It is a disease that affects fully 50% of people above 30 years of age. A disease on which thrives a cottage industry of quacks and Madrasi daktars. It is a disease resting on many a myth among its sufferers. It is also a disease that has doctors trying hard to do good, but often ending up doing harm to the patient. This disease is called piles, or hemorrhoids.
Excepting an occasional old dog, man is the only animal that suffers from piles. Once thought to be just a collection of dilated veins arising out of man’s erect posture and chronic constipation, things have changed considerably. Without going into the old misconcepts let us go into the current perspectives and how they have changed the treatment of piles.
First things first, piles are present in ALL human beings. They are normal. Obviously, they are there for a reason. In all individuals, in the anal canal there are three protrusions called anal cushions. They keep the anus closed, grip the stools when they pass and are therefore helpful in the control of defecation. In some people, they come out with the rectal lining and pass through the anus. As the rectal lining comes out of the anus, the stretched veins and arteries break and cause the characteristic bleeding, which is so shocking to the average person. The rectal lining that is out of the anus (a condition known as mucosal prolapse) gets irritated and secretes mucus, causing the anus to be wet and itchy. At a particular stage the protruded mass gets squeezed by the anal sphincter muscle (the ring of muscle that helps us to hold the urge to pass stools at odd places and times), causing a blockage of its blood supply. This is known as gangrenous piles.
The whole concept of piles has changed from it being a problem of abnormal anal blood vessels to a problem of rectal lining. So what, you ask?
Look at it this way: if you have a problem due to a bunch of abnormal veins, you would remove them. If you have a problem because the rectal lining slides down you could set the patient okay by fixing the slide, not by removing the anal cushions or piles. On this rests the whole new development of the latest treatment modalities of hemorrhoids.

When the bleeding occurs silently from the internal cushions without them coming out, it is known as Grade I piles. They are treated by prescribing laxatives like Isabgul, or by a procedure called banding, where the vessels to the piles are pinched by placing rubber bands at their roots. This is essentially a painless outdoor procedure and requires little time, cost or hospitalization. An alternate approach is to inject a chemical into the piles to scar its vessels, thereby stopping the blood loss. This is called sclerotherapy or injection treatment.
Both these are simple and painless quick methods but may need repetition to give better results.
When the piles come out of the anus and also go back, they fall in Grade II category. These are also similarly treated. Avoiding surgery in either of these grades could prevent the bulk of the post-operative complications of piles surgery.
When the pile mass becomes large enough to come out of the anus and stays out permanently, it is in the last stage, called Grade III. These are the surgical cases. The traditional surgery has involved operative removal, with its resultant pain, slow healing and need for dressings.
Since the 1990s the concept of piles has changed. It was proposed by Antonio Longo of Italy that it was the sliding of the rectal lining that was the cause of the patient’s symptoms. Longo invented a device along with Ethicon Endosurgery, a division of the giant Johnson and Johnson of the USA, to create a device that removed the excess rectal mucosa from inside the rectum, sealing the cut edges with rows of staples (tiny metal pins) at the same time. This procedure was called Procedure for Prolapsed Hemorrhoids, or PPH, in short. The operation is low on postoperative pain because it is done higher up in the painless rectal lining, and has no external wounds for the same reason. As a result the patient has a smooth post operative recovery and can join work much more quickly than after the conventional operation. The device has become hugely popular all around the world, with the company touting it as one of its most successful products. Today, even patients know of the ‘staples’ procedure for piles as the latest in treatment.
According to renowned colorectal specialist, Dr. PO Nystrom of Karolinska Hospital, Stockholm, Sweden, “ The problem of hemorrhoids is essentially one of mucoanal prolapse. We do not give importance to the presence of the pile masses themselves, and ignore them. If the slide of the excess rectal lining is prevented by fixing it, then the patient’s symptoms are resolved.”
In other words, what Nystrom is saying is that there has been a major shift in the philosophy of treatment from the old concept of surgical removal (hemorrhoidectomy) to a newer one of fixing the lining (anopexy). This is giving results equivalent to the old operation, but causing less pain and problems of wound healing.


I. The piles (PPH) stapler:
This is the big boy on the block. Manufactured by Johnson and Johnson, it is marketed in aggressive style, with myriad workshops and seminars arranged for both doctors and patients, creating a market for an unheard of price. The stapler, for all the benefits it offers, is priced at around Rs. 15,000 only! The costs of the hospitalization are separate, of course.
Its success can be gauged from the fact that around three hundred staplers are fired annually in Eastern India alone. Today, patients demand the surgery even if they are not suitable candidates, a tribute to the marketing success of the PPH and its company!
The stapler works like this: the gun pushes up the pile masses into the rectum, and it removes a ring of excess rectal tissue at the root of the piles, essentially pulling up the piles towards the rectum.
If external piles are present they may need to be removed separately or ignored.
The procedure, marketed as a bloodless removal of piles, can have disastrous consequences in certain cases. A stapler misfiring can result in severe, life-threatening bleeding. It may also result in infections and narrowing of the rectum in the late post-operative phase. However, these are rare instances seen more in the hands of the inexperienced surgeon.

II. Hemorrhoidal Arterial Ligation (HAL):
In this new procedure, a Doppler (a form of ultrasound machine) locates the artery that feeds the piles and the area is stitched, causing shrinkage in the size and reducing the bleeding.
It has not been launched in India as of now.

