Colorectal Surgery

We deal with general colorectal problems such as bowel cancer, inflammatory bowel disease and diverticular disease. Symptoms that could be related to a colorectal problem include: bowel bleeding, abdominal pain, constipation /diarrhoea, anal pain and anal lumps. We use the most recent knowledge and proven technology to provide the highest quality of care in the management of these diseases.

Piles / Hemorrhoids

WHAT ARE HEMORRHOIDS?

Hemorrhoids are engorged blood vessels covered by the lining of anal canal that may slide down or prolapse, enlarged and bleed.

PREVALENCE

about 4-5% of population have haemorrhoidal problems based on US data¹
Only 1/3 went to see a doctor¹
It usually affects people in the age group 45 –65 years and decreases after 65¹
It rarely affects people <20 years old¹

WHAT CAUSES HAEMORRHOIDS?

Haemorrhoids are associated with straining and an irregular bowel habit,
especially constipation.
Hormonal changes during pregnancy predisposes to the development of
haemorrhoids or exacerbation of pre-existing haemorrhoids.

CLASSIFICATION

It is important to understand the differences between the following structures:

1/ Anal skin tags
Folds of skin arising from the anal verge. They are usually the end result of thrombosed (clotted) external hemorrhoids.

2/ External hemorrhoids
Dilated blood vessels that are easily seen at the anal verge. They are usually bluish in appearance.

3/ Internal hemorrhoids
They are the haemorrhoids that can cause prolapse, bleeding, swelling, leaking mucus or cause itchiness in the anal region. The operation haemorrhoidectomy aims to treat this hemorrhoid.

WHAT ARE THE SYMPTOMS OF HEMORRHOIDS?

1/ Bleeding
Typically, this is bright red, painless and occurs at the end of defaecation. The bleeding is often described as blood on the paper, dripping or spraying into the toilet bowl. The bleeding may also be “hidden”, i.e. tested positive on stool test (Faecal Occult Blood Test) but not visible on inspection.
It is very important not to assume all bleeding are due to hemorrhoids. Bowel cancer can give rise to bleeding as the only symptom.
Therefore, it is essential to exclude other causes of bleeding first before blaming the hemorrhoids. Investigations include flexible sigmoidoscopy/colonoscopy.

2/ Anaemia
With prolonged history of bleeding, the patient will become anaemic. The recovery from anaemia after haemorrhoidectomy is rapid.

3/ Prolapse
It usually occurs during straining at bowel opening. In the majority of situations, the hemorrhoids reduced by themselves. Occasionally, they need to be pushed back in. When the hemorrhoids become very large, they are not reducible and they stay out of the anus all the time.

4/ Pain
Pain is not a symptom of uncomplicated hemorrhoid. It may indicate other diseases such as an abscess or anal tear (anal fissure).
Painful aemorrhoids are uncommon and they are usually a result of thrombosis (clotting) or strangulation (prolapse leading to obstruction of blood flow in and out of hemorrhoids).

5/ Itchiness (pruritus ani)
This is related to mucous leakage which can lead to itchiness and burning discomfort in the skin around the anus.

HEMORRHOIDS TREATMENT

1/ NON-OPERATIVE TREATMENT

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

2/ MINOR OPERATIVE PROCEDURES

Rubber Band Ligation
*Putting rubber bands over the hemorrhoids to cut off their blood supply. This lead to the shrinkage of the hemorrhoids and dropped off from the bowel wall. Maximum 3 haemorrhoids ligated at any one time.

Effective for small haemorrhoids
Risks: <1% of bleeding
Usually dull ache for 24-48 hours
Severe pain is uncommon
Severe infection is rare

Sclerotherapy

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

3/ HEMORRHOIDECTOMY

Open haemorrhoidectomy

Necessary for large or complicated hemorrhoids
This procedure is performed under anaesthetic in a hospital or Day Surgery Centre
It involves the cutting out of the hemorrhoids. A maximum of 3 hemorrhoids can be removed at any one time.
Disadvantages:
Significant pain for at least 2 weeks
May need to be performed in 2 stages if the hemorrhoids are circumferential
Risks: bleeding – < 5%
Faecal incontinence - uncommon
Anal stenosis - rare

Stapled Haemorrhoidectomy

1. 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.

1	2
3	4
5	Images sourced from brochures on Stapled Haemorrhoidectomy prepared by Johnson & Johnson Medical.

2. What are the benefits of stapled haemorrhoidectomy?
It gives minimal pain after the operation. It does not need to be performed in stages. It also allows patients to return to work or normal activity in a significantly shorter time compared to conventional (open/closed) haemorrhoidectomy.

3. Risks and Complications

1. Bleeding	<5%
2. Pain	low risk
3. Faecal urgency	20%
4. Stapled line leak	rare
5. Pelvic abscess	rare

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