Longterm effects of compression method in the surgical treatment of bleeding haemorrhoids

Objective: Present study was undertaken to find out the long term effect of application of compression probe after haemorrhoidectomy in the treatment of bleeding haemorrhoids. Materials and methods: They study was carried out in the Department of Clinical Surgery, Russian People's Friendship University, Moscow, Russia, from January 1992 to December 2001, on 80 patients, equally divided into two groups, case (haemorrhoidectomy plus application of compression probe) and control (haemorrhoidectomy only). Results: Long term follow up showed higher good outcome in case group (82.1%) compared to control (53.8%) (P<0.05), satisfactory and unsatisfactory outcome was higher in control group (17.9% and 28.2%) compared to case group (12.8% and 5.1%). Conclusion: Application of compression problem after haemorrhoidectomy in patients with bleeding haemorrhoids gives better long term results. Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13 Page 129-132 DOI: http://dx.doi.org/10.3329/bjms.v12i2.14939


Introduction
The surgical illnesses of anorectum are frequently observed disease among the persons of working age.Haemorrhoids is one of the most common disease of anorectum.The frequency of it among the adult population varies within the limits of 60 to 70 per-cent1.According to data, absolute increase of this pathology only in Russia annually 600,000 patients are admitted to hospitals.A large number of patients receiving outpatient treatment engaged a self treatment plan is not included in the statistics 2. Majority of the patients are from the working age group 30 65 years.Among these patients, 29 90% encounter from 2 6 episodes per year, and for each episode loss of working days range from 6 to 35 days.Therefore, haemorrhoids represent an important social problem 3. Patients with bleeding haemorrhoids have the agonizing problems due to passage of blood per rectum after defaecation which are worrisome and may result in fatal outcome due to loss of excessive blood.
Various methods of surgical treatment of bleeding haemorrhoids have been described in the literature but none of these are considered to be radical because of their side effects, complication and even fatal outcome 4 6.Compressive probe was used effectively in bleeding haemorrhoids as part of conservative treatment in patients in whom general or spinal anaesthesia was contraindicated 7. Surgical treatment of haemorrhoids, especially, the bleeding haemorrhoids is a concern of colorectal surgeons, and this article shows the effectiveness of compressive probe with the combined surgical treatment of bleeding haemorrhoids.patients were subdivided into case (n=40) and control (n=40).Patients with bleeding haemorrhoids concomitant with rectal polyp, chronic anal fissure, partial prolapsed rectal mucosa and patients with condyloma of anus were included in the case group.Histologically confirmed cases with rectal carcinoma were excluded from the study.Informed consents were obtained from study patients and hospital authorities.Ethical approval was taken from the hospital authorities before study.

Methods
All 80 patients underwent Milligan Morgan haemorrhoidectomy.After operation, in 40 case group patients, after operation, compressive probe was applied at the internal and external haemorrhoidal sites of the anorectum with inflated balloon (50 mmHg in each balloon) for 24 hours (Fig. 1).In control group, after operation proper haemostasis was ensured and antibacterial ointment soaked tampon was introduced into the anorectum.The patients were discharge from hospital only after full recovery.
All 80 patients were followed up on outdoor basis for a period ranging from 6 months to 9 years.Long term follow up results could be obtained from 78 patients, as one patient from each group died due to other disease not related to haemorrhoidectomy.
Out of 78 patients, 21 patients were followed up at the outpatient department, and data from the rest 57 patients were obtained with the help of data collection form provided to them as they were unable to Ethical approval: This protocol was approved by institutional Ethics Committee.

Long term assessment
Long term follow up results were evaluated as (1) Good: when a patient has no complaint related to the operation on anorectum, as there are no exacerbation or relapse of haemorrhoids, i.e. there is no nodulation, bleeding or prolapse of haemorrhoids; (2) Satisfactory: when there is no nodulation or prolapse of haemorrhoids, but only periodic bleeding or difficulties at defaecation (with or without pain) or disturbance in micturition; (3) Unsatisfactory: when there are relapse of haemorrhoids which demanded repeated operative measure.

Statistical methods
Data were expressed a number (percentage) and mean (±SD).Statistical analyses were done by unpaired Student's 't' test and Chi square test.

Results
Table I shows patient data.Mean (±SD) are showed no significant difference between case (42.70±7.88years) and control (43.55±6.72 years) groups.Sex also showed to significant variation between groups.
None of the case group of patients required blood transfusion, however, 9 (22.5%)control group of patients required blood transfusion (P<0.01).Mean (±SD) hospital stay was significantly high (P<0.001)for control group of patients compared to case (12.3±1.54 vs 6.83±0.98days).
Table II shows long term follow up results.In case group, out of 39 patients, 32 (82.1%) were evaluated as good.In these patients, there was no complaint related to the performed operation.Satisfactory results was obtained in case of 5 (12.8%) patients though they did not show any sign of relapse.Two patients (5.1%) of case group showed unsatisfactory results.In one case, there was only internal nodulation, but there was no bleeding per rectum or haemorrhoidal relapse, In second case, periodic bleeding per rectum was present without any sign of haemorrhoids.
Out of 39 control patients, outcome results in 21 (53.8%) were evaluated as good based on their health and absence of any complaints connected to anorectum operation.treatment of bleeding haemorrhoids.The compressive probe applied after haemorrhoidectomy revealed better results in comparison to haemorrhoidectomy alone.Long term compression in haemorrhoidal zones of anorectum results in the reduction of influx of blood on arteriolovenular anastomoses of cavernous bodies and simultaneous elimination of stagnation of blood in the haemorrhoids.Therefore, the pressure in the lumen of cavernous bodies is reduced; they are drained and the lumens of the cavernous bodies collapse.In addition to this, at pressure on haemorrhoids, the nerve receptors are irritated, simulates the contraction of muscles of anal sphincters, which even more signifies compression on haemorrhoids and accelerates the process of collapse of walls of ecstatic vessels.
There is an oxygen deficiency in tissues of haemorrhoids, the physicochemical properties of walls of pathologically changed vessels and their surrounding tissues are changed; stimulation of development of young connective tissues and the process of cica-trization is magnified 7 .
The walls of pathologically changed vessels of haemorrhoids in connection with a long time compression and local hypoxia are squeezed, gradually scleroses, emptying of haemorrhoids and bleeding ceases 8 .
From our data, we found that the application of compressive probe in the conservative method of treatment of bleeding haemorrhoids intended for stoppage of haemorrhoidal bleeding, lowering of activity of arteriolovenular anastomoses, normalization of microcirculation in cavernous bodies, and thus it was effective as conservative treatment of bleeding haemorrhoids.The duration was for 4 hours per day, and the process was repeated for 4 5 times at an interval of 1 4 days 7 .
The application of compressive probe after surgical treatment of bleeding haemorrhoids was directed to stop the residual bleeding, restoration of bloodflow and normalization remaining cavernous bodies, adaptation of edges of sutures mucosa and to reduce perianal oedema.The time of application of compressive probe was for 24 hours after operation.

Conclusion
The application of compressive probe at the end stage of haemorrhoidectomy in patients of bleeding haemorrhoids provided the elimination of stagnation of blood in the cavernous derivations, resulting in all and aseptic pasting together of their walls, sclerosis and shrinkage of haemorrhoidal clusters.Thus, it prevented relapse of haemorrhoids in the long term.

Table I :
Patient data