Symptomatic Hemorrhoids Susan L Gearhart, MD Assistant Professor of Surgery, Colorectal Surgery, Johns Hopkins Medicallnstitutions, Lutherville, Maryland

CHAPTER 9 Symptomatic Hemorrhoids Susan L Gearhart, MD Assistant Professor of Surgery, Colorectal Surgery, Johns Hopkins Medicallnstitutions, Lutherville, Maryland

1though the true incidence of symptomatic hemorrhoids is Adifficu1t to estimate, the significance and management of this disorder has been well documented. The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BCby Hip- pocrates.1 In these writings, symptomatic hemorrhoids were described as the resu1t of infection of the veins within the rectum with stool, causing the temperature within the vein to rise and the vein to swell. Successful treatment could be obtained by cauterizing the hemorrhoids with a red-hot iron. Napo1eon was finally defeated by the British at the Battle of Waterloo in 1815. Severa1 accounts by those who were dose to him have indicated that the battle was 10st because ofNapoleons aftliction with hemorrhoids.2 Contrary to his usual batt1e conduct, he spent most of his time resting on a hilltop overlooking the battlefield rather than on his horse. When he did wa1k, he had a difficu1t time. Furthermore, a 1etter to his brother written severa1 years before the Battle of Waterloo indicated he had been routine1y treating his hemorrhoids with 3 to 4 1eeches. Today, if one browses the Internet on the topic of hemorrhoids, there are more than 65,000 sites that can be visited. ANATOMYANDPATHOPHYSIOLOGY Figure 1 demonstrates the anatomic abnormalities associated with the development of symptomatic hemorrhoids. Hemorrhoidal cushions are essential to the function ofthe anal canal. The hypervascu- lar nature of these cushions allows control of fecal continence and the easy passage of formed stool. In contrast with the submucosa of the proximal gastrointestinal tract, the submucosa of the anal canal is not a continuous rim, but a discontinuous series ofvascu1ar cushions. 3,4These hemorrhoidal cushions are found in the right anterior,

Advances in Surgery@, vol 38 167 Copyright 20M, Mosby, Inc. Ali rights reserved.

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Superior rectaJ a.andv. Mlddle hemorrholdaJ a.andv.

Inferior hemorrhoidal a.andv. \

FIGURE1. Cross-sectional view of nonprolapsing and prolapsing hemorrhoid complexes.

right posterior, and left lateral position. These cushions are sup- ported by a connective tissue framework derived from the internal anal sphincter and longitudinal muscle within the anal canal. The blood supply to the anal canal. which terminates in the anal cushions, stems from the superior rectal artery from the inferior mesen- teric artery and the middle and inferior rectal arteries from the internal iliac artery. Above the dentate line within the anal canal, the venous drainage follows the portal system into the inferior mesen- teric vein. In contrast, below the dentate line. the venous plexus drains into the systemic system. In the process of elimination of stool, anal cushions serve 2 purposes: 1) the control of fine continence and 2) the evacuation of

45 Symptomatic Hemorrhoids 169

formed stool through a muscular tube without injury to the mucosal lining. The distention of the rectum with waste results in engorgement of the vascular cushions of the anal canal. Within the mucosa overlying the anal cushions are sensory receptors that are essential to fine adjustments in continence.5.6 These receptors function. for example, to promote the elimination of gaseous waste in preference to liquid or solid waste. The engorgement of the vascular cushions allows solid waste to be evacuated completely and without injury to the anal canal. Although severa! theories exist regarding the pathogenesis of symptomatic hemorrhoids, it is generaIly believed that this disorder arises from a history of straining with defecation and as part of the aging process.7-9It is believed that the supportive connective tissue gives way with constant straining resulting in prolapse of the hemorrhoid cushion. Once the hemorrhoid complex begins to prolapse. venous return is impaired. resulting in engorgement, irritation, and inflammation. Erosion of the inflamed epithelium results in bleeding. Congenital internal anal sphincter hypertension has also been implicated in the pathogenesis ofhemorrhoidal disease.9.10

