This document provides biographical information about Dr. Goh and summarizes his expertise in endoscopy and treatment of hemorrhoids. It notes that Dr. Goh was the top student in his medical class, has pioneered many endoscopic procedures, and helped establish endoscopy centers in Singapore and Germany. The document then summarizes various treatment options for hemorrhoids including medications, injections, banding, stapling, and THD (Transanal Hemorrhoidal Artery Ligation), the latest minimally invasive technique developed in Italy. THD is described as a safe, painless outpatient procedure with quick recovery and good results in experienced hands.

2. Pioneered many therapeutic procedures through the scope.

3. Head of NUH Endoscopy centre: Was involved in design and building of NUH endoscopy centre > 650 cases per month

4. Head of Endoscopy Service in University of Cologne, Hospital at Merheim.

5. Taught Endoscopy to many doctors and surgeons worldwide

7. The Problem with Piles Dr. Peter M.Y. Goh FRCS Advanced Surgical Group Singapore Singapore 2010

8. Toilet becomes an agony? Disturbing symptoms? Lump Pain Bleeding One in 4 people have piles! Is something wrong at the rear end?

9. Anal cushions Distinguish gas from liquid Swell and prolapse from straining at stool What are piles?

10. Straining and pushing Piles elongate and grow bigger Pushed outside the anal sphincter May be strangulated How Piles Develop

11. May be perianal hematoma Or prolapsed internal pile External Piles

12. Pain Bleeding Lump in the anus (Prolapse) What are the symptoms of piles

13. Heamatochezia Piles may bleed profusely Usually stains the toiletpaper or coats the stool. Bright red blood Blood in the stools

14. 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

15. Discover other causes of bleeding Very comfortable procedure Heavy sedation No recollection Takes about 10 to 15 minutes. Colonoscopy

16. Diagnosis Lower GI symptoms Screening Family history of Cancer Previous Polyps Over 40 years Which patients need a Colonoscopy

17. Polyps can be removed Lesions can be biopsied Diagnostic and Therapeutic at the same time Colonoscopy saves lives! Most important Benefit of Colonoscopy

18. Many diseases can be treated through the scope Makes Operation uneccessary Therapeutic Potential of Endoscopy

19. 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

20. 1st and 2nd Degree piles

21. 3rd and 4th Degree piles

22. 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

23. Pregnancy and Piles Increase intrabdominal pressure Pushing during delivery Piles common in pregnancy Can be treated even when pregnant without danger to baby

24. Constipation Very common problem Old and young people Excessive straining because of constipation can lead to Piles Can have other causes…?Cancer

25. When should I worry? Diarrhoea can also cause piles Frequent bowel movement and straining. Must worry when there is blood or mucous Diarrhoea

26. Common causes of Diarrhea Infection Inflammatory bowel disease Irritable Bowel Cancer Food allergy intolerance

27. Frequency Consistency Caliber Alternation of diarrhea and constipation regularity Change in Bowel Habits

28. Other Pathology in the Perianal area Fistulas Warts Polyps Peri-anal abscess Cancer Be aware that there are many differential diagnosis

29. Treatment of piles depend on the degree of prolapse. The more prolapse the bigger the treatment. Hemorrhoids :Treatment

30. Medication : Daflon Suppositories Diet change Fiber, fruits, vegetables Drink more water Good Bowel habits Treatment of Early Piles

31. Daflon 500 mg: Indications chronic venous insufficiency acute & chronic hemorrhoids

32. Cylindrical air micronizer Micronized purified flavonoid fraction Purified flavonoid fraction Compressed air (1000 km/h) Daflon 500 mg: a unique micronized form A unique high-tech process using an air-jet stream at supersonic speed

33. Daflon 500 mg: a unique micronizedform for provenbetterbioavailability Nonmicronized diosmin ** Urinary excretion (%) Daflon 500 mg 57.9 * P=0.0001 ** P=0.0004 * 32.7 31.1 15.9 24 Hours 168 Hours Crossover study in 12 healthy volunteers taking [14C] diosmin orally (micronized vs nonmicronized) Garner RC, Garner JV, Gregory S, et al. J Pharm Sci. 2002;91:32-40.

