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Haemorrhoids: Newer concepts in the treatment!

Is it curable?

No. 1

Pile is gift of erect position, not for patients but surgeons. It is most common condition in proctology, particularly in industrial and computer workers. Usually middle age group use to suffer most but now Information Technology younger workers are most common sufferer.

No. 2

Haemorrhoids are developed in rectal venous plexus but it is confirmed histologically that the plexus is formed by cavernous venous, arterial, capillary net work of sinusides, arteriovenous shunts surrounded by connective tissue in the submucosal layer. The cavernous tissue is similar like penile tissue. The cavernous tissue is anchored by fibers of Treitz muscle to the internal sphincter.(Treitz, 1853, Parks 1956,Thomson, 1975; Mosley et.al. 1980)

No.3

Classically blood supply of the anal canal and rectum is by, 3 arteries, Superior Rectal artery,  branch of  inferior mesenteric artery; Middle Rectal artery,  branch of  internal iliac artery;  Inferior Rectal artery,  branch of internal pudendal artery.

Internal haemorrhoidal plexus receives  blood supply exclusively from  terminal branches of  superior rectal artery spread over entire cylender of the recum and upper part of the anal canal.

No.4

Haemorrhoidal plexus is large vascular spaces. Artero-venous shunts: called “Corpus Cavernosum Recti (CCR”) an atero-venous cavernous network. (Selzner et al. 1962; Staubesand et al. 1963; Thulesius et al 1973). Superior Rectal Artery exclusively contributes to CCR and it is a functional blood supply that fills this cavernous network. (Widmer 1955; Thomson 1975; Patricio et al 1988; Sun et al.1992; Shafik 1996; Aigner et al 2004)

Arteriovenous anatomises in the submucosa of the rectum  contribute to increase in volume of the anal cushions which assists in sealing the anal canal and anal cushions contribute  15 –20% of the resting anal pressure. It acts as wiser in tap to prevent dribbling. Piles plug to ensure complete closure of anal canal cushions achieves water / air tight continence. (Stieve 1928; Widmer 1955, Selzner 1962; Thomson 1975; Gibbons et al. 1986; Lestar et al. 1989; Selzner  1992 ). Haemorrhoids begins, from  dilatation within the cavernous bodies of  anal cushions, by multi-factorial mechanisms  such as:

  • Defects in regulation of artero-venous shunts
  • Increased arterial  blood flow
  • Blocked venous drainage

The anal cushions are three in number, found in relation to respective end arteries of superior rectal artery at 3, 7 and 11 clock in the lithotomy position. According to Thomas, these cushions take part in anal continence. The main part of the cushion lies, just above the dentate line which is covered by insensitive mucosa. On cross section between the cushions and internal sphincter muscles is sub mucosal layer, which consists of veins, arteries, muscular and connective fiber tissue. Piles cushion is composed of plexus of veins and arterial vessels and their multiple anastomosis and is full of elastic collagen fibrous tissue, lined by simple cylindrical epithelium some times in multiple layers without any keratinization. They are located between the lamina muscularis mucosa and internal sphincter muscle structure. The piles mass is supported by fibro elastic collagen tissue and the muscular structure of Treitz (muscularis canalis ani). It is divided by the dentate line into two parts superior and inferior muscularis canalis ani. [5] The pile mass is compressible which has significant role in air / water tight continence mechanism of internal sphincter. The venous plexus is called as “corpus cavernosum of recti” [2]. Etio-pathology of hemorrhoid is essential part of treatment which is divided in two parts, one is mechanical and other is dysfunctional part of vascular shunts theory.

The vascular supply of the anal cushions and their anatomical study has suggested in many original theories of hemorrhoid etiology. The pressure in plexus of these cushions is increased due to obstructive pathology like pregnancy or large ovarian cysts. The increase in pressure also occur due to a variety of activities, such as straining during bowel movements, lifting heavy objects, sitting for extensive periods, obesity and severe coughing. The similar condition prevails when persistent straining during defecation in a constipated patient. During straining, relaxation of the anal sphincters is but natural and simultaneously veins which are without valves are engorged. The anal veins drain blood away from the anal canal and the hemorrhoids. These veins drain in two directions. The first direction is upwards into the portal veins of the rectum, and the second is downwards to systemic veins beneath the skin surrounding the anus. The dentate line is a line in the anal canal that denotes the transition from anal skin (ano derm) to the lining of the rectum. The veins exit through the seromuscular wall of the rectum and drain into the portal venous tributaries. These portal veins are trapped and blocked in the seromuscular wall during strong contraction of muscle wall of the rectum, straining while defecation and at the same time arterial blood supply is continued; which keeps on engorging the venous plexus progressively in the lumen of the anus. The vascular concept of engorged cushion and increasing vascularity during straining; explains the increase in tension and size of hemorrhoids. [6]

