Credential of Dr. Goh 

• President Scholar and top of NUS Medical Class 1980• Pioneered many therapeutic procedures through the scope.• Head of NUH Endoscopy centre: Was involved in design and building

of NUH endoscopy centre > 650 cases per month• Head of Endoscopy Service in University of Cologne, Hospital at

Merheim.• Taught Endoscopy to many doctors and surgeons worldwide• Trained in GI Endoscopy in Massachussetts General Hospital,

Harvard Medical School, Boston.

Massachussetts General Hospital

Dr. Peter M.Y. Goh FRCSAdvanced Surgical GroupSingapore

The Problem with Piles

Singapore 2010

• Toilet becomes an agony?

• Disturbing symptoms?• Lump• Pain• Bleeding

• One in 4 people have piles!

Is something wrong at the rear end?

• Anal cushions• Distinguish gas from

liquid• Swell and prolapse from

straining at stool

What are piles?

• Straining and pushing• Piles elongate and grow

bigger• Pushed outside the anal

sphincter• May be strangulated

How Piles Develop

• May be perianal hematoma

• Or prolapsed internal pile

External Piles

• Pain• Bleeding• Lump in the anus

(Prolapse)

What are the symptoms of piles

• Heamatochezia• Piles may bleed

profusely

Usually stains the toiletpaper or coats the stool.

Bright red blood

Blood in the stools

• Piles is not the only cause of rectal bleeding

• Important to exclude cancer

• Colonoscopy is recommended before treatment of the piles.

Other causes of Bleeding

• Discover other causes of bleeding

• Very comfortable procedure

• Heavy sedation• No recollection• Takes about 10 to 15

minutes.

Colonoscopy

• Diagnosis– Lower GI symptoms

• Screening– Family history of Cancer– Previous Polyps– Over 40 years

Which patients need a Colonoscopy

• Polyps can be removed• Lesions can be biopsied• Diagnostic and

Therapeutic at the same time

• Colonoscopy saves lives!

Most important Benefit of Colonoscopy

• Many diseases can be treated through the scope

• Makes Operation uneccessary

Therapeutic Potential of Endoscopy

• First Degree – Internal• 2nd Degree –

Occasionally prolapsing• 3rd Degree – Prolapsed

but can be pushed back• 4th Degree-prolapsed

and cannot be pushed back

Degrees of Piles

1st and 2nd Degree piles

3rd and 4th Degree piles

Causes of Piles• Excessive straining during bowel movement, or

when constipated• ·Chronic diarrhoea• ·Lack of adequate fibre in the diet.• ·Pregnancy and childbirth• ·Family history• ·Cancer or growths in the pelvis or bowel• ·Age, which causes the anal cushions’ supporting

ligaments to lax

Pregnancy and Piles

• Increase intrabdominal pressure

• Pushing during delivery• Piles common in pregnancy• Can be treated even when

pregnant without danger to baby

Constipation• Very common problem• Old and young people

• Excessive straining because of constipation can lead to Piles

• Can have other causes…?Cancer

• When should I worry?

• Diarrhoea can also cause piles

• Frequent bowel movement and straining.

• Must worry when there is blood or mucous

Diarrhoea

Common causes of Diarrhea

• Infection• Inflammatory bowel

disease• Irritable Bowel• Cancer• Food allergy intolerance

• Frequency• Consistency• Caliber• Alternation of diarrhea

and constipation• regularity

Change in Bowel Habits

Other Pathology in the Perianal area

• Fistulas• Warts• Polyps• Peri-anal abscess• Cancer

• Be aware that there are many differential diagnosis

Treatment of piles depend on the degree of prolapse.

The more prolapse the bigger the treatment.

Hemorrhoids :Treatment

• Medication : Daflon• Suppositories• Diet change

Fiber, fruits, vegetablesDrink more waterGood Bowel habits

Treatment of Early Piles

Daflon 500 mg: Indications

chronic venous insufficiency

acute & chronic hemorrhoids

Daflon 500 mg: a unique micronized form

Cylindrical air micronizer

Compressed air (1000 km/h)

Purified flavonoid fraction

Micronized purified

flavonoid fraction

A unique high-tech process using an air-jet stream at supersonic speed

Daflon 500 mg: a unique micronized form for proven better bioavailability

0

10

20

30

40

50

60

Urinary excretion (%)

24 Hours 168 Hours

Daflon 500 mg

* P=0.0001** P=0.0004

** Nonmicronized diosmin

Crossover study in 12 healthy volunteers taking [14

C] diosmin orally(micronized vs nonmicronized)

15.9

31.132.7

57.9

*

Garner RC, Garner JV, Gregory S, et al. J Pharm Sci. 2002;91:32-40.

