1. THE RISE AND FALL OF LORD’S ANAL STRETCH. Also, stay glued to your seats for the riveting unveiling of the derivation of the word ‘metastasis’…

2. WHAT IS LORD’S ANAL STRETCH? It was used as a therapeutic surgical intervention for hemorrhoids. However, to fully grasp the rationale for its use and the reasons for its abandonment, one must have basic knowledge of the pathophysiology of hemorrhoids and anatomy of the rectum and anus.

8. SUBCLASSIFICATION OF INTERNAL HEMORRHOIDS: Internal hemorrhoids are classified according to the degree of prolapse. 1 st degree hemorrhoids – bleeding without prolapse. 2 nd degree hemorrhoids – prolapse on straining but reduce spontaneously. 3 rd degree hemorrhoids – prolapse on straining and require manual reduction. 4 th degree hemorrhoids – irreducible prolapse, incarcerated.

16. PRECAUTION!! A SIGMOIDOSCOPY or PROCTOSCOPY should always follow a digital examination so as not to miss a diagnosis of carcinoma of the rectum.

18. HOW DOES IT CAUSE FECAL INCONTINENCE? Rectal Distention Ext. anal sphincter (EAS) and Puborectalis muscle(PR) contract Int. anal sphincter(IAS) relaxes Defecation urge If appropriate EAS & PR relaxation Stool passage Not appropriate (EAS and PR remain contracted) IAS recovers tone Defecation urge passes Disruption of these ‘voluntary’ muscles via Lord’s procedure

19. Hemorrhoidectomy vs. Lord’s method: 17-yr follow-up of a prospective, randomized trial PURPOSE: The trial was performed between 1979 and 1981 comparing anal dilation and hemorrhoidectomy for hemorrhoidal disease at the Maastricht University Hospital, Netherlands. AIM: To update the trial to assess long-term outcome and complications such as fecal incontinence. METHODS: 138 patients with 2 nd and 3 rd degree hemorrhoids entered the study. Median follow-up was 17 years and was achieved for 118 (86 %) patients. Group A (n=35) – Hemorrhoidectomy. Group B (n=39) – Anal dilatation and aftertreatment with Lord’s procedure. Group C (n=44) – Dilatation only. (14 patients died during the trial.)

20. CONT’D… RESULTS: Recurrent hemorrhoids noted for 26 percent of the patients treated with hemorrhoidectomy, for 46 percent with operative dilation with the postoperative dilation program, and for 39 percent with operative dilation without the postoperative program. The percentage of repeated treatment for the three subgroups was 11, 23 and 18 percent respectively. The continence status remained approximately the same during the first year of the trial. However, 17 years later, the anal stretch procedures caused various incontinence disorders in 52 percent of these patients. Significance was found for incontinence of flatus in the anal dilation groups.

21. CONT’D… CONCLUSIONS: Hemorrhoidectomy can be considered to be a safe procedure for treatment of hemorrhoidal disease as it has excellent long-term results. Anal dilation however, is associated with a high percentage of complaints of fecal incontinence. Hence, the procedure should be abandoned!! END OF TRIAL

22. History of Hemorrhoids … In medieval times, hemorrhoids were known as St. Fiacre’s curse and today, those around the world afflicted with this visit St. Fiarce's stone in order to obtain a miracle cure. St. Fiacre, also known as the patron saint of gardeners, was told he could farm all the land he could cultivate in a single day being given a particularly small shovel by a less than benevolent bishop. After a particularly long day at the garden, in order to obtain the maximum amount of land, he developed a terrible case of prolapsed hemorrhoids. Seeking a solution, he sat on a stone and prayed for resolution of his problems. This resulted in a cure and he became free of hemorrhoids.

23. CONT’D According to the legend, the imprint of St. Fiacre’s hemorrhoids remains on the stone today and sufferers from all over the world continue to sit on this stone and pray for relief.

24. TRIVIA… Reader’s Digest has identified the bathroom as the number one site for reading for Adults in the United States. Spending significant amounts of time reading on the commode is thought responsible for the development of hemorrhoids in many individuals!

25. AND SO…WHAT ARE THE ALTERNATIVES IN MODERN COLORECTAL SURGERY?

37. ONCOLOGICAL DEFINITION: Metastasis refers to the transmission of pathogenic microorganisms or cancerous cells from an original site to one or more sites elsewhere in the body, usually by way of blood vessels or lymphatics.