INTRODUCTION - DEFINITION
The hemorrhoids, known since antiquity, had always been a matter of argue as to precise their anatomical position, their role in the defecation mechanism, the effectiveness of one or the other treatment. The hemorrhoidal disease, although so common, barely is beginning to reveal all its own secrets.
Hemorrhoids are being gradually developing and occurring over the adults. Factors favoring their occurrence are hereditary, chronic constipation, pregnancy as well as specific dietary habits.
The hemorrhoidopathy is a frequent pathology of the anal region, it is completely benign, but with a wide impact on quality of life. The hemorrhoids result from hypertrophy and dilatation of the hemorrhoidal veins, which create varicose veins situated in the lowest rectal and anal portion.
They are divided into internal, when developed in the anal canal and external when developed low and can be “visible”.
Sometimes hemorrhoidopathy may not give any symptom but usually causes 4-typed symptoms:
i. Congestion Crises – it is a sense of heaviness in the anus, often accompanied with itching. Clinical examination shows a dilatation of usually internal hemorrhoids and the crisis recedes under gentle treatment in a few days.
ii. Thrombosis: - it is due to the formation of a thrombus (from coagulated blood) in an internal or external hemorrhoid. The main symptom is a severe anal pain suddenly occurred. In case of external hemorrhoid, it is occurred a round, mauve lesion which is very painful on palpation.
iii. Haemorrhage: - it’s about loss of vivid, red blood in small quantity during defecation. If these hemorrhages are frequent, may cause anemia with drop in hematocrit.
iv. Hemorrhoidal prolapse: - it is an occurrence of hemorrhoids, mostly after defecating, which patient can push back into the anal canal with a finger tip.
The surgical treatment known since the era of Hippocrates is the one providing the best and long-term, definitive results. Many techniques have been proposed from time to time, most of which present only historical interest.
The treatment is not always surgical but even if it is, it can be performed without hospitalization. Medical management lies in dietary instructions, in avoidance of excesses, alcohol and spices. It is usually provided a combination of oral and topical (ointment) treatment.
The endoscopic treatment includes sclerosing injections preventing hemorrhoids from filling with blood, elastic bandage ligation or radiofrequency application.
Only the attending physician is responsible for the selection of treatment, which must be completely adapted to the patient’s needs.
It is required a small enema before surgery. The depilation (shaving) of the region is essential. There are applied compression stockings. The operation is performed under epidural or general anesthesia.
The two main operations are:
i. Hemorrhoidectomy according to MILLIGAN & MORGAN technique
ii. Hemorrhoidectomy according to LONGO technique
MILLIGAN & MORGAN hemorrhoidectomy: lies in the removal of hemorrhoids in 3rd -7th - 11th (anal) part and in the ligation of feeder vessels. With the use of new technologies (e.g. Laser, ultrasonic scissors), the postoperative course has nothing to do with the painful postoperative course a decade ago, since the reintegration into everyday life is quiet fast. It has a recurrence rate of 2% at 5 years.
LONGO hemorrhoidectomy: it is the latest concept for simultaneous treatment of hemorrhoidopathy and rectal mucosal prolapsed. With this technique, the operation is internally performed over the anal canal, in an area without nerves and therefore not sufferable, resulting in almost nonexistent, postoperative pain. The philosophy of intervention is the cutting and stapling of the mucosal remnant, i.e. the interior rectal lining and simultaneously the feeder vessels for hemorrhoids.
Patient's return to room is approximately obtained in 1 hour, gets up and receives nutrition on the same day. The hospital attendance usually lasts 24 hours.
COMPLICATIONS & LIFE AFTER SURGERY
After returning home, the diet is the usual, avoiding the excesses of course. Treatment after surgery concerns analgesia (no aspirin) and the treatment of constipation. It is usual the detection of a very small amount of blood when defecating even one month after surgery.
The recovery is rapid and the patient returns to his social and labor obligations in two 24-hr.
The hemorrhoidopathy is a very common disease but it requires surgeon’s careful evaluation and especially the selection of the appropriate therapeutic method. There is not a method for all the cases, but it should be preferred with regard to the patient's problem.