Daflon 500 mg: a comprehensive mode of action

On venous tone On lymphatic drainage

On microcirculation

Reduction in inflammatory process

Daflon 500 mg: a comprehensive mode of action

***

*****

*** ******

** ****

0

1

2

3

4

5

1 2 3 4 5

Increases venous tone and lymphatic drainage

1. Duhault J, Pillion G. Artères Veines. 1992;11:217-218.

2. McHale NG, Hollywood MA. Phlebology. 1994;(suppl 1):23-25.

Time (days)

Lymph flow(mL/h) 2

** P<0.01

*** P<0.001

Daflon 500 mg

PlaceboVenous relaxation after maximum noradrenaline-induced contraction (%) 1

* P<0.05

0

20

40

60

80

100

120

5 15 252010 30

* *

* * *

+ 50%

Time (min)

Daflon 500 mg: a comprehensive mode of action

0

50

100

150

200

250

300

350

Time (weeks)

140

160

180

200

220

240

260

280

0 2 4 6

Mean capillaryresistance (mm Hg)

n=60

Protection of microcirculation

1. Bouskela E, Donyo KA. Int J Microcirc Clin Exp. 1995;15:293-300.

2. Galley P, Thiollet M. Int Angiol. 1993;12, 1:69-72.

Increases capillary resistance 2Decreases capillary hyperpermeability 1

Maximum number of leakage sites/cm² induced by inflammatory mediators

Histamine Bradykinin Leukotriene B4

*** *** ***

344 347323

91 110

161

n=100

*** P<0.001

Daflon 500 mg

Placebo

Daflon 500 mg: a comprehensive mode of action

Reduction of local inflammation

Damon M ,Flandre O, Michel F, Perdrix L, Labrid C, Crastes-de-Paulet A. Arzneimittelforschung/Drug Res. 1987;37:1149-1153.

** P<0.01

Time after granuloma induction (days)

n=14

Granuloma TxB2

production*

0

50

100

150

200

4

- 59.5%

***

Granuloma PGF2

production*

0

10

20

30

40

50

60

16

- 45.2%

**

Granuloma PGE2

production*

0

10

20

30

4

- 78.4%

**

*** P<0.001

* pg/mg proteins

Placebo

Daflon 500 mg

Daflon 500 mg: clinical efficacy in hemorrhoidal disease

0.2

0.3

0.4

Micronization provides 30% more clinical efficacy

Cospite M, Cospite V. Phlebology. 1992;7(suppl 2):53-56.

Mean number of acute episodesafter 2 months’ treatment

*

Time (months)

n=59

* P=0.02

Nonmicronized diosmin

Daflon 500 mgPain score

*

- 50%

- 84%

0

1

2

1 20

Daflon 500 mg: clinical efficacy in hemorrhoidal disease

62

20

0

20

40

60

80

On the 3rd day, 3 times less patients with sustained bleeding

* P<0.01

Placebo

Daflon 500 mg

Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

% Patients with sustained bleeding on the 3rd day

n=100

*

3x

Daflon 500 mg: clinical efficacy in hemorrhoidal disease

60

8

48

8

42

6

40

6

0

20

40

60

80

4 5 6 7

Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

* P<0.01

n=100

Placebo

Daflon 500 mg% Patients with sustained bleeding from D4 to D7

Time (days)

Progressively and significantly less bleeding during 1 week treatment

7.5X

6x7x 6.7x

****

Daflon 500 mg: clinical efficacy in hemorrhoidal disease

60

36.2

0

20

40

60

80

Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

* P<0.05

n=100

Placebo

Daflon 500 mg

Significantly less patients with recurrent bleeding

% Patients with recurrent bleeding at D90

*

Duration: 3 months

Daflon 500 mg: the essential treatment in HD and CVD

Micronized form

Comprehensive mode of action

The only phlebotropic drug shown to be effective in venous leg ulcer healing

CHRONIC VENOUS DISEASE 2 TABLETS DAILY

HEMORRHOIDAL DISEASE UP TO 6 TABLETS DAILY

• Known as sclerotherapy• Thrombovar or Fibrovein• Causes destruction of the

vessels and fibrosis• Good for 1st degree• Bleeding• May be repeated• Painless and no downtime• Operator & Skill Dependant• 70% cure rate

Injection of Piles

• Good for early 2nd degree

• Fleshy piles but still internal

• Painless and no downtime

• 87% cure rate• Operator & Skill

Dependant

Rubber Banding

• Piles are excised• Large wounds are left• Very painful• Agony for 2 weeks• Bleeding• Difficult to Pass Motion

Classical Hemorrhoidectomy

• Italians are great innovators

• Fashion, Architecture, Art, Food etc

• New techniques in pile treatment

• Stapling (Longo)• THD

Solutions from Italy

• Has been popular for last decade

• Less painful/some pain• Day surgery• Complications can

happen• Stricture• Fistula• Operator & Skill

Dependant

Stapling

Advantages of Stapling

• Removes all the piles• Great for 4th degree and advanced 3rd degree piles• Instant result• Technically straightforward to perform.