CLASSIFICATION As in most disease states, classification is considered useful for the management of symptomatic hemorrhoids. Hemorrhoids historically have been classified based on their location and the degree of prolapse.ll The dentate line demarcates the upper anal canal, lined with columnar epithelium. from the lower ana! canal, which is lined with sensate squamous epithelium. Internal hemorrhoids, in the most common location ofhemorrhoids, occur above the dentate line. External hemorrhoids are found below the dentate line (see Fig 1). Internal hemorrhoids are further classified by the degree of prolapse. · First-degree hemorrhoids do not prolapse with straining. but can be associated with bleeding. ·Second degree hemorrhoids protrude below the dentate line during straining but wiIl spontaneously retract. · Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction. ·Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible.

46 170 S. L. Gearhart

PRESENTATlONAND DIAGNOSIS Bleeding is the symptom most commonly associated with hemorrhoids. The bleeding is bright red, noted on wiping or filling the toilet bowl, and occurring predictably with defecation. Prompt reduction of the prolapsed hemorrhoid will significantly reduce the bleeding. Patients with third- or fourth-degree hemorrhoids com- plain of protruding, irritated tissue in the perianal region. Third- and fourth-degree hemorrhoids may aIso cause a feeling of incom- plete evacuation. The prolapsed tissue gives a sense of fullness and a continuing sense of the need to evacuate. Soiling in the form of mucus discharge is not uncommon, because of an impairment ofthe fine control of continence. Constant exposure of the perianal skin to mucus may result in irritation and itching. Discomfort may be associated with prolapsed hemorrhoids; however, intolerable pain is rare. A painful hemorrhoid is usually an acutely thrombosed, prolapsed internal or external hemorrhoid. Pain is associated with a perianal mass, which is immediately evident on physical examination. The diagnosis ofhemorrhoidal disease is usually made with pal- pation and direct visualization ofthe perianal region and anal canal through anoscopy. Prolapsing or thrombosed hemorrhoids are evident on inspection of the perianal tissue. These findings can be exaggerated with straining. Thrombosed hemorrhoids have a blue hue as a result of the clotted blood inside. On anoscopy, inflamed hemorrhoids may be visualized in their previously mentioned anatomi- cal position. Individuals seeking medical attention for perianal discomfort often report that they have hemorrhoids. Unfortunately, this is due to the lack ofpatient and physician education. Most perianal conditions are incorrectly labeled as "hemorrhoids." Anal fissures arise in the sensate portion of the anal canal and are associated with excru- ciating pain more so than bleeding. It is true that because the patho is similar to that of hemorrhoids, it is not uncommon for the two to exist together. Mucosal prolapse, a circumferential prolapse of the anal canal mucosa, is a common condition of older women. The symptoms resulting from mucosal prolapse as well as the medical management are similar to hemorrhoidal disease. Most importantly, a more serious condition often mistaken for hemorrhoids is anal or rectal cancer. Any examination of patients with hematochezia should include suf:ficient investigations to rule out a proximal source of bleeding if the bleeding does not cease afier appropriate

47 Symptomatic Hemorrhoids 171

therapy. Furthermore, hemorrhoidal bleeding rarely causes iron- deficiency anemia.12 Other disorders, such as intlammatory bowel disease or cancer, should be ruled out.

