2. The Rise And Fall Of Lords Anal Stretch

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  • 1. THE RISE AND FALL OF LORD’S ANAL STRETCH. Also, stay glued to your seats for the riveting unveiling of the derivation of the word ‘metastasis’…
  • 2. WHAT IS LORD’S ANAL STRETCH? It was used as a therapeutic surgical intervention for hemorrhoids. However, to fully grasp the rationale for its use and the reasons for its abandonment, one must have basic knowledge of the pathophysiology of hemorrhoids and anatomy of the rectum and anus.
  • 3. Relevant anatomy of the Anal Canal…  Fibrovascular cushions are part of the normal anatomy within the anal canal and are thought to be important in maintaining continence. These fibrovascular cushions are classically found in the 3,7 and 11 o’clock positions. Upon any increase in intraabdominal pressure ( coughing/sneezing/straining), these cushions engorge and maintain closure of the anal canal in order to prevent leakage of stool. Fibrovascular cushions are also important in sensation of the anal canal, specifically in differentiating liquid, solid and gas It is important to note that surgical removal or disruption of these cushions may result in varying degrees of incontinence particularly in individuals with marginal preoperative control.
  • 4. WHAT ARE HEMORRHOIDS? Synonymous with Piles. Dilated veins occurring in relation to the anus. Hemorrhoids are thought to represent the engorgement or enlargement of the normal fibrovascular cushions in the anal canal. Originates from the Greek words haima (blood), and rhoos (flowing).
  • 5. CLASSIFICATION OF HEMORRHOIDS… • Divided into internal and external hemorrhoids. • Internal hemorrhoids arise from the internal hemorrhoidal venous plexus above the dentate line. • External hemorrhoids originate from the external plexus below the dentate line. • This line lies at 2 cm from the anal verge. • It demarcates the transition from the upper anal canal, lined with columnar epithelium, and the lower anal canal which is lined with stratified squamous epithelium.
  • 6. SUBCLASSIFICATION OF INTERNAL HEMORRHOIDS: Internal hemorrhoids are classified according to the degree of prolapse. 1st degree hemorrhoids – bleeding without prolapse. 2nd degree hemorrhoids – prolapse on straining but reduce spontaneously. 3rd degree hemorrhoids – prolapse on straining and require manual reduction. 4th degree hemorrhoids – irreducible prolapse, incarcerated.
  • 7. PATHOPHYSIOLOGY OF HEMORRHOIDS… It has been postulated that chronic straining secondary to constipation results in pathologic hemorrhoids. After prolonged and repeated straining, these fibrovascular cushions lose their attachment to the underlying rectal wall. As these hemorrhoids engorge, the overlying mucosa becomes more friable and the vasculature engorges too. Arterio-venous shunts normally exist within these cushions and they lie loosely in the submucous connective tissue of the anorectum. As these veins pass through the muscular tissue, they are liable to be constricted by the contraction of the rectum during defecation. The superior rectal vein is commonly implicated in the manifestation of internal hemorrhoids. Hence, factors that result in an increase in resting anal pressure are etiologically responsible for the production of hemorrhoids. These factors are : Chronic straining 2o to constipation/ tenesmus Tumour (compression/thrombosis of superior rectal vein) Pregnancy( comp.of sup.rectal vein and relaxant effect of progesterone on smooth muscle of veins leading to an increase in pelvic circulatory volume) Contrary to usual belief, in 128 cases of portal HT, not a single case of hemorrhoids was encountered that could be attributed to cirrhosis.
  • 8. RATIONALE FOR USE OF LORD’S ANAL STRETCH: • In 1968, Peter Lord decided to utilise the fact that patients with hemorrhoidal disease tended to have higher resting pressures in the anal canal and that outlet obstruction led to straining and subsequent hemorrhoidal disease. • Hence, he came up with the concept of manual anal dilatation. • Procedure was first introduced in Great Britain. • Aim of the procedure was not only to cure hemorrhoids, but to also reduce the length of hospitalisation. • With a Lord’s procedure, a patient would only need to be in hospital a few hours and subsequently treated as an outpatient as opposed to excision and ligation which would involve a few days of hospitalisation. • Lord’s anal stretch was normally indicated in patients with second degree prolapse and as an aggressive approach for the treatment of anal fissures.