Dysfunction of arteriovenous shunts is also responsible for engorgement of hemorrhoids. For capillary blood exchange, normally arterio-venous shunts are closed. Due to specific irritation, shunts are open and perfusion drops and pre capillary sphincter undergoes spasm which increases flow through the shunts. The rectal bleeding is the main symptom of the internal haemorrhoids. The blood is characteristically bright red. It has been suggested that the internal hemorrhoid plexus is like corpus cavernosum with direct arterio-venous communications. [7] The blood is filtered without metabolic role and therefore it remains arterial, which is bright red in appearance and it has pH of arterial blood. The bleeding from Porto-systemic anastomosis is venous blood, dark black red in colour and it has pH of venous blood. [8] Vascular theory explains the concept of why piles mass increases in size.

The microscopic examination revealed connective tissue fibres of submucosa is main factor, which anchors the piles cushion to the internal sphincter and longitudinal muscles. The mechanical theory explains why piles mass prolapse down. The muscular-fibroelastic supporting tissue of the piles cushion (Parks ligament) is degenerated due to old age or loose elasticity due to constant stretching during straining while defecating. It is possible that the large piles mass slide down due to stool bulk. The supportive action of these musculo-collagen fibres is compromised and piles cushion slides down due to increased intra-rectal pressure, relaxation of sphincters and straining in a constipated patients or long sitting on commode.[9] As prolapse of these piles mass protrude out of anal canal the mucosal covering becomes fragile which bleeds easily. The sliding of the hemorrhoid is may be due to familial disorder of collagen structure of connective tissue in the submucosal layer of the rectal wall. The fixation of these loose prolapsing cushions of anal canal has been understood to be the main principle of newer modalities of treatment of hemorrhoids.

No. 5

Etiology can be described in different factors.

  1. Genetic association of haemorrhoids, hernia and genitourinary prolapse or varicose vein indicates deficiency in connective tissue formation. (Selzner 1962, Burkitt 1975; Loder et all 1944)
  2. Environmental

CONSTIPATION STRAINING (Stern 1964; Burkitt 1974; Hyams 1970; Thomson 1975, Haas et al. 1984) In the country like India, diet is ideal, water intake adequate and additional spicy food should cause no constipation and abnormal straining during defaecation. The culture in India is to clear the bowel before taking every day bath and going for routines. In younger age due to lot of exercise and good appetite food intake is more than sufficient. As age increases food intake is reduced so as stool formation is reduced. Rectum does not get similar filling sensation as earlier age. But as per habit everybody wants that bowel should move in the morning & strains. Prescribing fiber diet or supplement looks funny.

  1. Low-fiber diet
  2. Obesity
  3. Sedentary lifestyle

DETERIORATION OF CONNECTIVE SUPPORTIVE TISSUE (Gass-Adams 1955, Thomson 1975, Haas et al. 1980.Loder et al.1994) As per age deterioration of connective tissue supporting plexuses of haemorrhoid occur and haemorrhoid  mass prolapse.

  1. Pregnancy

9. Associated disease

The fundamentals of haemorrhoids treatments require to qualify following points.

  1. Mass of Haemorrhoids should be reduced
  2. Prolapse of haemorrhoids are mandatory to be fixed to internal sphincter muscles to its original position.
  3. Recurrence should be avoided by stopping accessory haemorrhoids

We should review the standard procedures how they qualify for ideal treatment

Milligan & Morgan

The gold standard procedure for haehrroids is Milligan & Morgan and its modifications.

In principle removal of piles mass & ligation of pedicle, allow wound to heal by secondary intentions. The recurrence rate is around 18 to 20% gives impression to patients that piles are not curable they recurred even after removal. The flow of patients tried to find cure by other ways.