TREATMENT DIETARYAND UFESTYLEALTERATlONS It has been shown that fiber supplementation reduces the bleeding and discomfort associated with hemorrhoids.13 However, fiber supplementation will not reduce the prolapse. It may be weeks before the use of fiber for the treatment of symptomatic hemorrhoids is effective. It is recommended that patients take 30 gm of fiber a day and increase liquid intake. This goal is difficult to reach without the assistance of fiber supplementation. Fiber therapy should be insti- tuted gradually over the course of a week. This will reduce the incidence of unwanted side effects of bloating. Supplemental semi- synthetic tlavonoids are commonly prescribed in Europe and Asia for the treatment of hemorrhoids. This remedy willlikely improve venous tone and inhibit the release ofprostaglandins, thus resulting in symptomatic relief.14 Patients should be counseled on specific activity related to defecation. Avoiding straining is essential. The bathroom is to be used for the sole purposes of evacuation of waste and not for reading. Pa- tients should be instructed to remain on the toilet seat for no longer than 1 minute. Furthermore, attempts at defecation should be made only afier the patient receives a clear call to eliminate waste. MEDICALMANAGEMENT Historically, symptomatic relief from acutely intlamed hemorrhoids was bed rest and ice packs. Acute surgical therapy was deemed un- safe because of the risk of internal sphincter injury. However, with improvement in surgi cal techniques, patients need not suffer end- lessly with acute disease. Studies have shown that offering surgical therapy is safe and effective.15 There is a plethora of ointments avail- able that contain steroids, local anesthetics, or mild astringents and can provi de short-term relief from acute or chronic hemorrhoidal discomfort or bleeding. Some common commercial preparations include: Thcks, Anusol, Preparation H, and Balneol. Other remedies include warm-water sitz baths to ease the discomfort often associated with a thrombosed hemorrhoid. Persistent use of local remedies should be avoided because sensitization of the anoderm may result in a permanent dermatologic condition.16

48 172 S.L. Gearhart SURGICALMANAGEMENT Surgical management is dictated by the folIowing: 1) the degree of prolapse (Tables 1 and 2) associated medical conditions; 3) and the lifestyle of the patient. The folIowing section describes the various methods of surgical treatment of symptomatic hemorrhoids. In general, treatment is performed either in the clinic or in the outpatient operating room. Patients are rarely admitted to the hospital. Before treatment, patients should be counseled on dietary and lifestyle modifications. Regardless of age, evaluation for alternative sources of bleeding should always be incorporated into the treatment plano AlI patients should be prescribed 2 enemas to be administered the morning before undergoing treatment. Procedures that ean be performed in an OUlpatientclinic: · Simple excision: For the painful thrombosed external hemorrhoid, relief is provided by excision of the thrombosis. This is ac- complished by complete excision and not by simple incision (Fig 2). Simple incision wilI result in recurrence of the thrombosis and probable infection. However, if the thrombosis has been present for more than 2 to 3 days, and the discomfort has begun to subside, conservative management should be recommended. This consists of warm sitz baths and stool softeners, as well as local analgesics. The inflamed mass will resolve in 8 to 10 days. Whether or not the thrombosis is excised, further treatment of the prolapsed hemorrhoid can be offered in the form of either banding or excisional hemorrhoidectomy. - TABLE1. Recommended Treatment of Hemorrhoids Based on Degree of Prolapse Grade Treabnent

1 Fiber supplementation or Sclerotherapy 2 Fiber supplementation or Sclerotherapy 3 Fiber supplementation and Rubber-band ligation Stapled hemorrhoidectomy Conventional hemorrhoidectomy 4 Fiber supplementation and Mild Stapled hemorrhoidectomy Severe Conventional hemorrhoidectomy

49 Symptomatic Hemorrhoids 173

TABLE2. Randomized. Controlled Trials for the Treatment of Prolapsing Symptomatic Hemorrhoids

Clínical Return to Recurrence or Prolapse Procedures Patients. n FoUow-up Work (dy) (patients. n)

