Proctology is the branch of medicine that deals with the study and treatment of colorectal and anal disorders. Proctology is a particularly wide-ranging area of expertise, since the problems and disorders affecting the colorectal and anal systems, especially over the last 50 years and thanks to recent scientific discoveries, seem to be ever more numerous and specific. As a result, patients may see a specialised proctologist for a large number of issues, ranging from common ones such as colitis through to more specific problems such as haemorrhoids, Crohn's disease, irritable bowel syndrome, diverticulitis, fissures, fistulas, diverticulosis, anal warts, perianal abscesses, etc.
In the context of modern medical care, proctology has now become a particularly important specialisation, as a large number of medical problems and therapeutic procedures (of all kinds) very often require an assessment of the colorectal system, and therefore the expertise of a proctologist.
The first book to discuss proctological problems was the BIBLE, where in the SECOND CHRONICLES a rectal prolapse is described. But the first documents that specifically deal with anorectal diseases come from the Egyptians (Fig. 1): documents such as the EBERS PAPYRUS or THE CHESTER BEATTY PAPYRI (Fig .2), where you can find information related to the diagnosis and treatment of proctological disorders. The latter, in particular, has an entire chapter dealing solely with anorectal diseases.
Like the Egyptians, Indians in the pre-Hippocratic era were also very concerned about proctological disorders. Indeed, the father of Indian surgery, SUSHURUTA, left behind a text (the SUSHURUTA SAMHITA) in which he deals with the most common anorectal diseases, with particular attention given to haemorrhoids and fistulas. The Chinese, too, mentioned haemorrhoids in their religious (Taoist) texts, and recommended ACUPUNCTURE for their treatment in the fifth century BC. With HIPPOCRATES and the medical revolution that he brought about, proctology left the field of religion and became a matter for science, thus establishing some therapeutic principles which are still valid today; haemorrhoids take their name from a combination of the terms EMOS (blood) and REO (I flow) because of their characteristic bleeding. Hippocrates and his pupils established the basis for a pathogenic explanation of this disorder. In Ancient Rome the practice of proctology flourished as well. Indeed, among the ruins of Pompeii many surgical instruments were found, including excellent autostatic anoscopes (Fig. 3).
AULUS CORNELIUS CELSUS, who lived under Augustus and Tiberius, was considered the Roman Hippocrates. In his work "DE MEDICINA", he lays down principles which are still valid today; he urged against taking laxatives too frequently, and proposed a means of treating fistulas based on the attachment of a string which would gradually sever the fistula. Furthermore, he identified remedies against fissures and rectal and uterine prolapses. · GALEN (131-201 BC) in his "FINITIONES MEDICAE" offers a functional anatomical description of haemorrhoids which was very apt, and favoured the LIGATION OF HAEMORRHOIDS to treat them. · Paul of Aegina left us an excellent description of techniques for the treatment of haemorrhoids and fistulas. · Arabic doctors were against surgery and AVICENNA (980-1037) cured fistulas with pig bristles, turning to surgery only in extreme cases. He also followed Hippocrates's edict to always leave a haemorrhoid in place, to allow the body to eliminate harmful humours. · MAIMONIDES (1135-1204), a doctor in Saladin's court, recommended a light diet and sitz baths in his "TREATY ON HAEMORRHOIDS". · ALBUCASIS (1013-1106): (Fig. 4) wrote a book on surgery where he described operating on haemorrhoids
as follows: "Make the patient push so that the swellings come out; seize them with hooks and snip them at the root. .... If the swellings are already outside the body, grab them with a fingernail and cut them" (Fig. 5).
During the Middle Ages, superstitions and pagan rituals arose. One example was the RITUAL OF BELPHEGOR, the demon to whom sufferers turned to free them from haemorrhoids and to whom they offered faeces and flatulence, hoping to be healed from such desperate suffering. At the same time, however, the SCHOLA MEDICA SALERNITANA opposed this and laid down unquestionably valid hygienic principles to prevent haemorrhoids and other disorders, both proctological and otherwise (Fig. 6). Also during these dark ages, superstitions arose which live on today, such as walking around with a piece of wood in your pocket to treat haemorrhoids, and other even more absurd theories.
