SMITH : EARLY OPERATION FOR ACUTE HAEMORRHOIDS 141

We would like to thank Mr. P. W. Clarkson, Casualty Surgeon to Guy’s Hospital, for his en- couragement and assistance. W’e are also indebted to Sister Cousens and Sister Bellamy and their nursing staff, and to children’s house physicians, Drs. George Klauber, Roger Parker, Sarah Marshall, and Gary Hambleton, for their help under often trying conditions.

REFERENCES ALWALL, N., and KJELLSTRAND, C. M. (1965)~ Lancet, 2,

ANDERSON, J., LEE, N. A., and STROUD, C. E. (1969, Br. 389.

med.J., I, 1405.

34, 713. BALSLPIV, J. T., and JBRGENSEN, H. E . (1963), Am.J. Med.,

BATCHELOR, A. D. K., KIRK, J., and SUTHERLAND, A. B. (1961)~ Lancet, I, 123.

BROD, J., and SIROTA, S. H. (1948),J. elin. Invest., 27,645. BROWNE, J. S. L. (I943), in Conference on Metabolic

Aspects of Convalescence ancludijug Bone and Wound Healing: 4th Josiah Macy, Jr . Foundation Conference, New York, p. 97. New York: Josiah Macy, Jr., Foun- dation.

BULL, G. T., JOEKES, A. M., and LOWE, K. G. (1950)~ Clin. Sci., 9, 379.

BUTTERFIELD, W. J. H., and EVANS, E. E. (1952), unpub- lished observations.

BYWATERS, E. G. L. (1942), Br. med.J., 2, 643. CAMERON, J. S., and TROUNCE, J. R. (1965), Proc. Eur.

Dial. Transd. Ass.. I. 7 . CASON, J. S. (;966), Tri‘raniactions of the Second International

Congress on Research in Burns, 1965, p. 12. Edinburgh: - Livingstone.

CLARKSON, P. W. (1960), Proc. R . SOC. Med., 53, 317. -- (1969, Ann. R . Coll. Surg., .37, 207. CREYSSEL, J., DELEUZE, R., GATE, .A., and CAILLARD, B.

CUTHBERTSON, D. P. (1932), Q.31 Med., I (N.s.), 233. DUDLEY, H. A. F., BATCHELOR, A. D. R., and SUTHERLAND,

DUVAL, P., and GRIGAUT, A. (1918)~ C. r . SLanc. Soc. Biol.,

DZIEMIAN, A. J. (1948), Fedn Proc. Fedn Am. SOCS exp.

EVANS, A. (1964), personal communication. GOLDHAHN, W. E. (1960), Zbl. Chir., 85, 1983.

(1961), Lyon. Chir., 58, 137.

A. B. (1957), Br. J. plast. Surg., 9, 275.

81, 873.

Biol., 7, 29.

GOLDSMITH, H. G., NAKAMOTO, N., and KOLFF, W. J.

GRABER, J. G., and SEVITT, S. (1959),J. clin. Path., I2,25. GREEN, A. (1966), Guy’s Hosp. Rep., 115, 129. HAYNES, B. W., DEBAKEY, M. E., and DENMAN, F. R.

(195I), Ann. Surg., 134, 617. LAUSON, H. D., BRADLEY, S. E., and COURNAND, A. (1944)~

J. din . Invest., 23, 381. LUCKE, B. (1946)~ Milit. Surg., 99, 371. MCANINCH, J., MATTER, P., LYNCH, J. B., LEWIS, S. R.,

and BLOCKER, T. G. (1964)~ Tex. Rep. Biol. Med., 22, 348.

METCOFF, J., BUCHMAN, H., JACOBSON, M., RICHTER, H., BLOOMENTHAL, E. D., and ZACHARIAS, M. (1961), New Engl. J. Med., 265, 101.

MOORE, F. D. (1959)~ Metabolic Care of the Surgical Patient. Philadelphia: Saunders. -- LANGOHR, J. L., INGEBRETSEN, M., and COPE, D.

(1960), Lancet, 2, III.

(I950), Ann. Surg., 132, I.