34. Daflon 500 mg: a comprehensive mode of action On venous tone On microcirculation On lymphatic drainage Reduction in inflammatory process

35. Daflon 500 mg: a comprehensive mode of action * * * * * Increases venous tone and lymphatic drainage Placebo Daflon500 mg Venous relaxation after maximum noradrenaline-induced contraction (%) 1 Lymph flow(mL/h)2 ** P<0.01 * P<0.05 120 5 *** P<0.001 100 *** *** *** 4 *** ** ** 80 ** ** *** 3 60 + 50% 2 40 1 20 0 0 5 15 25 20 10 30 1 2 3 4 5 Time(days) Time (min) 1. Duhault J, Pillion G. Artères Veines. 1992;11:217-218. 2. McHale NG, Hollywood MA. Phlebology. 1994;(suppl 1):23-25.

36. Daflon 500 mg: a comprehensive mode of action Protection of microcirculation Increases capillary resistance 2 Decreases capillary hyperpermeability 1 Placebo Maximum number of leakage sites/cm² induced by inflammatory mediators Mean capillaryresistance (mm Hg) Daflon500 mg *** P<0.001 344 347 323 *** *** *** 161 110 91 Leukotriene B4 Histamine Bradykinin n=60 n=100 Time(weeks) 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.

37. Daflon 500 mg: a comprehensive mode of action Placebo Daflon500 mg Reduction of local inflammation Granuloma PGE2production* Granuloma TxB2production* Granuloma PGF2production* n=14 ** P<0.01 *** P<0.001 - 45.2% - 78.4% ** - 59.5% ** *** Time after granuloma induction (days) * pg/mg proteins Damon M ,Flandre O, Michel F, Perdrix L, Labrid C, Crastes-de-Paulet A. Arzneimittelforschung/Drug Res. 1987;37:1149-1153.

38. Daflon 500 mg: clinical efficacy in hemorrhoidal disease Pain score 2 1 - 50% * - 84% Nonmicronized diosmin 0 1 2 0 Daflon500 mg Micronization provides 30% more clinical efficacy Mean number of acute episodesafter 2 months’ treatment n=59 * P=0.02 * Time (months) Cospite M, Cospite V. Phlebology. 1992;7(suppl 2):53-56.

39. Daflon 500 mg: clinical efficacy in hemorrhoidal disease Placebo Daflon500 mg On the 3rd day, 3 times less patients with sustained bleeding % Patients with sustained bleeding on the 3rd day n=100 * P<0.01 3x * Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

40. Daflon 500 mg: clinical efficacy in hemorrhoidal disease Placebo Daflon500 mg Progressively and significantly less bleeding during 1 week treatment % Patients with sustained bleeding from D4 to D7 n=100 * P<0.01 7.5X 6x 7x 6.7x * * * * Time(days) Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

41. Daflon 500 mg: clinical efficacy in hemorrhoidal disease Placebo Daflon500 mg Significantly less patients with recurrent bleeding % Patients with recurrent bleeding at D90 n=100 * P<0.05 Duration: 3 months * Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

43. Comprehensive mode of action

44. The only phlebotropic drug shown to be effective in venous leg ulcer healingCHRONIC VENOUS DISEASE 2 TABLETS DAILY HEMORRHOIDAL DISEASE UP TO 6 TABLETS DAILY

45. 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

46. Good for early 2nd degree Fleshy piles but still internal Painless and no downtime 87% cure rate Operator & Skill Dependant Rubber Banding

47. Piles are excised Large wounds are left Very painful Agony for 2 weeks Bleeding Difficult to Pass Motion Classical Hemorrhoidectomy

48. Italians are great innovators Fashion, Architecture, Art, Food etc New techniques in pile treatment Stapling (Longo) THD Solutions from Italy

49. Has been popular for last decade Less painful/some pain Day surgery Complications can happen Stricture Fistula Operator & Skill Dependant Stapling

50. 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.

51. 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

52. 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

53. 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

54. Large 2nd degree 3rd degree piles Not for badly prolapsed piles. Indications for THAL

55. 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

56. 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 fistulectomysome months after THD.

57. 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?

58. 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

59. Discomfort Frequent stools Constipation Slight bleeding Mucous discharge Remnant skin tags Large piles may take a while to shrink Post-operative sequelae

60. 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

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

62. 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.

63. Testimonial by Our Patient 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 Kustov 8 Jan’10

64. 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

65. Testimonial I’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.

66. Video