For the next valuable contribution to the evolution of proctology, we have to wait until the 14th CENTURY, and the figure of JOHN ARDERNE (1307-1380). Arderne was a very skilled military doctor, and during the Hundred Years' War he experimented with various procedures, adopted a system of illustrating pathologies and surgical techniques, and set down a very modern description of rectal cancer and its diagnosis through digital exploration. He also described an operation for anal fistulas based on a combined method of binding and cutting (Fig. 7), which was not followed by his peers at the time, but whose value was realised some 300 years later, when the method was used on Louis XIV of France.
In the 16th CENTURY three figures who contributed much to the art of medicine loomed large: ANDREA VESALIO, known as the Father of Anatomy; AMBROISE PARÉ, surgeon to various Kings of France; and GIROLAMO FABRIZI D'ACQUAPENDENTE, who designed and modified various surgical instruments including the fenestrated anoscope (Fig .8)
and also ordered the construction of the ANATOMICAL THEATRE OF PADUA (Fig. 9), a splendid example of architecture used for educational purposes, which bore his name. Furthermore, he was the author of several surgical works, including some dealing with the treatment of fistulas and haemorrhoids.
Between the 17th and 18th centuries FILIPPO MASIERO, surgeon at the Hospital of San Francesco Grande in Padua, wrote "LA CHIRURGIA COMPENDIATA" (Surgery Abridged) and introduced developments to proctological scalpels and anoscopes. (Fig. 10);
In addition, FÉLIX DE TASSY used the procedure described by Arderne for fistulas on Louis XIV after a bitter struggle with the medical staff of the court. It was so successful that he was personally honoured, and from a surgical standpoint this led to the formation of the Royal College of Surgeons in 1731, and an edict from Louis XIV forbidding barbers from practising surgery.
· During the same period, GIAMBATTISTA MORGAGNI described the columns that still bear his name and DOMENICO SANTORINI, G.B. WINSLOW and D.L. HEISTER described the three sections of the external anal sphincter.
· Also in the 18th century, LITTRÉ designed the procedure of COLOSTOMY, which following a failed attempt by PILLORE 66 years after its conception, was successfully applied by DURET in 1793 in the case of a 3-day-old baby boy with a perforated anus.
· In 1828 BARONE DUPUYTREN designed and built the first enterotome;
· In the same year, AMUSSAT invented the lumbar colostomy;
· In 1826 JACQUES LISFRANC made the first resection of the rectum.
· In 1835, F. SALMON founded an infirmary with 7 beds in London, known as: "THE INFIRMARY FOR THE RELIEF OF THE POOR AFFLICTED WITH FISTULAS AND OTHER DISEASES OF THE RECTUM" which in 1854, with 25 beds, became ST MARK'S HOSPITAL. Today, the hospital is considered a Mecca for proctologists. It still retains the original name on its facade (Fig. 11).
At the beginning of the 19th century there was a great deal of interest in intestinal wounds, and in 1812, after studying cadavers, B. TRAVERS concluded that it was better to attempt to suture than only do one ileum or colostomy.
· In 1826, DENANS described an interesting prototype of Murphy's button and modern autosuture devices, and in the same year LEMBERT described a suturing technique that continues to be used today. (Fig. 12) BILLROTH, who was the father of modern abdominal surgery thanks to his introduction of antisepsis and anaesthesia, carried out 45 excisions of the rectum between 1860 and 1872. In 1873, in order to increase the area that could be operated on, VERNEUIL proposed the removal of the coccyx in a modified version of the Lisfranc procedure (amputation of the rectum through the perineum).
· In 1875 KOCHER closed the anus with a tobacco pouch, excised the coccyx and part of the sacrum, lowered the colon and sutured it to the anus. This procedure was fine-tuned in 1885 by KRASKE.
