. If the third degree is not so severe, RBL or sclerosing agent injection can also be applied, but severe third degree or fourth degree hemorrhoids must be dealt with surgery.
For incarcerated and strangulated hemorrhoids, there are two methods of treatment: an emergency surgery and a scheduled surgery after conservative treatment. If the patient’s condition permits, it is advisable to perform an emergency surgery even if the mucosa is weak, friable, and easy to bleed. Hemorrhoidectomy is needed on the following conditions, regardless of prolapse:
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1.
Hemorrhoid with large skin tag
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Hemorrhoids with combined anal disease such as fissure or anal fistula
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3.
Large thrombosed hemorrhoid
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When rubber band ligation or sclerotherapy has already failed
5.2.3 Pain
The internal hemorrhoids show no pain. But the incarcerated hemorrhoids or thrombotic hemorrhoids cause pain and should be treated. The small thrombotic external hemorrhoid is treated conservatively. However, if it covers more than 40 % of the anal circumference, surgery is better. Also, as the hemorrhoid combined with fissure causes pain, surgery is recommended. But the pain from the levator ani syndrome needs to be treated conservatively.
5.2.4 Fecal Incontinence
Fecal incontinence and sphincter muscle tone must be checked before operation. If the incontinence is derived from sphincter abnormality, it would be aggravated after hemorrhoidectomy.
5.2.5 Mucus Discharge, Pruritus Ani
With inappropriate condition such as prolapsed hemorrhoids, the patients are unavoidably destined to suffer from mucous discharge from the anal mucosa. The skin around the anus complains itching sensation from persistent irritation due to the discharge. Even though the prolapsed hemorrhoid pile doesn’t show any symptoms, the severe pruritus ani with or without mucous discharge can be the indication for operation.
References
Goligher JC, Duthie HL, Nixon HH. Surgery of the anus, rectum and colon. 5th ed. London: Balliere Tindall; 1984. p. PP98.
Graham-Stewart CW. Injection treatment of haemorrhoids. BMJ. 1962;i:213–16.
Morgado PJ. Histochemical basis for a new classification of hemorrhoidal disease. Dis Colon Rectum. 1988;31:474–80.
Buckshee K, Takker D, Aggarwal N. Micronized flavonoid therapy in internal hemorrhoids of pregnancy. Int J Gynecol Obstet. 1997;57:145–51.
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Yang, H.K. (2014). Indications for the Treatment of Hemorrhoids. In: Hemorrhoids. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-41798-6_5
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