Stapled vs Banding Peng 2003 55 6mo NA Stapled vs Diathermy Cheetham 2003 31 8mo 10 vs 14 2 vs 1 Kairaluoma 2003 60 12 mo 8 vs 14 5 vs 0* Ortiz 2002 55 15 mo 3 vs 4 7 vs 0* RowseU 2000 22 6wk 8 vs 17* NA Ho 2000 119 19wk 17 vs 23* Stapled vs Conventional Palimental 2003 74 6mo 28 vs 34 NA Ovs O Smyth 2003 36 37 mo NA Wilson 2002 89 6wk 14 vs 18* NA Correa-Rovelo 2002 84 7mo 6 vs 15 1 vs O Hetzer 2002 40 12 mo NA 1 vs 1 Boccasanta 2002 80 20 mo 8 vs 15* O vs O Brown 2001 30 6wk NA O vs O Ganio 2001 100 16 mo 5 vs 13* 3 vs 2 Shalaby 2001 200 12 mo 8 V5 54* 1 vs 2 Pavlidis 2001 80 3 mo NA O vs O Mehigan 2000 40 4mo 17 vs 34* O vs O

.Statistica11y significant resulto (Data from BMJ 327:649. 2003.J

. Injection sclerotherapy: For first- and second-degree hemorrhoids, when the primary complaint is bleeding and not protruding tissue, sclerotherapy can be employed. The agents commonly used are sodium morrhuate and sodium tetradecyl sulfate. The procedure is performed in an officevisit while the patient is in the prone jack-knife or left lateral position. A 25-gaugespinal needle is used to insti1l1 to 2 ml of the sclerosing agent into the submu- cosal space afier careful aspiration to avoid intravascular injection. Injection of sclerosant for first- and second-degree hemorrhoids should be painless. given that. by definition, these hemorrhoids are located above the dentate line. . Rubber-band ligation: Rubber-band ligation has been a recognized technique for symptomatic second- and third-degree hemorrhoids since Barron's first description in 1963.11 The technique is easy to do in an outpatient setting and is associated with very little discomfort. The steps using the McGivney ligator with forceps are

50 174 S.L. Gearhart

A ; ..1'" B C

FIGURE2. Complete excision of a thrombosed hemorrhoid. A, An elliptical excision that fully encompasses the thrombosed hemorrhoid should be made. B, The excision should completely remove the hemorrhoid complexo C, The excision site is left open to heal. (Reprinted with permission from Cameron JL:Atlas of SurgeIj, 2nd ed. Hamil- ton, Ontario, Inc. [In press].)

outlined in Figure 3. Alternatively, a suction ligator, which elim- inates the need for a grasping forceps and for an assistant, can be used. Patients are placed in the left lateral position or the prone/jackknife position. It is recommended that the banding instrument be loaded with 2 bands, because this will prevent break- age and recurrence.11 It is important to identify the dentate line and place the band above this line. It is recommended that no more than 2 bands be placed per visit. Although, triple banding has been shown to be effective, it has also been associated with 37% incidence ofprolonged post-ligation pain.17 Following banding, the patient might experience a feeling of pressure or rectal fullness for a period of 24 to 48 hours. Furthermore, approximately 10 to 14 days following the banding, a small amount of tissue associated with bleeding might be passed. Associated complications are rare «2%) and include vasovagal response to the procedure itself, pelvic sepsis, and secondary thrombosis of external hemorrhoids. Severe, life-threatening sepsis has been re-

FIGURE3. The technique of rubber band ligation. A, Twobands are placed on the McGivney hemorrhoid ligator. B, Hemorrhoidal tissue is localized and grasped with the forceps. C, The ligating instrument is advanced above the dentate line and fired. D, The hemorrhoid ligator is removed. (Reprinted with permission from Cameron JL: Atlas of Surgery, 2nd ed., Hamilton, Ontario. BCDecker.[Inpress].)