· In 1883 CZERNY, unable to complete a rectal resection via the sacrum, made the first abdominoperineal intervention, a technique which was perfected by MILES at the start of the 20th century.
· At that point, the problems facing surgeons around the world were intestinal anastomosis and surgical oncology, procedures for which the morality rate was extremely high; THIERSH documented 10 resections of the colon with a 70% failure rate, while from 1880 to 1890, 48 of these operations were carried out with a lower mortality rate of 45%.
· In that period, BILLROTH carried out a colon resection closing off the distal stump, and a colostomy with the proximal extremity.
· In 1878-79 GUSSENBAUER, of Liège, and MARTIN, of Hamburg, removed sigmoid tumours with lymph nodes and the mesentery, crafting a colostomy bag from gunmetal.
· In 1892 CONNEL described his method of suturing, which is still widely used today.
· Meanwhile, new progress was being made in our anatomical knowledge of this area of the body; HILTON described the line that still bears his name today, and in 1855 GEROTA identified the perirectal lymph nodes and lymph vessels of the rectum and perirectal area (Fig. 13).
· At this point we enter the 1900s, a period of exponential growth in all the sciences, including surgery and diagnoses. Miles perfected the ABDOMINOPERINEAL RESECTION METHOD; the evolution in related fields of surgery (anaesthesia, pharmacology, etc.) did the rest, bringing the discipline as a whole to new heights.
In 1937, Milligan and Morgan invented the open haemorrhoidectomy, where the haemorrhoidal swellings are surgically isolated before being excised and the wounds that remain are left open to prevent stricture of the anal canal. (Fig. 14/15)
The problem with this technique is the very painful post-operative period, with the possibility of complications, particularly bleeding and infection due to contact with faeces. Patients always mention above all the extreme pain experienced when removing the rectal tampon.
· In 1963 Edgar Barron, a surgeon from Detroit, perfected the technique devised by Blaisdel in 1958, called band ligation for haemorrhoids (Fig. 16/17), which is based on the application of a rubber ring at the base of the haemorrhoidal swellings
In 1982, I was the first in Italy to start practising rubber band ligation for haemorrhoids and occult anterior mucosal prolapses, and I modified the procedure with suction.
· CRYO-GUIDED FISTULECTOMY As we have seen, procedures for the treatment of anal fistulas date back to before the time of Napoleon, so in 1983 I felt it was necessary to come up with a new technique: the Cryo-Guided Fistulectomy, which avoids the extensive pain and recurrences that hampered the old techniques. For this reason, I devised a technique where fistulas are frozen and excised in this state, and the wound sutured to heal by primary intention.
This method offered exactly what I was looking for: it was an outpatient procedure with little pain, a fast healing process and zero recurrences. (Fig. 18/19)
We come now to the year 2000, when special effects are arriving in the field of medicine, such as techniques that use lasers (a scalpel which cuts using light rather than a blade or conventional electricity, but the result is the same: a burn); hyper-advanced staplers, expensive but rather dangerous and whose results are very controversial; Doppler-guided arterial ligatures which aim to stop a flood by turning off a tap; expensive robots that replace the hands of the surgeon to whom God has given gifts that no mechanical device can ever recreate etc.; all techniques which produce advantages mainly for multinationals that sell their expensive equipment, with few benefits for the patient.