Fundamental Errors in MILLIGAN &  MORGAN procedure

Piles cushions control 20% of continence it is likely in some cases impairment of anal sphincter function can occur. As open wound heals heal by secondary intention stenosis of anal canal is likely. The Secondary piles are common and recurrence in 18 – 20% cases occur. The procedure is not recommended for circumferential piles. As wound in sensitive mucosa Is kept open are very painful and requires long time for healing. External piles do not require treatment is now evident in stapler we do not treat external haemorrhoids.  Only in 1- 10% cases may be required as they settle as soon internal haemorrhoids are treated. As such there is nothing called pedicle in the haemorrhoids as blood supply is through circular plexus.

Before surgery pant has  come down as prolapse piles

After surgery piles are excise and pant is shortened.

 

Stapler mucopexy

A Strip of sensitive mucosa of the rectum is removed from 5-6 Cm. from dentate line. The lower margin depends on the edema of tissue and grade of hamorrhoids. In case of edema and large mass excision of tissue depends on the size of casein of the stapler. The control over lower margin is not as good as upper one.

The strip of sensitive mucosa which recognizes fluid, solid or liquid stool is removed. The size of the rectum is reduced to one half of the diameter to 3.5Cm and causes hour glass deformity. It results in  tenusmus, frequency and urgency.

The mucosa is anastosed by using stapler which is weakest part of the rectal layers. The dehiscence of wounds are common, causes post operative bleeding episodes. In the stapler procedure no blood vessels or mucosal plexus are ligated. In the procedure the mucosa or piles mass is not fixed to the int. sphincter that results in prolapse of heamorrhoids. The rate of complications like operative .post operative bleeding, more frequent incidences of reoperation and mortality is commoner than any other methods. The recurrence rate is nearly 20% and cost of disposable instrument is exuberant which causes loss of to the country

 

Planning of stapler                     excision of rectal mucosa                     Blood plexus still persist

 

Doppler Guided Haemorrhoid artery Ligation

In DGHL special instruments and proctoscope with Doppler trancducer is essential. It searches the arterial blood flow and figure of eight stitch is used to ligate the artery. The depth of every artery is not same and difficult to find out. Usually 1, 3, 5, 7, 9, 11 o’ clock position six branches are ligated blindly. There may be more branches than the found. There is no provision to control secondary haemorrhoids. The success rate varies from 85 to 45 % in second and third and fourth degree haemorrhoids. The cost of instrument is exuberant and still recurring cost with every case.

 

Prolapsed piles                               Fixed only at few places

Problems in treatment,

In none of the procedure the criteria to treat the haemorrhoids are full filled. In Miligan Morgan only mass is removed. In stapler mucosa is just pulled up. In DGHL circular haemorrhoid plexus is ligated at few spots. In the haemorrhoids treatment planned is according to the grades of them which seem to be inadequate.  No procedure cures mass. prolapse and recurrence of piles.

Fundamentally mass of haemorrhoid is to be reduced, the mucosa should be fixed to internal sphincter and provision should be made to avoid secondary haemorrhids.

How to control recurrence/ secondary haemorrhoids?

The haemorrhoid plexus is formed from end arteries of superior rectal artery. The ligation of end artery usually should cause ischaemia and gangrene of the part supplied by the artery. Nature do not allow any part to die. It develops collateral circulation. If these end artery is ligated at two places at distance of 2 Cm. or more the development of the collateral is unlikely. This principle is useful to control the recurrence of haemorrhoids.

 

If the end artery is ligated at one place collateral can develop.

The end artery ligation at two places avoids collateral formation

 

PRINCIPLES of new procedure invented by Dr. Chivate

l  Reduction of mass by

Head Low position & Massage of piles mass by fingers & Sims speculum.

l  A stitch of 5 Mm. to 10 Mm. lengths through mucosa submucosa and partial thickness of muscle of internal sphincter.

l  Ligation of plexus of blood vessels all around the rectal circumference at two levels, 2Cm & 5 Cm. above dentate line, in pain free area.

