2. The Rise And Fall Of Lords Anal StretchPresentation Transcript
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’…
WHAT IS LORD’S ANAL
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.
Relevant anatomy of the Anal
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
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.
WHAT ARE HEMORRHOIDS?
Synonymous with Piles.
Dilated veins occurring in relation to the
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).
• 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
Internal hemorrhoids are classified according to the degree of prolapse.
1st degree hemorrhoids – bleeding without prolapse.
2nd degree hemorrhoids – prolapse on straining but
3rd degree hemorrhoids – prolapse on straining
and require manual
4th degree hemorrhoids – irreducible prolapse,
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.
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
• 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
WHAT IS LORD’S
• 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
INDICATIONS FOR LORD’S
• 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
• Constipation caused by a tight anal
• Patient is under 50 years .
• Patient has a tight sphincter.
• History of painful defecation.
A SIGMOIDOSCOPY or
PROCTOSCOPY should always
follow a digital examination so as
not to miss a diagnosis of carcinoma
of the rectum.
SO WHERE’S THE
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
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
Hence, this procedure in uncommonly used today.
HOW DOES IT CAUSE FECAL
Disruption of these ‘voluntary’
muscles via Lord’s procedure Rectal Distention
Ext. anal sphincter (EAS) Int. anal sphincter(IAS)
If appropriate EAS & Not appropriate (EAS and PR
PR relaxation remain contracted)
IAS recovers tone
Defecation urge passes
Hemorrhoidectomy vs . Lord’s method: 17-
yr follow-up of a prospective, randomized
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
Group A (n=35) – Hemorrhoidectomy.
Group B (n=39) – Anal dilatation and aftertreatment with Lord’s
Group C (n=44) – Dilatation only.
(14 patients died during the trial.)
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
The percentage of repeated treatment for the three subgroups was 11,23 and 18
The continence status remained approximately the same during the first year of the
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.
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
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
This resulted in a cure and he became free of hemorrhoids.
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
Reader’s Digest has identified the bathroom as
the number one site for reading for Adults in the
Spending significant amounts of time reading
on the commode is thought responsible for the
development of hemorrhoids in many
AND SO…WHAT ARE
THE ALTERNATIVES IN
• 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
• 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.
SIDE EFFECTS OF RUBBER BAND
Bleeding (usually immediately after banding or
7-10 days later when band falls off).
Perineal sepsis (life threathening/ pain/fever/ diff.
• Coagulator generates infrared radiation which
coagulates tissue protein and evaporated water from
• Amt. Of destruction depends on intensity & duration
• 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.
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
This has led to poor patient tolerance and has
minimised the effect of the procedure.
• 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.
• 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
• 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.
• ‘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
WHAT DOES IT MEAN?
A spiritual change as during baptism.
A change in the location of a disease, as from one part
The act or process by which matter is taken up by cells
or tissues and is transformed into another matter.
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.