5, 91. MOYER, J. H., and HANDLEY, C. A. (1952), Circulation,

O L ~ O ~ , W. H., and NECHELES, H. (I947), Surgery Gynec.

PARSONS, F. M., HOBSON, S. M., BLAGG, C. R., and

PROYARD, G., and CUYPERS, Y. (1963), Acta chir. belg., 62,

Obstet., 84, 283.

MCCRACKEN, B. H. (1961)~ Lancet, I, 129.

519.

Invest., 34, 62. REISS, E., PEARSON, E., and ARTZ, C. P. (1955), 3. clin.

RUBIN, M. J., BRUCK, E., and RAPOPORT, M. (I949), Ibid.,

SEVITT, S. (1957)~ Burns: Pathology and Therapeutic 28, 1144.

Amlications. London : Butterworths. -. (1959)~ Lancet, 2, 135. --

-- (1965),J. clin. Path., 18, 572. SHACKMAN, R., MILNE, M. D., and STRUTHERS, N. W.

SMITH, H. W. (1956), Principles of Renal Physiology. (1960), Br. med. J., 2, 1473.

London: Oxford Universitv Press. -- FINKELSTEIN, N., AL~MINOSA, L., CRAWFORD, B.,

and GRABER, M. (I945),J. clin. Invest., 24, 388. STEPHENS, F. O., and STEWART, J. H. (1965)~ Lancet, 2,15. TESCHAN, P. E., POST, R. S., SMITH, L. H., ABERNATHY,

R. S., DAVIS, J. H., GRAY, D. M., HOWARD, J. M., JOHNSON, K. E., KLOPP, E., MUNDY, R. L., O’MEARA, M. P., and RUSH, B. F. (I955), Am. J. Med., 18, 172.

WYNN, V. (1960), ‘ Some Problems of Water Metabolism following Surgery’, in The Biochemical Response to Injury (ed. STONER, H. B.), p. 291. Oxford: Blackwell.

EARLY OPERATION FOR ACUTE HAEMORRHOIDS BY MERVYN SMITH ADELAIDE, SOUTH AUSTRALIA

THE time-honoured method of treating acute pro- lapsed, thrombosed, and ulcerated haemorrhoids is to tide the patient over the acute episode and to recom- mend surgery as an interval procedure some weeks or months later. Tiding the patient over the acute attack consists of putting him to bed, with the foot of the bed on blocks, giving him morphine for pain, attempting to replace the pile mass with the gloved finger, and applying soothing and mildly antiseptic lotions to the part.

Anyone who has used this method must have been impressed by the inefficiency of it. Reduction of

acute pile masses is not easy, the maintenance of the reduction is even more difficult, and the whole treatment thus becomes a tedious and sometimes worrying affair until, by effluxion of time, the patient’s natural resilience gets the upper hand and the con- dition slowly resolves. But this is not the end of the course, as arrangements need then to be made to readmit the patient to hospital at a later date for haemorrhoidectomy, an event to which he will not look forward to without some apprehension after his previous ordeal. Yet there has appeared to be no very satisfactory alternative to this rkgime, as we have

142 BRIT. J. SURG., 1967, Vol. 54, No. 2, FEBRUARY

been taught over the years the great danger of surgery at these times, and deaths from ascending infection and portal pyaemia have always been hinted at.

FIG. ac acute thrombosed and ulcerated haemorrhoids. Note the freedom from involvement of the pile pedicles.

The supposed dangers of surgery in these acute cases, however, exist largely on hearsay evidence, and a search of the literature does not bring to light many actual cases. For example, Ackland (1961) was able to find reported only 3 tragedies following haemor- rhoidectomy and, of these 3, 2 in fact followed the

gave him confidence to accept early operation as a feasible and safe procedure. Laurence and Murray (1962), also believing in operation in the acute case as a safe procedure, and for the same reason, carried out histological studies on a series of haemorrhoids removed at operation-thrombosed and non- thrombosed, with intact and with ulcerated epithelial covering. They found that if the overlying mucosa was intact there was virtually no difference in the amount of inflammatory infiltrate present between the thrombosed and the simple pile. There was nearly always a small amount of inflammatory exudate present, but the amount did not vary whether there was thrombosis present or not. On the other hand, when there was ulceration present the amount of inflammatory change noted was considerably more, and this tended to be a little more marked in the thrombosed ones. They concluded from this that it was not the thrombosis that was significant, but rather the presence or absence of ulceration. More important, I think, they showed that the inflammatory exudate tended to be limited almost exclusively to the ulcerated area irrespective of whether the haemor- rhoids were thrombosed or not.