Method

Under the saddle block / spinal anesthesia, patient was positioned in lithotomy with steep head low position, which helped in reducing piles mass in grade II, III and IV cases and lax mucosal and submucosal tissue was replaced upward at its original position. The closed lateral internal sphincterotomy was done to avoid mechanical dilatation of the anus by proctoscope in the cases where tight sphincter was present. In case of lax sphincter there was no need for sphincterotomy. The anal canal was lubricated generously with lot of anesthetic jelly and massaged. The Sim’s speculum was used to compress and push the piles masses upwards. Eventually lax mucosal and submucosal layer containing vessels were replaced up. A self illuminated slit with sliding valve ano-proctosope was used. [Fig no1] The proctoscope with 3.6cms. inner diameter helped in retracting rectum from all the sides and haemorrhoid masses too. The sliding plate was removed. The dentate line and engorged mucosa was visualized and stretched due to the proctoscope. The replaced lax mucosa and submucosa was fixed to the deeper muscles of the rectum by the stitches of 0.5 to 1 cm. length. The stitch was passed through the depth of the mucusa-submucosa and part of muscle, starting at 3’ o clock position at 4cms. distance proximal to the dentate line. For the stitch a 2/0 polyglactin on atraumatic 30mm. ½ circle needle was used. The precaution was taken that stitch was not passed through the rectal wall but only part of the rectal muscles was taken. The first stitch was tied and the next stitch was started 1-2 mm. overlapping to the end of first stitch which was double locked.  The double locking was continued for every stitch to avoid purse string effect. The suturing was continued all along the complete circumference of the rectum at the same level. The second circumferential suture line was completed at 2cms. level proximal to the dentate line. Minor oozing occurred with few stitches which stopped automatically. In the surgery no incision or cutting was required anywhere in the anal mucosa or in the perianal region. Both the suture lines were above dentate line which caused no pain in the post operative period. This simple procedure was used in II, III and IV grades of the piles.

In short, in the procedure only two circumferential suturing lines were implemented; at 2 and 4 cms. proximal to the dentate line in the rectal wall.

Thrombosed prolapsed piles were excluded from the series. These thrombosed piles were treated after conservative treatment.

 

 

Proctoscope

The proctoscope is made up of a uniform metal tube of 3.6cms. inner and 3.7 cms. outer diameters along with fibro-optic connection. The tube is cut 1/8th of its diameter and sliding flap is prepared opposite to the fibro-optic connection. The leading end of the tube is conical and smooth which closes the tube, which facilitates the introduction of the proctoscope and prevents faecal matter to enter in the operation field. The slide can be adjusted at any length. The proctoscope has calibered of one centimeter marking all over the inner aspect of the tube. The scope retracts anus and rectum without excessive dilatation. It is good as operative scope. In other scopes the retraction is not controlled.

 

 

The changes at the site of stitch are first natural process of inflammation – Edema develops in between two suture lines in 3% of cases. No necrosis of the strip occurs as blood supply from muscular layer continues. In second stage fibrosis at the site of stitch occludes the haemorrhiod plexus and mucosa is fixed to the muscles of internal sphincter. The blockage of aterio venous blood flow the haemorrhoids of any size will reduce.

The strip of mucosa in between two suture lines is relatively less vascular strip. The development of collaterals is impossible which prevents recurrence and secondary haemorrhoids.

PATIENTS 498

SYMPTOM    GR. II        GR. III       GR.IV

l  BLEEDING      162           264            72

 

l  PROLAPSE     108           258            66

 

l  ITCHING          72             114            57

 

l  DISCHARGE   48              60             54

 

l  PAIN                33              60             48

RESULTS-- 5Yr.FOLLOWUP

l  BLEEDING               24 /498 Post Operative

l  PROLAPSE              9 /498   GRADE  I

l  PAIN                         MINIMUM

l  Mucosal Edema        20 / 498

l  STENOSIS               NIL

l  RECURRENCE        NIL

l  INCONTINENC      NIL

NECROSIS             NIL

Symptomatic Recurrence in 6 cases / 498

ADVANTAGES

Bleeding stops immediately.

No Wound –> Dressing -> Pain

Pts. discharged in 24 hours.

No costly instruments or disposables  necessary.

Cost Effective in India.

No post op. Rectal Stenosis or Secondary Haemorrage.

The procedure -> Can be used

post operative bleeding from open

haemorrhoidectomy

Prolapse Mucosa

Post stapler bleeding

DISCUSSION

The study is compared mainly with three types of the procedures, in respect to pain, safety, bleeding, hospital stay, recurrence, incontinence, other complications and cost. The open haemorrhoidectomy or conventional procedure is known as gold standard procedure. The recently established two painless procedures hit to new height in business world as stapled haemorroidopexy and Doppler guided haemorrhoid artery ligation as compared with new procedure.