III. Transanal Hemorrhoidal Dearterialisation (THD):
This is another recent procedure that not only seals the arteries of the pile masses at the root, but also uses stitches on the excess rectal lining to result in a pull up of the entire pile mass. The results seem to be promising.

IV. Infra Red Coagulation (IRC):
Here an infrared light comes out of a probe and is focused on the pile mass to cause it to coagulate and shrink. It is not really a new procedure, and is, at best equivalent to banding for early stages of piles. Those with large, prolapsed piles are not suitable candidates for this.

V. Botox (Botulinum Toxin) injection:
The new wonder drug called Botox, so much a favorite of the cosmetologist for treating wrinkles and deep creases, is useful in some cases of fissure and piles. Injection reduces the pain after operation, and it may be used in combination with any of the above procedures. Botox, as users know, is expensive and a shot can make you poorer by several thousand rupees, plus the cost of the procedure.

1. Adopt a healthy lifestyle, eating enough portions of vegetables and fruits avoiding chronic constipation.
2. Avoid surgery unless there is the piles come out of the anus. Surgery for bleeding alone is not advisable.
3. For the prolapsing, large piles a newer fixation operation is better than a conventional cutting operation.

Many of our so-called ‘piles’ cases suffer from some other disease; make sure your diagnosis is correct:
1. Rectal/colon cancer or polyp: Elderly patients often suffer from a growth as a cause of bleeding per rectum. They also have piles. Merely operating on the piles without ruling out a growth is dangerous! A colonoscopy would give the diagnosis easily.
2. Fissure: a tear in the anus is a fissure. Most patients who suffer from this have anal pain, especially at the time of passing stools. Though some patients respond to non-operative treatment, many require a small operation that weakens the anal muscle (sphincter).
3. Fistula: a small hole outside the anus with a history of discharge of fluid, blood or pus is a fistula. It may be cured by operation. Recently, fibrin glue has been tried to cure it without operation, with questionable results.

9 responses to “PILING UP TECHNOLOGY

  1. Pingback: HOT PICK OF THE MONTH! « A Twist of Word and Mind

  2. Thanks for the summary.

    I’m a patient outside India and doing my research. I’ve about covered all the bases and will go to my GP armed with new information. Last time I went in unarmed, and was sent to the surgeon who wanted to knife me. I chickened out, having watched my father go through extreme pain after the surgery, and suffer incontinence for the rest of his life.

    The PPH Stapler scares the life out of me, I’ll pass on that one thanks.

    I think we have the option of DGHAL and THD here (Australia) I guess I’ll find out soon. They seem very similar procedures, I’m wondering if I should prefer one over the other?

    Why are these two procedures ‘not launched’ in India as yet?



  3. Mike, I do ’em. The procedures have no commercial promoters in India, and so are unknown even to many surgeons. PPH, on the other hand, is a commercial gold mine for promoters and has been heavily marketed.
    Covidiene (formerly Tyco) has one, called the STRAM, which I am using these days. The stapler is a good method for treating Grade 3 or 4 piles. There is no need for any kind of panic.
    Best of luck!

  4. Hi Rambodoc,

    So are you saying that the surgeons in India only learn of new techniques from commercial promoters?

    Anyway, I’m sure the PPH is very effective, but to my mind, 6 absorbable sutures above the pain zone under minimal anaesthetic sounds a whole lot less invasive, potentially risky, and painful than a device that makes an incision, removes a ring of bowel and applies multiple staple closures to the rectum. I hear you when you say that there are very few complications, but when they do happen, they sound disasterous…


  5. Mike:
    PPH complications ARE dreadful, but in expert hands, they shouldn’t be an issue.
    “So are you saying that the surgeons in India only learn of new techniques from commercial promoters?”
    I meant to say that there are no vested interests to train surgeons in the new procedure, because of which this is unknown to most. PPH, on the other hand, has been taught to many surgeons because the company concerned has taken the initiative for that.

  6. I’ve been suffering with hemorrhoids for years and finally bought a toilet seat bidet. What a difference it made! Instead of using rough toilet paper which really caused more irratation, these new toilet seat bidets spray warm water to cleanse you which I found to be the perfect solution for my hemorrhoids. I haven’t suffered anymore since getting my toilet seat bidet.

  7. Pingback: A COGNAC OF A POST, NO LESS! « A Twist of Word and Mind

  8. Dear sir,
    i am suffering from grade 2 piles, is PPH stapler method of surgery advicable, i feel lot of pain after defacation, and i have done cholonoscopy, were the doctor said i have grade 2 piles, please advice, or i have to till new method of surgery that is THD is lounch in india.

  9. Hi Doc,

    I am from Mumbai. I have two piles, one is at 3rd grade and another one at 2nd grade. Its not bleeding. Specialist suggested to have Stapled surgery. But I don’t want to go through one as I have heard very bad reviews plus there are many side effects after surgery which one has to bare for life.

    Could you please suggest me any non surgical method with no side effects or even lesser side effects will do but painless and minimal recurrence.

    Do you think I can treat piles with help of Aurvedic medicine and proper diet?

    Would you suggest Kshar Sutra surgery over Stapled or Laser Surgery?

    Do you think injection method would solve my 3rd grade piles?

    Thank you and waiting for your response.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s