A long time ago I decided that haemorrhoidectomy must be possbile to do as an outpatient procedure. At the time there seemed to be two reasons why these patients were kept in hospital after the operation; viz. postop bleed and postop pain. I thought both reasons were related to the surgical technique. Most of you know that haemorrhoidectomy was a rather messy operation.
I devised a technique that allowed precise dissection and no bleeding. We knew exactly what had been done and sent the patients home. Some, and quite a few, reported considerable pain that prevented return to work for about two weeks. The pain usually reached a maximum about 4-5 days postop. I did not matter whether the wounds were closed or left open.
I thought the pain related to any engagement of the internal sphincter but with the dissection we did we knew that the sphincter was unharmed. You see, we operate fistula with much more extensive dissection and they have no pain. So what is the problem??
I then thought that a completly closed operation would do the trick. So I began to staple the haemorrhoids with the linear stapler (Ethicon TLC). I did a few patients with completely closed haemorrhoidectomy. They complained about the toilett paper sticking to the staples before they fell off. The funny thing was that a couple of such patients complained about severe pain. Then I gave up saying that there is a mechanism which I do not understand and which seemed not amenable to surgery.
I read this Lancet study a few months ago and agree there might be something to it. The effect of metronidazol is rather minor but statistically certain. I do not think it explains all the pain.
My current thinking about the problem is different. Most often, but not always, haemorrhoids seems to be a consequence of a colorectal dysmotility disorder of the type with urgency. It means that the piles are a secondary phenomenon. One can remove the haemorrhoids but the dysmotility remains and their anal problem persists. The haemorrhoids are not the cause of all the anal discomfort these patients experience.
I now regard piles as a prolaps of the anal canal. It takes it a bit far to also discuss the implications of this view. Let it suffice to say that there now is a new operation called anopexia by which the anal canal is repositioned with a circular stapler and the haemorrhoids are reduced but not excised. The pain is much less.
Apart from all surgical considerations it seems that the mechanism which produces the piles is the dysmotility disorder. We put all our patients on fibre for a period and sometimes also on loperamide if the urgency is pronounced. There are very much fewer patients being operated (any procedure) today than it used to be.
Sorry for such a long reply, but haemorrhoids is yet another of these trivial diseases which we do not understand and for which we use surgery which may not be adressed to the real problem.