In the new procedure simple suturing is required at 2 and 4cms. proximal to the dentate line. The each stitch  of 0.5 -1.0cm lengths which blend the mucosa, sub mucosa to the part of  muscles of the rectum. Each stitch is locked twice, overlapping 1-2mm. to each other. The stitches were implemented along the circumference of the rectum at the level of 2 and 4cms. above the dentate line. In the procedure the internal haemorrhoid plexus arterial and venous elements were obliterated completely at two levels. The bleeding from the hemorrhoids was stopped and the pile masses were reduced in 3 to 7 days.  The sutures are above the dentate line which gives nearly pain free post operative period and later on.

 

The most popular gold standard, “Milligan and Morgan” procedure was presented as an original paper on open haemorrhoidectomy; an excision of haemorrhoid and ligation of its pedicle, for haemorrhoids in 1937. [17] In the last 75 years many trials and numerous modifications of the procedure has been promoted. And more recently the use of different energy sources like, diathermy, [18] cryo, [19] laser, [20] ligature, [21] and harmonic scalpel was made to simplify the procedure, minimize pain and bleeding. [22] The procedure which is involved in excision of anoderm and perianal sensitive area is impossible to be pain free.  The method is very painful and required 3 -5 days hospitalization and analgesics & sedations. The patients are avoiding not only surgery but surgeons too.

 

The stapled haemorrhoidopexy developed, by Longo in the 1990s; 2-3cms. wide, circumferential strip of the sensitive rectal mucosa is excised and auto sutured with stapler. It reduces prolapse by a circular stapled mucosectomy 4cms. above the dentate line. [23, 24] This shortens and pulls the prolapsing mucosa above the dentate line and reduces the haemorrhoids but is also thought to disrupt the branches of the haemorrhoidal artery which feed the anal cushions. All the procedure is confined to the area above the dentate line, hence should give no pain. The reoperation rate after stapler hemorrhoidopexy was 11 percent and the most frequent indications for reintervention were persistent, severe anal pain (visual analogue pain score higher than 7). Early results of this technique were questioned with some series reporting complications of pain and urgency. [25]

 

In 1995, Morinaga reported a new technique for treatment of haemorrhoids by haemorrhoid artery ligation, in which specially designed proctoscope, coupled with Doppler transducer was used for location branches of the haemorrhoid arteries. The located arteries are ligated by figure 8 sutures. These arteries are sutured are at 1, 3, 5, 7, 9 and 11 o’clock positions; 4cms. above the dentate line which is pain free area. [14] The procedure (RAR) recto-ano repair for grade III and IV haemorrhoids is involved in plication of anal mucosa and thus cannot be pain free. [26]

In the past and now conventional open haemorrhoidectomy is considered to be safer than stapler haemorrhoidopexy. The incidence like severe sepsis, [27] perforation of the rectum, [28] retroperitoneal abscess [29] and severe bleeding [30] and requirement of anterior rectal resection and colostomy are rarely reported complications, which give injury to safety feeling of surgeons about the procedure. The D.G.H.L. and suture rectopexy for haemorrhoids are safe and had less chance for complications in the technique. In last 5 years and six months suture rectopexy is implemented in 498 cases, had no untoward incidences and is totally safe. In fact the new procedure can be used in primary or secondary bleeding from open haemorrhoidectomy or stapler haemorrhoidopexy. The suture haemorrhoidopexy had minor oozing from some stitches in 11% of cases which was controlled by compression. The mucosal tear was noted in early 3% cases required no treatment. Surgical complications consisted hemorrhage of the staple line (18.8%) and hemorrhage due to mucosal tear (5.9%) in stapler haemorrhoidopexy. In some cases perirectal, retroperitineal and mediastinal gas is reported after stapler haemorrhoidpexy. [31] The haemorrhage during operation is not comparable in the conventional haemohroidectomy.

The principle of open haemorrhoidectomy remains same in all modifications; to minimize loss of skin of the perineum and mucosa of the anal canal which bridges between the two excised haemorrhoids to prevent stricture. The wound is partially closed or kept open to heal with secondary intention. The intermediate mucosal bridge and its blood supply remains potential cause for the future recurrence of haemorrhoids. The pedicle ligation of haemorrhoid is done to occlude blood supply at the top of anal cushions. There nothing called pedicle for haemorrhoids, it is plexus all around rectum. The branches of the superior rectal arteries are ligated. Later on the smaller arterial branches of the ligated vessels start dilating and developing collaterals to join blood vessels of the intermediating tissue and are the potential cause of secondary haemmorrhoids. Milligan and Morgans haemorrhoidectomy and additional use of energy has not reduced rate of recurrence which remains about 18 -25%. [32]