• Disadvantage: painful in some cases.

• Latest high tech solution – 10 months in Singapore but many years in Europe

• No cutting, burning or stapling• Not painful• Much more effective &

efficient than any older techniques in our experience

• Day surgery• Operator & Skill Dependant

Transanal Hemorrhoidal Artery Ligation

• Vessels located by ultrasound

• Vessels are stitched deep in the rectum

• Prolapsed mucosa can be hitched back inside.

• Intervention is in area devoid of pain nerve fibres.

Technique of THAL

• 30 minute procedure• Day surgery• No pain or bearable

discomfort in recovery period for most.

• Instant solution• No downtime• Back to work the next

day in most cases

Advantages

• Large 2nd degree• 3rd degree piles

• Not for badly prolapsed piles.

Indications for THAL

Our own series

• 70 patients• Male: Female 1: 1• Age range 30 to 65• Symptoms:– Bleeding : 70%– Pain : 35%– Prolapse: 90%

• Procedure:– THD alone 85%– THD plus excision 15%

• Post Op– No pain 60%– Slight discomfort 20%– Some pain : 20%– Significant bleeding 2

patients

ASG Series

• 80% back to normal activities in 2 days

• 20% delay going back to normal activities because of pain or bleeding

• 70% complained of increase bowel frequency for a 2 or 3 days.

• One case required rubber banding for remnant tissue

• 3 cases had to have skin tags removed

• One perianal abscess• Two patients had

fistulectomy some months after THD.

• Most patients will feel absolutely no pain• A small minority will have a bearable discomfort in

the anus• Some will have discomfort from wind especially if a

colonoscope was done.• A small minority of 10% to 20% will have some pain.

What will I feel after the Procedure?

• Patients will be able to go to toilet normally• No pain during passing motion.• The doctor can put a finger in the anus the next day

without causing any pain.• More comfortable than after haemorrhoidectomy or

stapling.

Comfort after the Procedure

• Discomfort• Frequent stools• Constipation• Slight bleeding• Mucous discharge• Remnant skin tags • Large piles may take a

while to shrink

Post-operative sequelae

Role of the Family Doctor

• Treatment of 1st and 2nd degree piles– Medication– Dietary advice– Bowel habit advice

• Dealing with blood in the stools• Picking up patients with risk factors of cancer• Post-operative management after THD or Stapler

haemorrhoidectomy

What the Family Doctor can do• Analgesia• DAFLON• Antibiotics• Regulate bowel habits: Laxatives or Lomotil• Reassurance• Wound toilet and dressing• Lignocaine gel, suppositories• Advice on diet• Medical certificate

Conclusions

• 1st and 2nd Degree piles can be treated with medicine, suppositories, injections or rubber band

• THAL is the ideal treatment for most 2nd and 3rd Degree piles

• 4th Degree piles need stapling• Do a colonoscopy to detect cancer and polyps

• GPs have a big role to play in treatment of lower stages of piles and post-operative care.

I had piles for a long time and they bleed frequently. I was very happy that I went for the New piles removal procedure which was comfortable and not painful. Immediately after the procedure, I do not feel any pain and I could go about my normal activities. The services at ASG was very efficient with little waiting time. Overall, I was happy and satisfied with the procedure and also I would recommend it to my friends.

Sergey Kustov8 Jan’10

Testimonial by Our Patient

I had the THAL Procedure & Colonoscopy done on 2 Feb’10. 3 hours later, I was surprised to walking out of recovery normally without feeling pain from the procedure. In fact, my pain then was due to excessive diarrhea from Fleet before the procedure. After leaving the clinic, I went for dinner and I could sit on a wooden bench without a cushion. I was extremely pleased. I am back to work the next day. I could also pass motion normally. I was very satisfied with the overall outcome.

Chiang Sue Fern

Testimonial by Our Patient

TestimonialI’m very glad to share with anyone or everybody whom are suffering from piles my personal experience. It started about 28 years ago. I experienced piles when I was in the army. At that time, the medical officer claimed that it is not harmful at all. So I went along with the idea. As years go by, the piles that I had are getting worse. It became painful at times and it grew bigger with bleeding each time I visited the toilet, I can feel the pain to my head. I do have the habit of sitting too long in there (about 30 to 45 mins). I came across a newspaper advertisement on a seminar about piles removal procedure. I met Dr Peter Goh and his team of staff. At that point of time, I am still not very sure if I should go ahead with the procedure. But Dr Peter Goh was very assuring and given his many years of experience and the trust i had upon him, I decided to proceed with the procedure. To my surprise, after the procedure, I don’t feel any pain at all. I was all alright and could go back to work the next day. There was only a slight discomfort and felt a little feverish but the pile was no longer sticking out from my anus. Henceforth, I would like to take this opportunity to thank Dr Peter Goh and team for helping me and taking care of me before, during and after the operation.

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