When ointments, suppositories and physician-prescribed rubber band ligation fail to provide relief, 150,000 American hemorrhoid sufferers each year finally give in and undergo hemorrhoidectomies, only to experience weeks or months of pain and limitations resulting from the surgery itself.
But a relatively new outpatient procedure may bring an end to the long-term discomfort of internal hemorrhoid removal. With the Procedure for Prolapse and Hemorrhoids (PPH), surgeons use a circular stapling device that lifts hemorrhoidal tissue up to its original position and trims out a band of tissue above the "pain" line.
"The PPH procedure itself is performed in a part of the rectum where we do not perform traditional hemorrhoidal operations and where there are no pain fibers, so the discomfort afterward is almost non-existent and return to work or to normal activities is rapid," says Gary H. Hoffman, M.D., a specialist in colo-rectal surgery at Cedars-Sinai Medical Center in Los Angeles. I call my patients the first night after every procedure, and many of them have been out to dinner."
The PPH technique, which is similar in concept to a facelift and approved by the Food and Drug Administration (FDA), properly positions hemorrhoidal tissue and reduces blood flow to internal hemorrhoids, which causes them to shrink painlessly and unnoticed over the course of several weeks.
According to a study that was presented today at the annual meeting of the American Society for Colon and Rectal Surgeons (ASCRS), the intermediate results show that the new procedure is not only less painful, but appears to reduce the risk of hemorrhoidal symptoms returning.
"That is good news, indeed for hemorrhoid sufferers, because in the past, a major concern of patients has been the recurrence of symptoms after surgery,"says Dr. Hoffman. "In addition," he adds, "most patients experience very little post-operative pain and are back to work or their normal daily activities very quickly."
While patient results are immediate and the post-operative course is nearly pain-free, the technique itself is not simple. Therefore, Dr. Hoffman, who performs the procedure at Cedars-Sinai, collaborates with his partner, Eiman Firoozmand, M.D., on every operation.
According to Achilles Demetriou, M.D., Chair of the Surgery Department at Cedars-Sinai, within a few weeks the procedure will also be provided by all members of the Cedars-Sinai Division of Colon and Rectal Surgery.
"I had become aware of PPH through the literature and was lucky enough that Dr. Firoozmand had completely trained in it. The two of us set out to develop expertise and bring it to clinical use in the Los Angeles area," said Dr. Hoffman. "We believe this is becoming the 'gold standard' for patients who need to have their hemorrhoids removed, and we have very, very happy patients. When they leave the outpatient surgical center, their symptoms are essentially over. They can go back to work or back to their activities of daily life quickly, with hardly any discomfort."
Hemorrhoids are normal and actually beneficial, protecting and cushioning the anal canal. Only when they become enlarged to a point that they become symptomatic is treatment warranted. Symptomatic hemorrhoids affect men and women equally, and there is no geographic or racial predilection.
It is estimated that 25 million Americans experience hemorrhoidal symptoms each year. In fact, 50 percent of people over age 45 will have symptomatic hemorrhoids at some point in their lives. Five million sufferers -- about a million more people than the population of the city of Los Angeles -- seek help from physicians each year, although the decision to see a doctor is often delayed because of embarrassment, fear of pain and concern that cancer may be the cause of symptoms.
Remembering the experience of an uncle who underwent hemorrhoidectomy, patient Ellen C. Brener avoided treatment as long as possible. "He was miserable forever," she recalls. And she admits to being skeptical when Dr. Hoffman told her the new procedure offered relief without weeks of discomfort.
"He explained to me what the differences were. And, of course, who believed him? But I figured I had to have it done so I may as well have it done," she said. And she quickly became a believer. "The first hint you get is that it's not an inpatient procedure. It's an outpatient procedure. And then I would say I felt fine the night of the surgery. I had very little pain."
Brener, who is more willing to discuss her surgery than her age, knows that hemorrhoids affect thousands of people who don't like to talk about them but would seek relief if they were familiar with the new approach.
"It was really a good experience. First of all, they're wonderful doctors and their aftercare is fabulous, and I think that's because of the kind of people they are. But the procedure was minimal. It was easy," she said.
Ethicon Endo-Surgery, Inc., a division of Johnson & Johnson, produces the PPH device. The technique was conceived by Dr. Antonio Longo and developed in Italy in the early- and mid-1990's. It was quickly accepted worldwide, with approval coming in the United States in late 2001. About 12,000 of the 82,000 outpatient procedures performed last year were done in the United States.
"There are four degrees of hemorrhoids and each degree demands its own treatment," said Dr. Hoffman. "But in my opinion, this is quickly becoming the treatment of choice for symptomatic third- and fourth-degree hemorrhoids, and for selected patients with second-degree hemorrhoids who need definitive therapy."
A general surgeon with a subspecialty in colo-rectal surgery, Dr. Hoffman has been in practice for 20 years. After receiving his medical degree from Vanderbilt University Medical School, he completed a surgical internship at Los Angeles County Hospital + University of Southern California Medical Center before completing his surgical training at Louisiana State University/Charity Hospital of New Orleans. He has been in practice in Beverly Hills since 1987.
Cedars-Sinai is one of the largest nonprofit academic medical centers in the Western United States. For the fifth straight two-year period, it has been named Southern California's gold standard in health care in an independent survey. Cedars-Sinai is internationally renowned for its diagnostic and treatment capabilities and its broad spectrum of programs and services, as well as breakthroughs in biomedical research and superlative medical education. Named one of the 100 "Most Wired" hospitals in health care in 2001, the Medical Center ranks among the top 10 non-university hospitals in the nation for its research activities.
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