  • 9. WHAT IS LORD’S TECHNIQUE? • Anal canal is stretched until four fingers or each hand can be inserted. • Anus is gradually stretched over 3 – 4 minutes. • Once the fingers are inserted, they are pronated and distracted in opposite directions. The strain is applied to the 3 and 9 o’clock positions and the 6 and 12 o’clock positions are avoided as they are weaker. • Procedure is conducted under general anaesthesia or intravenous sedation. • Prior to procedure, perform a digital examination to feel for the constricting band which is usually at the level of the anorectal line. • If anus is tight, anal stretch tends to be more successful. If anus is loose, proceed to hemorrhoidectomy. • Patients were also asked to intermittently insert an anal dilator once at home. • By doing so, the anal sphincter will be dilated and it reduces the discomfort during defecation.
  • 10. INDICATIONS FOR LORD’S ANAL PROCEDURE… • 2ND or 3rd degree piles. • Acutely prolapsed and strangulated piles. • 1st or 2nd degree piles which bleed heavily, esp if patient has a tight sphincter. • Anal fissure including an associated anal tag. • Constipation caused by a tight anal sphincter.
  • 11. GOOD PROGNOSTIC FACTORS… • Patient is under 50 years . • Patient has a tight sphincter. • History of painful defecation.
  • 12. PRECAUTION!! A SIGMOIDOSCOPY or PROCTOSCOPY should always follow a digital examination so as not to miss a diagnosis of carcinoma of the rectum.
  • 13. SO WHERE’S THE PROBLEM?  There is no standard degree of dilation that is required. The necessary degree of dilatation varies with each patient.  As a rule of thumb, it is better to dilate too little rather than too much.  Hence the MAIN ADVERSE EFFECT is the unpredictable amount of sphincter injury sustained.  Hence the procedure was abandoned as it was associated with high levels of incontinence in the elderly, especially fecal incontinence.  It is important to note that this adverse outcome was very debilitating.  Hence, this procedure in uncommonly used today.
  • 14. HOW DOES IT CAUSE FECAL INCONTINENCE? Disruption of these ‘voluntary’ muscles via Lord’s procedure Rectal Distention Ext. anal sphincter (EAS) Int. anal sphincter(IAS) and relaxes Puborectalis muscle(PR) contract Defecation urge If appropriate EAS & Not appropriate (EAS and PR PR relaxation remain contracted) IAS recovers tone Stool passage Defecation urge passes
  • 15. Hemorrhoidectomy vs . Lord’s method: 17- yr follow-up of a prospective, randomized trial PURPOSE: The trial was performed between 1979 and 1981 comparing anal dilation and hemorrhoidectomy for hemorrhoidal disease at the Maastricht University Hospital, Netherlands. AIM: To update the trial to assess long-term outcome and complications such as fecal incontinence. METHODS: 138 patients with 2nd and 3rd degree hemorrhoids entered the study. Median follow-up was 17 years and was achieved for 118 (86 %) patients. Group A (n=35) – Hemorrhoidectomy. Group B (n=39) – Anal dilatation and aftertreatment with Lord’s procedure. Group C (n=44) – Dilatation only. (14 patients died during the trial.)
  • 16. CONT’D… RESULTS: Recurrent hemorrhoids noted for 26 percent of the patients treated with hemorrhoidectomy, for 46 percent with operative dilation with the postoperative dilation program, and for 39 percent with operative dilation without the postoperative program. The percentage of repeated treatment for the three subgroups was 11,23 and 18 percent respectively. The continence status remained approximately the same during the first year of the trial. However, 17 years later, the anal stretch procedures caused various incontinence disorders in 52 percent of these patients. Significance was found for incontinence of flatus in the anal dilation groups.
  • 17. CONT’D… CONCLUSIONS: Hemorrhoidectomy can be considered to be a safe procedure for treatment of hemorrhoidal disease as it has excellent long-term results. Anal dilation however, is associated with a high percentage of complaints of fecal incontinence. Hence, the procedure should be abandoned!! END OF TRIAL
  • 18. History of Hemorrhoids… In medieval times, hemorrhoids were known as St. Fiacre’s curse and today, those around the world afflicted with this visit St. Fiarce's stone in order to obtain a miracle cure. St. Fiacre, also known as the patron saint of gardeners, was told he could farm all the land he could cultivate in a single day being given a particularly small shovel by a less than benevolent bishop. After a particularly long day at the garden, in order to obtain the maximum amount of land, he developed a terrible case of prolapsed hemorrhoids. Seeking a solution, he sat on a stone and prayed for resolution of his problems. This resulted in a cure and he became free of hemorrhoids.
