Symposium

Diverse Methods of Managing Hemorrhoids:

L i g a t i o n w i t h C r y o t h e r a p y

JAMES BARRON, M.D.

Boca Raton, Florida

DR. BARaXON

First slide, please. Dr. McAdams, Dr. Ten'ell, ladies and gentlemen, i think it would be fair to say that ligation, over the years, has shown increasing popularity and is actually gradually spreading around the world. We all know that, with the rubber bands, we get complete necrosis in about 36 to 48 hours. During this time a certain percentage of patients will complain of some pressure or ache. T r u e enough, in the great majority, it is not too important, but it is also trne that it is of great impor- tance to a certain group. I have spent a good many years trying to find a method to accelerate this necrosis. ~vVe have tried in- jections; we have tried electrocoagulation, which arcs out very easily. (Next slide.)

In 1968, or thereabouts, I approached the Frigitronics Company for help with cryotherapy. At that time I gave serious thought to nitrogen, because it has the low- est temperature of all. However, at that time, the equipment was very unwieldy, and even today, handling and procuring the liquid nitrogen is not simple. Therefore, we went to Freon, and later changed to nitro.us oxide. With nitrous oxide, we go down to 85 degrees below zero C. I believed that ligating bands would give us a perfect landmark and they would give tissue com- pletely devoid of circulation, so they would be quite vulnerable to freezing. With excel-

Dis. Col. &Rect. ~tay-Sune 1973

lent landmarks and precise control, we felt that we could destroy the arteries. One reason tonsillectomy by cryotherapy has not gone over well is that the arteries are ex- tremely difficult to destroy. 3,Vith ligation we have anoxia and we have very vulnerable tissue, with parfect landmarks. (Next slide.)

Now, we are treating big hemorrhoids: we're not talking about small ones. (Next slide.)

If, when we applied the bands, we put one here and we didn't have enough tissue, we would put another one on and take this off. This is done through the anoscope. (Next slide.)

Here we have one set up for the freezing, completely devoid of circulation, completely vulnerable to freezing. (Next slide.)

This is the instrument I have been using for the last several yea rs -a very compact unit, which uses nitrous oxide. Here is the probe that we worked out. There is a slight angle. The tip here is a little less than 1 cm and is slightly angulated. (Next slide.) Here is a concavity that fits over the ligated hemorrhoid quite perfectly. This is all insulated. (Next slide.)

Now we will quickly run through a series. Here is a large hemorrhoid, obviously pro- lapsed. (Next slide.) We have put the bands on here, and we have a perfectly defined area, quite vulnerable to freezing because there is no circulation in it. We have the

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freezing started. Notice that we have no freezing of the surrounding tissue. \Vith a nitrous oxide unit, it would take a little over a minute to freeze such a hemorrhoid. (Next slide.) The freezing is progressing. (Next slide.) Now we are down to the bands. You will notice that we are not freezing any of the surrounding tissue. We have already carefully selected what we wanted to destroy before, and we have complete protection of the tissue nearby. (Next slide.)

Here is a frozen hemorrhoid. We are let- ting it thaw slowly. Many of the people that I get have had previous surgery and /or injections. They are very tough and, for the most part, I let these people get up, go to the waiting room, walk around, and then come back for a re-freeze. So this is the way the hemorrhoid looks at the end of the freeze and, incidentally, they shrink a ~ e a t deal with the first freeze. (Next slide.) T h e second freeze is much easier than the first because we have mostly dying tissue. Here again, we have perfect landmarks. (Next slide.) Then, at the end of this, we remove the bands; this has helped us a great deal. (Next slide.) Now the hemorrhoid (here's where the bands were located) will become quite engorged, and you have to be careful about tearing or cutting it because you can get bleeding. We have had no serious prob- lem with this. (Next slide.) At the end, we just push the tissue back into the inside and ask the patient to keep it there. This way we have no seepage, no drainage, and it's rare, indeed, for anyone to have to wear pads. (Next slide.)

Here is another case. (Next slide.) Here is the band in place, here is the hemorrhoid. (Next slide.) This hemorrhoid is now really quite necrotic. It is well on the way to being completely devitalized tissue. (Next slide.) This is the end of the procedure. (Next slide.)

You will hear a great deal about external hemorrhoids. We always hear this. We can apply the same thing to external hemor-

rhoids, but you will be amazed if you put the patient on a stool-softening program and get rid of the internal hemorrhoids how few patients feel that those external tags, which they thought were so important, are really giving them much trouble.

What are the disadvantages? There are disadvantages to everything, including this. T ime requ i red-an average hemorrhoidec- tomy could he done in much less time than we would spend on this. Expense--this equipment is not cheap. They now have out cheaper units but, nevertheless, it does add an extra expense. There is no injection with it; there is no anesthetic.

Now, the question of treating more than one hemorrhoid. We have a new anoscope that is almost perfected now; with this, we can easily treat more than one hemorrhoid at a time. Th e present problem is that when you freeze one of these things, anything else that touches that probe at that low tem- perature will stick, and you simply can't pull it o f f -you have to thaw and start over.

Another disadvantage is that we have had a slight increase in instances of bleeding with this type of procedure, as compared with ligation where the bands are left on. One of the interesting facts is that this will usually occur in an older patient and instead of coming in about seven to ten days, it wiI1 appear two to three weeks after treatment. It is very easily controlled with silver nitrate or a plain catgut stitch but, be that as it may, I think we have had some increased incidence. I do not put seepage as one of our problems. (Next slide.)

Now the advantages-we have complete control of destruction; we have lack of discomfort-we have no seepage, and we find that the procedure is well accepted by the patients. I believe that's the end. Thank you.

DR. T~RI~LL

A dilatation method of managing hemor- rhoids will be presented by Mr. Peter H. Lord of Buckinghamshire, England.