In stapler haemorrhoidopexy, only mucosectomy and autosuturing is done. The blood vessels which originate in piles masses in submuscularis layer are just disrupted and it gives similar predormant situation in which piles masses had develop before. If the causative factors like constipation, straining and long sitting for stool continues, the recurrence cannot be avoided. The fibrous tissue in submucosa remains same having defective lax collagen structure, remains unfixed to the deeper muscle layer. The overall incidence of recurrent hemorrhoidal symptoms as early as fewer than 6 months remain in stapler vs. conventional: 24.8 vs. 31.7 percent; or as late as 1 year or more recurrence rate of stapler vs. conventional: 25.3 vs. 18.7 percent. [33]

Doppler guided hemorrhoidal artery ligation procedure is safe, easy to perform, and should be considered as an alternative for the treatment of symptomatic hemorrhoids, it has recurrence rate of 12 percent in 12.5 months follow up. The ideal indication for these methods is non prolapsing hemorrhoids. In III and IV degree haemorrhoids the recurrence rate was reported between 12-40 % during first year. Scheyer et al. [14], Greenberg R, [16]

The suture rectopexy for haemorrhoid had only 2 years and six months of follow up which reported 3 cases of piles cushions bulging in to the anal canal without bleeding. In fact there is no recurrence of symptomatic haemorrhoid reported so far. In the suture rectopexy replaced mucosa submucosa is fixed to the deeper muscular layers of the rectum which prevents prolapse of the piles cushion downwards. In between sub mucosa and muscle layer of the rectum internal plexus and their arterial and venous elements are obliterated which shrinks the piles and the recurrence rate is less.

The factors affecting flow of the blood depending on, flow through the collateral circulation is heightened by increasing the pressure gradient across the site of occlusion of the haemorrhoid arteries. The superior rectal artery and its branches at level of the plexus are numerous which enhances in development of collaterals in short period. There is free arteriovenous communication through capillary circulation in the corpora cavernosa of the rectum which is probable cause for recurrence in stapler haemorrhoidpexy or Doppler guided haemorrhoid artery ligation.  If a long segment of an artery is occluded, important side branches arising within the area of occlusion are not available for the collateral circulation. The branches proximal and distal to occlusion are not able to join each other. In the procedure suture rectopexy, the vessels are blocked at two places at the distance of two centimeters which offer less chances of development of the collaterals and recurrences. All vessels are ligated at two levels which stops filling of sub mucosal veins and arteries.  In stapler and DGHL the ligation of the blood vessels is at one point which enhance recurrence of the haemorrhoids.

The blood supply from seromuscular layer is unabated which avoids the necrosis of the area of less vessel area. In last 2 years follow-up, no case of partial or complete necrotic patch was revealed. In stapled haemorrhoidpexy had post operative complaints which included symptoms of hemorrhoidal prolapse 24 %, anal bleeding 20%, anal pain 25 % and local discomfort 38 %.  A remarkable incidence of failures after stapled anopexy for hemorrhoids has been recently reported by several papers with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. [34]The significant factor which avoids recurrence is two level circumferential suture lines and fixation of mucosa to muscular layer in suture rectopexy. In stapled haemorrhoidopexy recurrence of the haemorrhoidal disease occurred in 18-24% and the overall reintervention rate was 42.8%, patients required decisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage. Stapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of III and IV degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term follow up. In another series, in few months after operation, 1-2% of recurrence of symptoms like bleeding was noted and later on after years recurrence accounts to 20-30% of stapled haemmorrhoidopexy. Certainly it is true that there is no pain in stapled haemorrhoidopexy procedure but no gain too. [35]

In stapler MIPH, purse string suture is at 4-6cms. distal to the dentate line, the stapler causing slides and pulls lower tissue without control as much as the capacity of casing. The ideal stapled line should not be more than at 4 centimeters highest or lesser than 2 centimeters from the dentate line. The staple line is unpredictable and 4cms. mucosa of the rectum adjacent to dentate line is removed.[36 ] The incontinence can be a result of multiple factors like; excision of the sensitive lower 2- 4 centimeters of the rectal mucosa which tests samples from the rectal content for flatus faeces or fluid. The capacity of the rectum is reduced and it is divided as hour glass. These are the factors which cause incontinence, tenusmus and frequency of stool. [37] In suture haemorrhoidopexy suture lines are two centimeters and four centimeters proximal to the dentate line. There is no disturbance of internal sphincter muscle or no excision of sensitive lower rectal mucous membrane and no change in the continence.