51 Symptomatic Hemorrhoids 175

.- ~ A

., -'

L 52 176 S. L. Gearhart

ported in immunocompromised patients undergoing rubber-band ligation. Proceduresrequiringan outpatientoperativesuile: More invasive procedures, such as coagulation, excision, ar stapling, are recommended for third- and fourth-degree hemorrhoids with an extensive external component or failure of more conservative procedures. In general, less than 10% of patients referred for treatment by a specialist wiIl require a more invasive procedure. These techniques are best performed accompanied with effective anesthesia. Any movement of the patient during these procedures can present a challenge. · Ligature: The ligature diathermy is used to treat third- and fourth- degree hemorrhoids. The underlying principIe is sjmilar to the conventional hemorrhoidectomy, but the ligature is used instead of using conventional monopolar cautery or Metzenbaum scis- sors. If necessary, the mucosa can be reapproximated using a 3-0 Vicryl stitch. · Conventianal hemorrhoidectomy: Excision hemorrhoidectomy is reserved for fourth-degree and occasionally third-degree hemorrhoids. This can be performed with an open technique, as origi- nally described by Milligan and Morganin 1937,18and in a closed manner, as described by Ferguson in 1959.19The patient is placed in either the lithotomy or prone jackknife position. A mixture of bupivacaine and adrenaline is useful in establishing hemostasis and in the dissection and removal of the symptomatic portion of the hemorrhoidal complexo Both methods emphasize the impor- tance of careful dissection ofthe internal sphincter. Care must be taken to avoid overzealous dissection ofthe mucosa, which could lead to anal canal stenosis. Despite low complication rates and high efficacy of conventional hemorrhoidectomy, severe pain can result because of excision of sensate anoderm below the dentate line. This leads to a delay in the retum to wark and patients' un- willingness to undergo the procedure. Stapled hemorrhoidectomy (procedure for prolapse and hemorrhoids): This procedure was largely developed to treat third- and small fourth-degree symptomatic hemorrhoids as an alternative to the conventional hemorrhoidectomy. The procedure itself repre- sents a paradigm shift in the management of prolapsing hemorrhoids in that the hemorrhoidal tissue is not actually removed, rather a circumferential mucosectomy is performed, which results in an anopexy. The procedure can be performed under sedation ar

53 Symptomatic Hemorrhoids 177

general anesthesia in the prone or lithotomy position. A purse- string suture with 2-0 polypropylene is placed approximately 2 to 4 cm above the dentate line. The 31-mm PPH stapler (Ethicon, Endo-Surgery, Ohio, USA) is used to pexy the hemorrhoidal tissue above the dentate line (Fig 4). Early reports on the use of stapled hemorrhoidectomy called attention to severe complications including pelvic sepsis, rectovaginal fistula, persistent pain, and fecal urgency.20-22However, there is, without question, a learning curve associated with the stapled hemorrhoidectomy, and, with increased surgical experience, these complications are rare. It is recommended that a careful vaginal examination be performed prior to firing the stapler to ensure the vagina was not caught up in the purse-string and, thus. the stapling device. CUNICALTRIALSOUTCOMES Outcome trials reviewing outpatient clinic techniques have demonstrated that sclerotherapy may provide a short-term benefit, but long-term improvements have been seen in only 28% of patients. Therefore, rubber-band lígation remains the most effective method for the management of symptomatic grade 2 and 3 hemorrhoids in the outpatient clínico This procedure is associated with nearly an 80% short-term cure rate for patients with up to third-degree hemorrhoids.23 Of the remaining 20% of patients, 18% wiIl be cured with a repeat procedure with only 2% failing to respondoUltimately, rubber-band ligation is associated with approximately 90% long- term success rate. For the management of grade 3 and 4 prolapsing hemorrhoids, there are several randomized, controIled trials comparing stapled hemorrhoidectomy to conventional hemorrhoidectomy (see Table 2). Ho et al24demonstrated that the stapled hemorrhoidectomy is safe and effective, associated with less pain; however, it is more ex- pensive than con~entional hemorrhoidectomy. Those in favor ofthe stapling procedure contend that there is an earlier return to work with the stapling technique andothus, a decreased cost to society.25 However, it is important to note that patients who are candidates for the stapling procedure are usually candidates for banding. It is also known that patients with severe grade 4 prolapse are best managed by conventional hemorrhoidectomy, because an anopexy procedure may not completely eliminate an extensive external component. Peng et al,26realizing this paradox, demonstrated that rubber-band ligation and the stapled hemorrhoidectomy were equally effective in controlling prolapse from third- and small fourth-degree hemorrhoids. Although the number of participants was small, with only a

