Modern TreaTMenT of Piles

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
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