  • 19. CONT’D According to the legend, the imprint of St. Fiacre’s hemorrhoids remains on the stone today and sufferers from all over the world continue to sit on this stone and pray for relief.
  • 20. TRIVIA… Reader’s Digest has identified the bathroom as the number one site for reading for Adults in the United States. Spending significant amounts of time reading on the commode is thought responsible for the development of hemorrhoids in many individuals!
  • 21. AND SO…WHAT ARE THE ALTERNATIVES IN MODERN COLORECTAL SURGERY?
  • 22. OUTPATIENT TREATMENT OF HEMORRHOIDS: RUBBER BAND LIGATION RUBBER INFRARED COAGULATION INFRARED BICAP ELECTROCOAGULATION BICAP INJECTION SCLEROTHERAPY INJECTION CRYOTHERAPY CRYOTHERAPY LORD’S ANAL STRETCH LORD’S
  • 23. RUBBER BAND LIGATION: • Technique was originally described by Barron in 1963. • Indicated for patients with 2nd degree hemorrhoids which are too large for successful handling by injections. • Tight elastic bands are slipped on to the base of the pedicle of each hemorrhoid. • These bands cause ischaemic necrosis of the piles. • Hence, they slough off within days. • Procedure is painless if done properly. • No more than 2 hemorrhoids should be done at each session. v • Most effective outpatient procedure for hemorrhoids.
  • 24. SIDE EFFECTS OF RUBBER BAND LIGATION: Bleeding (usually immediately after banding or 7-10 days later when band falls off). Pain Thrombosis Perineal sepsis (life threathening/ pain/fever/ diff. Urinating).
  • 25. INFRARED COAGULATION: • Coagulator generates infrared radiation which coagulates tissue protein and evaporated water from cells. • Amt. Of destruction depends on intensity & duration of application. • Recommended duration of 1.5 sec and each hemorrhoid be coagulated 3X . • Performed after administration of a phosphate enema. • Its designed to decrease blood flow to the region, but is not particularly effective in treating large amounts of prolapsing tissue. • Therefore, it is most beneficial in treating 1st degree and small 2nd degree hemorrhoids. • Less painful than rubber band ligation.
  • 26. BICAP ELECTROCOAGULATION:  Commonly used in operating theater when precise coagulation is needed as the penetration is less compared to the monopolar cautery.  Probe must be left in place for 10 minutes during procedure.  This has led to poor patient tolerance and has minimised the effect of the procedure.
  • 27. INJECTION SCLEROTHERAPY: • Commonly used for 1st and 2nd degree hemorrhoids as an alternative to band ligation. • Involves injection of an irritating material into the submucosa in order to decrease its vascularity and promote fibrosis. It also fixes the hemorrhoidal bundle to the rectal wall, therefore decreasing bleeding and prolapse. • Injecting substances have traditionally been phenol in oil, sodium morrhuate or quinine urea. • Occasionally results in a dull ache for 24-48 hours. • Rare reports of misplacement of the sclerosing agents leading to significant perianal infection and fibrosis.
  • 28. CRYOTHERAPY: • This procedure utilizes liquid nitrogen at extremely cold temperatures (-196o).This causes coagulation necrosis of the piles, which causes them to eventually separate and drop off. • Unfortunately results in foul smelling mucus discharge and pain associated with slow healing. • Hence, it has fallen into disfavor and has been abandoned.
  • 29. SURICAL TREATMENT: • HEMORRHOIDECTOMY • STAPLED HEMORRHOIDECTOMY
  • 30. SUMMARY: • While it was immediately effective in curing hemorrhoids, Lord’s anal stretch was abandoned due to the fact that it caused incontinence problems. Hence, other procedures have been introduced since then. The most effective of outpatient methods is the rubber band ligation.
  • 31. DERIVATION OF ‘METASTASIS’: • ‘Metastasis’ comes from the Greek word, ‘methistanai’, which means to change. • Meta + histanai means to cause to stand. • Comes from the Latin construction meaning ‘to change position’.
  • 32. WHAT DOES IT MEAN? • THEOLOGICAL: A spiritual change as during baptism. • MEDICAL: A change in the location of a disease, as from one part to another. • PHYSIOLOGICAL: The act or process by which matter is taken up by cells or tissues and is transformed into another matter.
  • 33. ONCOLOGICAL DEFINITION: Metastasis refers to the transmission of pathogenic microorganisms or cancerous cells from an original site to one or more sites elsewhere in the body, usually by way of blood vessels or lymphatics.