colorectal surgery — Dr Goh Hak Su Modern Treatment of Piles Depending on the type of piles, doctors will be able to recommend the best procedure to cure this ailment. to normal size and fixed in their normal positions. Because the cutting is on the insensitive or painless part of the rectum, the operation does not produce the sharp pain as experienced in the conventional operation. But staple haemorrhoidopexy does not take care of external skin tags or fibro-epithelial polyps. Those are trimmed and carefully stitched as in cosmetic surgery, but is usually not so painful. Piles or haemorrhoids are very common – probably 50% of adults in Singapore would have experienced symptoms of piles. This is because everyone has piles tissues (known as anal cushions), even babies, and if the tissues are removed completely, we would not be able to control leakage of gas or faeces from the anus. When they become enlarged and displaced, they become piles or haemorrhoids. When internal piles are left untreated, they can grow in size and prolapse (protrude outside), and develop secondary features like external piles, skin tags and hard scar tissues (called fibroepithelial polyps). The principle of treatment is to restore piles tissues to normal size and position, to remove the secondary features when present and to prevent recurrence. Since not all piles are the same, therefore no single procedure can suit all patients. It is important to select the most suitable treatment option for each patient. Before embarking on piles treatment, it is vital to make sure the diagnosis is correct and to accurately assess their severity. Some patients have small asymptomatic internal piles but they suddenly cause fresh bleeding because of constipation or diarrhoea, often after trips overseas. The correct management is to treat the constipation or diarrhoea. Elderly patients often attribute rectal bleeding to piles, when the cause may be due to rectal cancer. Two conditions which are often misdiagnosed as piles are blood clot (perianal haematoma) and anal tear (fissure-in-ano). The former presents with a painful lump at the edge of the anus and the latter, painful defecation with fresh bleeding. The treatments for these two conditions are entirely different. Specific treatment of piles depends on their severity as well as the secondary features. Early piles do not need surgery; they are managed by a combination of medications, injection with a schlerosing solution to shrink the piles, or rubber band ligation to trim the internal piles. Only large piles or troublesome external piles, skin tags or fibro-epithelial polyps, require surgery. The classic conventional operation, called open haemorrhoidectomy, was first described in 1937. Although it is effective, it is a very painful procedure. Staple haemorrhoidopexy was introduced by Dr Longo in 1998. It utilises a specially designed circular stapler, which cuts a ring of insensitive or painless part of the rectum above the piles. The piles are then pulled up and stapled in their normal positions. At the same time, the feeding arteries are cut and stapled. The piles tissue would then shrink THD (Transanal Haemorrhoidal Dearteriali sation) is the newest procedure. Introduced in 2005, it is based on the accurate ligation (or tying) of the blood vessels supplying the piles by using an ultrasound (Doppler or sonar) to detect the pulsating arteries. It has a specially designed anal dilator (proctoscope), sutures and needle-holder. Like the staple operation, it interrupts the blood supply to the piles, causing them to shrink to normal size. However, it does not cut any tissue. It is therefore less invasive and should be less painful. But because it does not cut any tissue, it is not very effective for big piles with significant prolapse. It is vitally important that early piles (Grade I or Grade II) should not be offered expensive and invasive operations (THD, stapled or conventional surgery) without first trying the less invasive methods like injection schlerotherapy or rubber-band ligation. This is not just a matter of cost (the difference to the patient could be 20 fold);it is also a matter of more serious and severe complications with more invasive procedures. But most important of all, it is a matter of sound medical practice and professional integrity and ethics. Dr Goh Hak Su Colorectal Surgeon MBBS, FRCS, FAMS Goh Hak-Su Colon & Rectal Centre 6 Napier Road #04-08 Gleneagles Medical Centre Tel: 6473 0408 www.gohhaksu.sg p. 57