PRESENT SERIES During the past 2 years we have carried out

operations on 15 cases of acute haemorrhoids. This is not a large series, but we think that it is enough to have confirmed the findings of previous authors and to make some points about management. I t can be said that the operation was always straightforward and

A B FIG. 2.-Routine haemorrhoidectomy. A, Section cut through apex of pile showing dilated blood-vessels; no surrounding

inflammatory change. 6, Section through base of same pile showing virtually the same picture.

performance of a routine haemorrhoidectomy and only I followed surgery for prolapsed piles. More- over, the significance of the last case is rather offset by the report of Lockhart-Mummery’s (1934) case. This, also, was a death from portal pyaemia, but it followed the conservative management of acute haemorrhoids.

Ackland (1961) reported several cases of throm- bosed, strangulated, and ulcerated haemorrhoids treated by immediate surgery. He referred particu- larly to the freedom from thrombosis in the vicinity of the pile pedicle, and it was this observation that

the postoperative convalescence no different from a routine haemorrhoidectomy.

The operation performed in all cases was the standard St. Mark’s type of haemorrhoidectomy with the three skin wounds left open. Under anaes- thesia, when it was possible to assess the situation more accurately than before operation, Ackland’s observations of the normality of the pedicle could usually be confirmed (Fig. I). In some cases the thrombotic process involved the region of the pedicle, but ulceration never did and the pedicles were always obviously free of infection.

SMITH: EARLY OPERATION FOR ACUTE HAEMORRHOIDS I43

well as being a painful and distressing acute illness. Conservatism has always been advocated in these conditions, but such treatment is time-consuming and largely unsatisfactory. While sometimes resulting in a spontaneous cure, so often it needs to be supplemented

The excised tissue was submitted to histological examination, as was the tissue from a similar number of routine haemorrhoidectomies performed in the same period. The findings were substantially those of Laurence and Murray (1962).

A 0 FIG. 3.-A Section through apex of one of the acute haemorrhoids with scattered polymorphs as well as thrombosis and

haemorrhage. 6, High-power view of same section’showing extravascular polymorphs.

A B FIG. 4.-A, Section through base of same acute pile as Fig. 3. Although thrombosis and haemorrhage are apparent, polymorph

infiltration is not a feature. Note ‘margination’ of leucocytes. 6, High-power view of same section showing the margination.

Thus in the routine cases lit was usual to find merely dilated vessels with no evidence of any inflammatory change. There was virtually no difference in this histological picture whether the section was cut through the apex of the pile or through the base (Fig. 2).

The acute cases, on the other hand, showed a very different picture. A section through the apex of such a pile, besides showing dilated vessels, thrombosis, and haemorrhage, almost invariably showed con- siderable polymorphonuclear infiltration of the extra- vascular tissues (Fig. 3). Section through the base of the pile, however, revealed no such reaction and showed merely haemorrhage in the tissues. (Fig. 4.)

DISCUSSION Acute episodes associated with internal haemor-

rhoids are a major economic event to the patient, as

by further hospitalization and operation at a later date, and thus any improvement in the management of the condition would be welcome.

Some of these cases, when first seen, show obvious gangrenous changes involving various degrees of the anal canal and it is believed that these should con- tinue to be managed in the classic manner.

However, a much greater proportion, despite extensive thrombosis and ulceration, exhibit com- paratively normal pedicles, and it is contended that such cases are well treated by early operation. Confidence in the safety of such operations is afforded by the histological study of material removed at operation and by comparing this material with similar material removed in routine haemorrhoid- ectomy cases. Although there may be thrombosis still present at the base of the acute haemorrhoid, there is no inflammatory exudate present, and

I44 BRIT. J. SURG., 1967, Vol. 54, No. 2, FEBRUARY

thus the danger of transfixing and excising such a pedicle is no greater than similarly removing a non- thrombosed pile.

