Histoclinical basis for a new classification of hemorrhoidal disease

Abstract

The present classification of first, second, and third grade hemorrhoids only reflects variation in size of a normal human tissue and does not relate to "hemorrhoidal disease." Cross-sections and coronal sections of the anal canal in 32 fetuses, with ages ranging from 28 to 38 weeks of development, were studied and the following fundamental facts were found: in the lumen of the anal canals of fetuses, there are prominences of mucosa formed by conjunctive and muscular tissue, arterial and venous vessels and glands, arranged without following any particular pattern, which resemble similar formations found in the adult that protrude equally in the inside of the canal, known as hemorrhoids. The muscular tissue, smooth or striated, is grouped in bundles, and bunches of collagen fibers of homogeneous, nonfragmented, and regular aspect are found between them. Blood vessels have an ample lumen with a defined structure of collagen tissue as well as muscular tissue in its walls. Prominences of mucosa are connected to the remainder of the intestinal wall by defined conjunctive thick, nonfragmented fibers, that permit firm adherence. In healthy adults, the findings were similar but there was an evident degenerative process in the collagen fibers. In 100 surgical specimens of hemorrhoidectomies, the histologic investigation demonstrated a severe inflammatory reaction that especially affected the blood vessel wall and conjunctive tissue, which probably produced an ischemic lesion of the mucosa that could condition the onset of a vascular thrombosis, allowing displacement of the mucosa and its protrusion through the anus. The files of 815 patients suffering from hemorrhoidal disease were also studied. The main physical findings were bleeding, thrombosis of the internal hemorrhoidal plexus, prolapse of the anal cushions, or a combination of these. The authors propose to classify hemorrhoidal disease as bleeding, prolapsing, thrombotic, and mixed hemorrhoidal disease, aiming toward a rational treatment.

Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients

“…The traditional classification does not incorporate haemorrhoidal symptoms although such attempts have been made with regard to bleeding [2,3,5,6]. The external component (7) Each symptom was graded from 0 to 3 points.…”

“…Goligher [1] Lunnis & Mann [2] Morgado et al [3] Thomson & Leicester [7] Grade 0 presence of mucoanal prolapse and the number of prolapsed haemorrhoids. This was performed during proctoscopy while the patient was asked to strain.…”

“…This classification is strictly anatomical and does not take into account the symptoms that are associated with prolapse such as bleeding, pruritus, pain and soiling. Some classifications propose a correlation between the grade of prolapse and increased bleeding [2], while others describe no such correlation between anatomy and symptoms [3] (Table 1).…”

Haemorrhoidectomy; Outcome Using Harmonic Scalpel Versus Conventional Closed Haemorrhoidectomy

“…The ultrasonically activated scalpel operates at high-frequency ultrasonic energy and at temperature less than 100°C, which divides the tissue in such a way that is associated with less unwanted tissue desiccation, char formation and zone of thermal injury in relation with electrocautery instruments. 16 After ultrasonic cutting and coagulation, the HS technique gives a signal that allows surgeon to finish the process more quickly. Furthermore, HS causes minimal intraoperative bleeding, which allows the surgeon better exposure, so surgery lasts less time than with other techniques, and causes minimal mucosal damage, leading to faster wound healing, less postoperative morbidity, and minimal pain.…”

Geleneksel diyatermi ile kıyaslandığında harmonik bistürinin hemoroidektomide faydası var mıdır?

“…The current theory about symptomatic hemorrhoids is the destruction of the anal cushions, which help the defecation and fine-tuning of anal continence. The muscle fibers are then replaced by collagen and there is an inflammatory process in the connective tissues around vessels which leads to ischemia and ulceration thus ending up in bleeding [3]. Hence the disease is very common and causes a significant number of operations and creates a community burden.…”