Hemorrhoids, fistulae and fissures: office and hospital management--a critical review.

We have tried to present a comprehensive survey of present-day management of hemorrhoids, fistulae and fissures, be it in the office or in the hospital. There is great socioeconomic pressure lately for cost-containment, which is apt to effect better medical judgment in the selection of type and place of management. Minor operations can and should be done, as always, on an outpatient basis. General anesthesia is not a minor matter and hemorrhoidectomy is not a minor operation. The major function of outpatient service in the management of anal disease is that of accurate and comprehensive diagnosis. Hundreds of patients come to us only because they fear cancer and it is not enough for us to hunt for and treat the vague little disorders of which they complain. The incidence of cancer of the colon rectum in this country just recently has slightly surpassed that of lung cancer. Adjuvant treatments (e.g., chemotherapy, radiotherapy, immunotherapy and their combinations) are promising but still in the investigational stage. Early diagnosis is our finest weapon with subsequent surgical management. The challenge and responsibility for early diagnosis of colorectal cancer is ours alone. We must first recognize it and then meet it firmly and squarely. We must feel for (digital rectal), look for (sigmoidoscopy), and search for (barium enema x-ray examination) colorectal cancer in all of our patients regardless of the insignificance of anal symptoms and anal findings. Our countrymen fear cancer. We have the devices to allay their fears or to cure their cancers if they are found early enough. We have a straightforward moral commitment and a national trust.