Piles | Fissure | Fistula
Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients’ lives. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical.
Treatment of Piles, Fissure & Fistula
What are Piles and how are they treated?
Hemorrhoids, also called piles, are swollen and inflamed veins around your anus or in your lower rectum.
The two types of hemorrhoids are
external hemorrhoids, which form under the skin around the anus
internal hemorrhoids, which form in the lining of the anus and lower rectum
Symptomatic hemorrhoids tend to be self-limiting and often respond well to conservative medical treatment: increasing fluid and fiber intake, regular exercise, avoiding constipation and straining, and spending less time on the toilet.
Rubber band ligation
Rubber band ligation is the most commonly performed office procedure for bleeding grade II and III hemorrhoids. During this procedure, a rubber band is placed around a hemorrhoidal column, causing tissue necrosis and fixation to the mucosa.
Sclerotherapy is another office-based procedure for treating internal grade I and II hemorrhoids. This is an especially good treatment for those on anticoagulation or with coagulopathy. Similarly to rubber band ligation, the procedure is performed with an anoscope and without anesthesia to visualize the hemorrhoids and inject them with a sclerosant, such as 5% phenol in vegetable oil, ethanolamine, quinine or hypertonic saline. This causes fibrosis and fixation of the tissue to the anal canal, effectively obliterating the redundant hemorrhoidal tissue.
Surgical treatment is indicated for grade III or IV internal hemorrhoids and for thrombosed external hemorrhoids with persistent symptoms. Excision is recommended within the first 48 h of symptoms for thrombosed external hemorrhoids. Incision and drainage is ineffective, and complete excision of the hemorrhoid with the associated external skin is advised.
Stapled hemorrhoidopexy is another surgical method for grade II and III hemorrhoids that uses a stapler device to resect and, more importantly, fixate tissue to the rectal wall.
Laser coagulation of vessels has the advantage of conservation of anatomy and physiology of anal canal, compared to other forms of treatment. Thus, it minimizes post-operative impaired anal function. Due to the highly selective effects of laser beams effect on arteries, the damage caused to the surrounding area is minimum.
What is Fissure and how is it treated?
An anal fissure is a linear tear in the anal mucosa, usually extending from the dentate line to the anal verge. Fissures are defined as acute if present for less than 8 weeks, and they are defined as chronic if present for more than at 8-12 weeks and feature edema and fibrosis. Chronic anal fissures persist as nonhealing ulcers by anal sphincter spasm and result in ischemia
Treatment of anal fissures starts with conservative treatment including stool softeners, fiber supplementation, sitz baths, and topical lidocaine gel for pain control.
Lateral internal sphincterotomy (LIS)
LIS is the surgical treatment of choice for chronic fissures
Local advancement flaps
Local advancement flaps are the first line surgical treatment for chronic anal fissures associated with normal or low anal pressures.
Fissurotomy and fissurectomy
Many fissures have subcutaneous tracts that extend distally from the chronic fissure to a sentinel tag. Fissurotomy is the act of incising that tract to release the perianal skin, therefore creating a widening of the anal canal. The wound is left open to heal by secondary intention.
What are Perianal abscesses and fistulas and How are they treated?
Anorectal abscesses represent a very common disease process that typically results from a cryptoglandular infection in the anal canal and can occur in the ischiorectal, intersphincteric, supralevator, perianal or submucosal spaces. They are more common in men and their incidence peaks around age 20-40 years. Abscesses and fistula often occur concomitantly, with 30-70% of those with active abscesses having a current fistula. Of people with anorectal abscesses who do not currently have a fistula, 30-50% will develop one in the future.
An anal fistula is a persistent epithelialized tract from the anal canal to the perianal skin, and can be intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric. Fistulas are considered simple if they are low transsphincteric or intersphincteric and cross less than 30% of the external sphincter. Complex fistulas include those that are high transsphincteric (involving more than 30% of the external sphincter), extrasphincteric or suprasphincteric, and cryptoglandular in origin, in addition to fistulas associated with inflammatory bowel disease, radiation, malignancy, chronic diarrhea or preexisting incontinence. Eighty percent of fistulas are secondary to cryptoglandular infection, with the remainder due to Crohn’s disease, trauma, radiation, malignancy or various infectious diseases.
Incision and drainage
Anorectal abscesses require incision and drainage for treatment. Since many of them will develop into fistula, it is important to keep the incision as close as possible to the anal verge to minimize the length of a potential fistula.
The overall goal of fistula surgery is to obliterate the internal os and epithelialized tract with minimal sphincter division.
Seton and staged fistulotomy
A seton is a suture, rubber band or vessel loop passed through the fistula tract, where it allows drainage and converts an inflammatory process to a foreign body reaction, causing perisphincteric fibrosis. This often causes shortening of the tract and decreases the amount of sphincter involved, allowing for subsequent fistulotomy in cases where initially too much sphincter muscle was involved. Cutting setons work through progressive tightening of the seton, and create a gradual fistulotomy with scarring of the tract over time.
LIFT is a newer technique used to treat simple and complex transsphincteric fistulas. First described in 2007, it utilizes dissection in the intersphincteric plane to identify, suture ligate, and divide the intersphincteric fistula tract.
The most recent and minimally invasive treatment for fistulas is the use of “Fistula Laser Closing” or FiLaC. This technique uses a radial emitting disposable laser fiber for endofistular ligation of the tract. This can also be supplemented with an endoanal advancement flap.
Prevention of Piles & Fissure
Piles and Fissure are Preventable. They need lifestyle modification:
High Fibre diet
Plenty of Oral Fluids
Regular Exercise so that your body keeps moving
Avoid sitting for longer time unnecessarily in toilet
Go to pass stools only when you have the urge. Don’t strain unnecessarily.
Treat your constipation. Take laxatives intermittently if you get hard stools
Can piles recur after surgery?
Yes Piles can recur after surgery if you apply undue straining while passing stools. You need to change your lifestyle by including fibres, plenty fluids in your diet and also avoiding constipation and hard stools.
When can I return to work after Piles Fissure surgery?
You can return to work in 2 to 3 days after surgery as LASER procedure is postoperatively less painful.
Return to normal life
From next day of surgery you can start walking and can do light work
Where can I find the best Piles Fissure Fistula surgeon in Mumbai? Near me?
Dr. Sunny Agarwal is one of the best Piles Fissure Fistula (Proctology doctor) surgeon in Mumbai. He aims at delivering good relief to his patients by using LASER, sclerosants, different surgical modalities, medications and proper follow up. Dr. Sunny Agarwal operates in many centers like Chembur, Sion, Ghatkopar, Mankhurd, Tilak Nagar, Andheri, Borivili, Dombivili, Navi Mumbai, Vashi, Kharghar, Thane.
What happens if I don't get piles fissure operated now?
A small pile can grow into a Grade 4 Pile mass which is completely prolapsed outside causing extreme pain and bleeding
Getting operated on time is important otherwise the problem keeps on increasing, affecting the Quality of Life. Also a surgery that can be done easily with LASER has to be done by cut technique.
What is the best treatment for Piles?
If you are getting relief with medications or if the pile mass is too big then surgery is the only option. It can be done with Laser, stapler or open method.
What is the best treatment for Fissure?
First step is to use muscle relaxant creams that include Calcium channel blockers along with tablets for pain relief and anti inflammation. This should be combined with a laxative. If these fail then surgery will definitely give you a quick relief.