54 """ 'i =

~ r Q~ 3- Q ::l

FIGURE4. Teehnique for stapled hemorrhoidectomy. A, A purse-string suture is plaeed approximately 2 to 4 em from the dentate line. B, The purse-string suture is seeured around the stapling deviee. At this point, in female patients, the vagina should be examined for the presenee of a stitch or pulling before firing the stapling deviee. C, The hemorrhoid complexes have been resuspended and an intaet staple Une is present. (Reprinted with permission from Cameron JL:Atlas ofSurgery, 2nd ed., Hamilton, Ontario, BCDeeker. [Inpressl.)

UI UI

"1 Symptomatic HemoIThoids 179

6-month follow-up, there was more perioperative morbidity assoei- ated with the stapled hemorrhoidectomy, and recurrent bleeding was more common in the banded patients. The benefits of ligature over conventional hemorrhoidectomy include reduced bleeding, anesthetic time, and healing time.27Those who oppose the use of the ligature are concerned that the lack of dissection may result in inadvertent injury to the internal sphincter. Further long-term studies need to be performed.

COMPUCATIONSOF SURGICALTHERAPY The most common complications associated with a hemorrhoidectomy are bleeding, pain, and urinary retention. Bleeding complication can occurwithin 24 hours (1%) or in 5 to 10 days (4%).28Early bleeding is usually secondary to a missed vessel, whereas delayed bleeding is a result of early separation of the ligated pedide. A re- turo trip to the operating room may be required. Insertion of a rectal Foley to tamponade the bleeding may suffice. To avoid bleeding complication from a stapled hemorrhoidectomy, an additional 3-0 Vicryl suture is used to oversew the staple line. Simple hemostatic material such as Gelfoam with thrombin can be placed in the anal canal following the procedure; however, excessive pacldng should be avoided. Investigators have shown that the use of intravenous metronidazole and the limitation of intraoperative tluid to less than 250 ml will prevent increased swelling and inflammation, which can result in pain and urinary retention.29,30Furthermore, the use of ketorolac to accompany oral narcotics may provide improved anal- gesia.31 Hemorrhoidectomy is the most common cause of anal stenosis and ectropion, with an incidence ranging between 2% and 4%. Anal stenosis results from an overzealous removal of the anoderm with loss of mucdsal bridges and scarring of the anal canal. Surgical correction of this condition requires either repeated dilatations or surgical anoplasty. Anal ectropion is the abnormal placement of the anal mucosa distal to the dentate line. Once this occurs, the continence mechanism is unable to prevent the leakage of mucus and small amounts ofstoo1.This will result in maceration ofthe perianal region and chronic pruritus. Treatment requires restoration of the ectopic mucosa to a position proximal to the dentate line. Diamond- shaped. house-shaped, or V-Y advancement tlaps have been used with excellent anatomic results.

