Haemorrhoid Treatment

Treatment of Haemorrhoids

Non-Operative Treatment

High fibre diet
Fibre supplement such as Metamucil, Benefibre, Normacol or Fybogel
Must not ignore the urge to open bowel.

Minor Operative Procedures

Rubber Band Ligation

This consists of putting rubber bands over the haemorrhoids to cut off their blood supply. This leads to the shrinkage of the haemorrhoids and they drop off the bowel wall usually in 7-10 days. Maximum 3 haemorrhoids ligated at any one time. This method is effective for small haemorrhoids.

Risks:

  • Less than 1% of significant bleeding
  • Usually dull ache for 24-48 hours
  • Severe pain is uncommon
  • Severe infection is rare

Sclerotherapy

  • Injecting 5% Phenol in Almond Oil into haemorrhoids
  • Good for small haemorrhoids
  • It has been shown to be less effective than rubber band ligation in some studies

Operative Procedures

  1. Open Haemorrhoidectomy (conventional)
    • Necessary for large or complicated haemorrhoids
    • This procedure is performed under general anaesthetic in a hospital or Day Surgery Centre
    • It involves the cutting out of the haemorrhoids. A maximum of 3 haemorrhoids can be removed at any one time with careful preservation of the mucosal bridges (to prevent anal narrowing) and the identification and preservation of internal anal sphincters (to prevent faecal incontinence).
    • Disadvantages:
      Main disadvantage is significant anal pain for at least 2 weeks despite laxatives, analgesia, oral Metronidazole and warm bath. It occasionally needs to be performed in 2 stages if the haemorrhoids are large and circumferential
    • Risks: <5% risk of bleeding requiring hospitalization or intervention, delayed wound healing acting like an anal fissure, faecal incontinence (uncommon) and rare anal narrowing
  2. Ligasure Haemorrhoidectomy
    • Similar to open haemorrhoidectomy in that the haemorrhoid is excised. However, the excision is carried out using Ligasure Small Jaw rather than standard diathermy. This instrument reduces postoperative pain and operating time.
    • It is suitable for patients who have large internal haemorrhoids, large external haemorrhoids and/or large skin tags (4th degree haemorrhoids)
  3. Stapled Haemorrhoidectomy
    What is stapled haemorrhoidectomy?
    An operation designed by Dr Antonio Longo in the late 1990s. This operation involves the use of a stapled gun inserted through the anus to cut the internal hemorrhoids out. There is no external wound.
    What are the disadvantages?
    It removes internal haemorrhoids very well but it does not remove the external haemorrhoids or anal skin tags. Therefore, it is not suitable for patients with fourth degree haemorrhoids or in patients who would like to have their skin tags removed. The literature also indicates a higher recurrence rate compared with open haemorrhoidectomy especially for prolapse.
    What are the risks?

    • 1. Bleeding
    <5%
    • 2. Anal Pain
    Minimal unless the stapled line is too close to dentate line
    • 3. Faecal urgency
    20%
    • 4. Stapled line leak
    Rare
    • 5. Pelvic Abscess
    Rare
  4. Transanal Haemorrhoid Dearterialisation (THD)
    In the search for a painless surgical treatment for haemorrhoid, transanal haemorrhoid dearterialisation (also known as Doppler-guided haemorrhoid artery ligation) is an innovation based on a different principle from conventional open haemorrhoidectomy. Since it was first reported by Morinaga and colleagues in 1995, it has gradually gained in popularity among surgeons.                                                                                                                                                                                           The operation involves the use of a specifically designed proctoscope together with a Doppler transducer. With the rotation of the proctoscope, the Doppler probe allows for the accurate localization of the terminal branches of haemorrhoidal arteries, which are then tied off with sutures. The reduced blood flow should lead to the shrinkage of haemorrhoids. The haemorrhoids were also reduced into the anal canal via a continuous stitch to compress the haemorrhoids tightly. In fact, the compression further reduces the blood flow to the haemorrhoids and therefore the internal haemorrhoids are removed by making them “die inside”. The external haemorrhoids were reduced into the anal canal to a certain extent via the pulling action by the same stitch.                                                                                                                                                              The postoperative pain from this operation is minimal because the technique avoids suturing the sensitive anal lining below the dentate line. It also avoids any external wound. Therefore, the main advantages are minimal postoperative pain, minimal analgesic use, no need to use warm/Sitz bath, a safe operation and quicker recovery (compared to open haemorrhoidectomy). The disadvantages are that it is not suitable for fourth degree haemorrhoids or in patients who would like to have their skin tags removed. Perhaps a combination of THD and excision of certain skin tags may be carried out for those with prolapsed haemorrhoids and large skin tags to minimize their postoperative pain.                                       In a systematic review published in Diseases of the Colon & Rectum in 2009 (DCR 52 (9): 1665-71), the overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding and 4.7% for pain at defaecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding and 8.7% for pain at defecation. The operative risks are bleeding and anal pain (especially if the suture is too close to dentate line).

Dr Chew does not perform stapled haemorrhoidectomy anymore. He replaces stapled haemorrhoidectomy with THD now. He believes THD is effective in controlling symptoms of PR bleeding especially in patients who had failed banding of haemorrhoids.  THD is used for second and third degree haemorrhoids. Dr Chew also believes Ligasure haemorrhoidectomy is a better option for fourth degree haemorrhoids or in those patients who have large external haemorrhoids.