SUMhk4RY I. Haemorrhoidectomy may safely be carried out

for haemorrhoids that are prolapsed, thrombosed, and ulcerated, but not gangrenous.

2. A review of the literature has failed to sub- stantiate the widely held belief that operation at this time carries with it a risk of infection and sub- sequent portal pyaemia.

3. This reassurance is strengthened by a careful observation of the pile pedicles revealing freedom from infection where the excision is made.

4. Histological examination of the excised tissue adds further confirmation.

5. With the safety of surgery assured, there can be little doubt that early operation promises the patient much saving of time and discomfort, and it is accordingly advocated in preference to the classic, but unsatisfactory, conservative management.

REFERENCES ACKLAND, T. H. (1961)~ Aust. N.Z.J. Surg., 30, 201. LAURENCE, A. E., and MURRAY, A. J. (1962), Dis. Colon

LOCKHART-MUMMERY, P. (I934), Diseases of the Rectum Rectum, 5, 56.

and Colon. London: Bailliere, Tindall, & Cox.

ASSESSMENT OF VASCULAR INTEGRITY OF INTESTINAL SEGMENTS BY DYE INJECTION*

BY KWOK-HAY KWONG, RONALD E. FRASER, AND BRUCE C. PATON FROM THE HALSTED LABORATORY FOR EXPERIMENTAL SURGERY, DEPARTMENT OF SURGERY, UNIVERSITY OF COLORADO MEDICAL CENTER,

DENVER, COLORADO

OBVIOUSLY non-viable bowel is black, haemorrhagic, 2 G dye. They considered that the use of this dye and oedematous, without pulsation in the mesenteric provided a quick and accurate method to delineate arteries and without peristalsis. In many doubtful the ischaemic margins. This present study was cases or when insufficient time may have elapsed designed to show whether this dye could be used to

assess the integrity of the intestinal circulation b immediately after the blood-supply had been

FIG. is isolated segments of bowel with reanastomosis at one end with intact blood-supply (a), and. with impaired blood-supply at other end (d). Shaded areas inmcate stained bowel; spotted segment, patchy dye; clear segment, no dye.

after the occlusion of the blood-supply to be certain of the outcome, these changes may not be so clear-cut. I t is in cases such as these that the injection of dyes or radio-isotopes might be of value in demonstrating whether a particular segment of bowel has an adequate blood-supply. Lazarus and Warren (1965) produced non-viable bowel by occlusion of the mesenteric vessels for 12 to 24 hours and demonstrated that non-viable bowel was not stained by alpha zurine

~~ ~

* This work was supported in part by a grant from the U.S. Public Health Service No. HE-02710.

interrupted and before any pathological changes had occurred.

METHOD Group A (10 Dogs).-A segment of jejunum (5

dogs) or right colon ( 5 dogs) measuring 20-30 cm. was delivered through a midline incision. The segment selected was supplied by at least three branches of the jejunal or ileocaecal arteries. At one end of the segment the arteries were ligated where they joined the collateral arcade, and the bowel was divided and reanastomosed at a point where the blood- supply was intact on one side but compromised on the other (Fig. I). At the other end of the segment the bowel was divided and reanastomosed at a point where the blood-supply was intact on both sides (Fig. I, a). The bowel was anastomosed with a single layer of interrupted silk sutures.

After the bowel was reanastomosed, 20 mg. per kg. of body-weight of alpha zurine zG dye were injected into a peripheral vein. After 1-15 seconds all the bowel was uniformly stained green by the dye except for a segment about 7.5 cm. long at (d), which was not stained. Ten to 15 seconds later a short segment 2'5-5 cm. long was patchily stained (Fig. I, b-c), leaving a segment (c-d) unstained even after 10-15 minutes. The dye did not diffuse across the anasto- mosis between the ischaemic segment and the normal bowel. Stitches were placed at (b) and (c) to mark the patchily stained and non-stained segments (Fig. 2). The bowel was returned to the abdomen. The