In the conventional haemorrhoidectomy piles cushions are removed and stapled haemrrhoidopexy the sensitive rectal mucosa is removed which impairs continence in both. In mega series fecal soiling/leakage 31%, fecal urgency 40% was observed in the stapled hamorrhoidopexy. [38] In suture rectopexy no mucosa is excised, the mucosa of two centimeters breadth was fixed to the deeper muscular layer of the rectum. There was no change in bowel habit or any incontinence  reported. Same thing is true in cases of the haemorrhoid artery ligation.

Reoperation was required in 7.6 % patients; for complications within 30 days which occurred in 6.4% patients for the following reasons bleeding in 2.2%, dehiscence in 0.6%, thrombosed external hemorrhoid in 0.5%, fecal retention in 0.4%, in fistula 0.3% and in fissure 0.3%. [39, 40]

In another series of a total of 232 primary stapled hemorrhoidopexies and 65 reinterventions after stapled hemorrhoidopexy were performed by the authors in five centres devoted to colorectal surgery, for severe postoperative bleeding in 20 to 31 %, anal fissure in 21 %, prolapsing piles in18 %, rectal polyp in 16 %, anorectal sepsis in 16%. Thirteen different types of reintervention were needed. Excisional hemorrhoidectomy, removal of staples, and fissurectomy and/or internal sphincterotomy were the most frequent operation (n = 41). Bleeding requiring treatment occurred in 10%, anal stricture requiring dilation occurred in 5%, and fecal incontinence in 5 %. [41]

In one more series in which stapled haemorrhoidopexy and Milligan & Morgan hamorrhoidectomy were compared; there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. Postoperative complaints included symptoms of hemorrhoidal prolapsed in 24% cases, anal bleeding in 20%, anal pain in 25%, fecal soiling/leakage in 31%, fecal urgency in 40% and local discomfort in 38% cases. Nine patients (5 %) were reoperated on, during the follow-up period. Recurrent hemorrhoids were treated by ligation in 40% cases and by Milligan-Morgan procedure in 32% cases. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. [42]

Special Doppler probes are incorporated in special proctoscope to identify branches of the superior haemorrhoidal artery and they are ligated and fixed by transmucosal figure of eight stitch. Once main branches of haemorrhoid arteries are ligated, the minor arteries develop in to larger vessels and collaterals develop with anal and accessory vessels. In haemorroid artery ligation has a specificity of procedure which has deficiency in principle to cure. Recurrence rate remains very high. The prolapsed part of mucosa and haemorrhoids are very difficult to control as there is no fixation of mucosa and deeper layer in haemorrhoid artery ligation.  The procedure is very simple and less of complications are noted, still long follow up is necessary. [43]

The significant observation made was in relation to the delayed secondary haemorrhage.  When in the procedure of HAL ligated only three arteries, and then later, either four or five arteries.  This series had eight cases of severe delayed haemorrhage. In all of these cases, either four or five arteries were ligated there has not been any major secondary haemorrhage in those patients where the full six arterial ligation had been performed. The ligation of lesser number of arteries increases pressure in unidentified and not ligated branches of the superior haemorrhoid artery. There are numerous minor branches which may not be identified by the ultra sound. [44] The HAL is potentially good method to treat the non prolapsing piles, which controls bleeding but not prolapse. There are stitch free locations not detected by Doppler which requires serious attention. The area in between 1, 2, 3, 5, 7, 9 and 11 ‘ O clock position are free to develop significantly, fast collaterals and recurrences. In the suture rectopexy the deficiency is corrected by continuous stitches with double locking along the complete circumference of the rectum and recurrences are prevented by two circumferential suture lines at the distance of two centimeters.

CONCLUSION:- Trans anal suture rectopexy for haemorrhoid is very simple procedure, learning curve is minimal, has uniform & successful outcome in all grades of piles,  different hospitals and similar results by five different surgeons. Other procedures are simple without pain but cost is exuberant and recurrence is around 20%. The evidence was collected from Meta analysis longitudinal prospective study, which is considered as evidence level one and the degree of the recommendation A. The new procedure had proved cure, still requires long follow up to consider it as a cure for the haemorrhoids in future.

REFERENCES

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