Let's take a quick look at these new techniques that the new millennium has to offer: 1. LONGO TECHNIQUE: (Fig. 20) Based on the modification of a stapler designed for intestinal resections, from which the peritoneal blade is removed, so that when applied it cuts into the rectal mucosa, and in theory lifts it, thus raising the haemorrhoidal prolapse. When the technique was first unveiled, ETHICON (manufacturer of the project applied by Dr Longo of Palermo) launched a huge advertising campaign in the media around the world, thanks to the political and economic contacts typical of a powerful multinational, and established "partnerships" with a large number of surgeons, allowing this technique to become the most used worldwide. Unfortunately, due to the thousands of operations using this technique carried out over just a few years, its inherent flaws became apparent, and now interest is decreasing for the following reasons: a) costly technique, in fact the single-use stapler costs about €800; b) requires hospitalisation for at least 3 days and at least one epidural, therefore it is not an outpatient technique; c) violates Golligher's postulate (anorectal mucosa should never be resected with a full turn due to the risk of stricture) and in fact the most frequent complication turns out to be anal stricture which requires months of painful dilation to be resolved; d) mucosal resection is not so precise, indeed very often arteries are resected entailing unclean intraoperative haemostatic sutures, including with the abdomen open, resulting in a risk of infection and post-operative complications; e) often nerves are resected, which leads to incontinence problems; f) constant post-operative pain; g) post-operative bleeding often requires a further operation; h) cases of intestinal perforations have been reported. One only needs to take a look at the various internet forums discussing the Longo technique to understand that it is a technique with a few pros and a lot of cons, not easy to reproduce and very much down to the skill of the surgeon and the luck of the patient, who without a doubt exposes his or herself to serious risks.
FOTOCOAGULAZIONE A RAGGI INFRAROSSI:(Fig.21) Si tratta di una tecnica la cui unica indicazione sono le emorroidi di I° grado che vengono fotocoagulate con l’apparecchiatura di cui in figura. Si tratta sempre di una ustione prodotta nel canale anale che non ha senso fare visto che le emorroidi di I° si giovano bene di una terapia medica con venotropi e poi non danno disturbi anzi fino ad un certo punto compartecipano alla continenza anale per cui non andrebbero toccate. Questa tecnica potrebbe avere una indicazione in caso di piccole emorroidi sanguinanti e nel trattamento di ragadi anali piccole e superficiali.
LASER PHOTOCOAGULATION: The same technique as above, but carried out with a laser. Same recommended usages and more complications, since bleeding is common and fissures are possible. Finally, the equipment is much more expensive than the infrared device. It may be used for small perianal lesions, such as warts, verrucas etc., but there are more economical approaches. Very much a 'special effects' procedure, at least in the field of proctology.
4. THD METHOD: (Fig. 22/23) This method is based on the principle that by reducing the arterial inflow to the haemorrhoidal veins they should deflate and shrink, but unfortunately the system of haemorrhoidal veins is a sort of go-between for the hepatic portal system and the general venous circulation system. The origin of the vascular dilation is therefore not excessive flow from the arteries, but an anterograde or retrograde flow between the two venous systems, which is why in the case of liver cirrhosis the haemorrhoidal and gastroesophageal circuits become secondary circuits, thus patients display oesophageal varices and haemorrhoids - not because of an increased arterial inflow, but due to venous congestion of the portal system because of a narrowing of the cirrhotic liver filter. The technique works using a special anoscope connected to a Doppler probe. This identifies the arterial vessel which is then tied with a suture. The reduction in transcapillary flow due to this technique could lead to pain in the sphincter, such as chronic ischemia. This technique aims to fix a factor which is not the cause of haemorrhoidal disease.
5. SCLEROTHERAPY Consists of an injection of sclerosing fluid into the haemorrhoidal swelling, causing the closure of the vessel. It is painless, does not require anaesthesia and is to be used especially when there is bleeding. It does not require admission to hospital. There is also a form of regenerative sclerotherapy borrowed from phlebology, but whose effect on the rectum has not yet been demonstrated.
6. CRYOTHERAPY A very important technique for the treatment of fissures and fistulas, but when treating haemorrhoids it should be considered anachronistic due to the lengthy recovery time required, since it causes thrombosis with all the typical symptoms of haemorrhoidal thrombosis. On the other hand, it has a part to play in the treatment of external haemorrhoids whose ligation is painful, since the skin is lined with nociceptors. The ligation of these haemorrhoids must therefore be done only after freezing the haemorrhoid to destroy the sensory receptors. (Fig. 24/25)