Massive prolapsed haemorrhoids managed by ablation and correction in a poor resourced area
A 75-year-old man was admitted electively to the hospital for assessment and management of persistent prolapsed haemorrhoids (Fig. ), despite recurrent surgery, thrice in the past 3 years. This was associated with constipation and straining at stool. There was fresh rectal bleeding not mixed with stool during defaecation. He had no loss of appetite nor weight loss. On examination, he was pale and tired-looking. Chest, cardiovascular and abdominal examinations were unremarkable. A rectal examination revealed massive, irreducible, prolapsed, circumferential haemorrhoids that were ulcerating, bleeding and occluding the anal orifice. The external components showed squamous hyperplasia with keratinization and a frond-like, friable appearance. Proctoscopy revealed solid palpable internal haemorhoidal components with a similar pigmentation (acanthosis) as the external components at their classic anatomical positions—the left lateral, right posterior and right anterior positions—but no definite rectal mucosal lesion was seen. Rigid sigmoidoscopy was normal. He was found to be anaemic with a haemoglobin level of 7 gm/dl. The differential diagnosis included an extensive locally advanced anal carcinoma, an extensive fungating perianal condylomata acuminata (Buschke-Lowenstein's disease), chronically prolapsed (fourth degree) haemorrhoids with external components or a chronic rectal prolapse. A biopsy revealed haematoma consistent with a haemorrhoid. His iron-deficiency anaemia was corrected by blood transfusion prior to an examination under anaesthesia.\nIn the lithotomy position, an extensive Milligan–Morgan haemorrhoidectomy with mucocutaneus skin bridges and high ligation was performed (Fig. ). The external component of the haemorrhoidal tissue disintegrated into black clots on dissection (Fig. ). An intussucepting rectal prolapse with a sulcus between the prolapse and the edge of the anal canal became evident. A modified Delorme's procedure was done by excising the redundant mucosal sleeve, reducing the prolapse and plicating the prolapsed muscle wall to the proximal rectal mucosa cuff (Fig. ). However, as most of the anal canal skin at the level of the dentate line was incorporated in the extensive internal and external haemorrhoidal engorgement and thus been excised en-bloc, the distal component of the plication was sutured but to the fascia (epimysium) overlying the internal anal sphincter. Pouting of the rectal mucosa at the anal orifice causing a mucoid leak was prevented by not stitching to the perianal skin. The wide perianal skin defects were approximated to facilitate healing and reduce pain (Fig. ). The estimated intra-operative blood loss was <300 ml. The anal sphincteric tone was satisfactory. His postoperative haemoglobin level was 9 g/l, for which he received a further unit of blood. A laxative (lactulose) was prescribed and the patient mobilized. He made good recovery with no passive or active (urge) incontinence. He was discharged on the eighth postoperative day on iron supplements and advised a high-fibre diet and regular follow-up.