56 180 S. L. Gearhart

HEMORRHOIDSASSOCIATEDWlTHOTHERDISEASES

· Coagulation Disorders: Patients with known coagulation disorders and those requiring anticoagulation are a challenge to manage. Most physicians advocate either sclerosing or banding of hemorrhoids in patients with this condition. If surgery is under- taken for failure of less invasive techniques, assistance from a he- matologist in optimizing the patient for surgery may be a benefit. · Crohn's disease: Confusing enlarged sldn tags for symptomatic hemorrhoids can be severely problematic for patients with Crohn's disease. Poor perianal wound healing in Crohn's disease may lead to a persistent fissure or fistula if hemorrhoidectomy is performed. Perianal symptoms are usually exaggerated by bowel frequency and correction of this will often lead to resolution. For this reason, hemorrhoidectomy is not recommended in Crohn's disease. · HIV infection: Medical therapy is preferable because of the risk of septic complication and poor wound healing afier surgery. Other causes of perianal symptoms, induding condyloma, should be ex- cluded. With the addition ofhighly affective anti-removal therapy and an improved immune status, symptomatic hemorrhoids can be treated with rubber-band ligation safely. . Pregnancy: This condition clearly predisposes patients to symptomatic hemorrhoids. Although the etiology is unknown, it is thought to be the result of increased hormone levels and pelvic venous congestionoPatients revert to their pre-pregnancy condition following delivery. Conventional hemorrhoidectomy pro- vides symptomatic relief from severe disease. This can be performed under local anesthetic safely during the third trimester when the fetus is viable without maternal or fetal complication.32 However, approximately 25% ofthese patients require additional hemorrhoidal treatment. For this reason, surgical intervention is reserved only for intractable symptoms. SUMMARY Themost important aspect in the diagnosis ofhemorrhoidal disease is the exclusion of other, more life-threatening conditions. Hemor- rhoidal banding remains the most successful method to manage hemorrhoids in the outpatient clinic. Chronic application of local medications to the perineum may result in dermatologic conditions. It is safe to manage acutely inflamed hemorrhoids surgically. Table1 is a summary ofthe various methods for the surgical management of symptomatic prolapsing hemorrhoids. Dietary manipulation, in-

57 Symptomatic Hemorrhoids 181

cluding fiber supplementation, should always accompany surgical therapy.

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20. Singer MA, Cintron IR, Fleshman JW, et aI: Early experience with stapled hemorrhoidectomy in the United States. Dis Colon Rectum 45: 360-367,2002. 21. Maw A, Eu K, Seow-Choen F: Retroperitoneal sepsis complicating stapled hemorrhoidectomy. Dis Colon Rectum 45:826-828, 2002. 22. Molloy RG, Kingsmore K: Life-threatening pelvic sepsis afier stapled hemorrhoidectomy. Lancei 355:810, 2000. 23. MacRae HM, McLeod RS: Comparison of hemorrhoidal treatments: A meta-analysis. Can / Surg 40:14-17, 1997. 24. Ho HY, Cheong WK, Tsang C, et al: Stapled hemorrhoidectomy: Cost and effectiveness. Randomized controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 43:1666-1675,2000. 25. Nisar PJ, Scholetield JH: Managing hemorrhoids. Br Med /327:847-851, 2003. 26. Peng BC, Jayne DG, Ho YH: Randomized trial ofrubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Vis Colon Rectum 46: 291-297,2003. 27. Palazzo FF, Francis DL, Clifton MA: Randomized clinical trial of ligature versus open hemorrhoidectomy. Br / Surg 89:154-157,2002. 28. Beck DE: Hemorrhoidal disease. In Beck DE, Wexner SD (eds): Funda- mentals of Anorectal Surgery. 2nd ed. London: WB Saunders; 1998: 237-253. 29. Carapeti EA, Kamm MA, McDonald PJ, Phillips RK: Double-blind randomized controlled trial of effect of metronidazole on pain afier day case hemorrhoidectomy. Lancet 351:169-172,1998. 30. Hoff SD, Bailey HR, Butts DR, et al: Ambulatory surgi cal hemorrhoidectomy: A solution to postoperative urinary retention? Dis Colon Rec- tum 37:1242, 1994. 31. O'Donovan S, Ferrara A, Larach S, Williamson P: Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy. Dis Colon Rectum 37: 793,1994. 32. Hulme-Moir M, Bartolo DC: Hemorrhoids. Gastroenterol Clin North Am 30:183-197,2001.