Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy

Randomized Controlled Trial to Compare Stapled Hemorrhoidopexy Plus Ligation Anopexy With Stapled Hemorrhoidopexy for Managing Grade III and IV Hemorrhoidal Disease

BACKGROUND

Despite the benefits of the stapled hemorrhoidopexy in the short term, management of prolapsing hemorrhoids, the long-term results are still insufficient regarding recurrent prolapse and patient satisfaction. The current study investigates the addition of ligation anopexy to stapled hemorrhoidopexy.

OBJECTIVE

Valuation of adding ligation anopexy to stapled hemorrhoidopexy in improving short-term and long-term results in the treatment of grade III and IV hemorrhoids.

DATA SOURCES

Between January 2018 and January 2020, we recruited 124 patients with grade III and IV hemorrhoids at Alexandria Main University Hospital.

STUDY SELECTION

Randomized controlled trial.

INTERVENTIONS

One hundred twenty-four patients were blindly randomly assigned to 2 equal groups: stapled hemorrhoidopexy (group I) and stapled hemorrhoidopexy plus ligation anopexy (group II).

MAIN OUTCOME MEASURES

Recurrence of hemorrhoids and patient satisfaction after a follow-up period of at least 2 years.

RESULTS

The average operating time was noticeably less in the stapled hemorrhoidopexy group. Postoperative pain, analgesia requirement, hemorrhoid symptoms score, return to work, complications rate, and quality of life 1 month after surgery were similar between groups. Following a mean follow-up of 36 months (interval, 24-47), in group I, 10 patients (16%) reported recurrent external swelling and/or prolapse compared to 3 patients (5%) in group II ( p  = 0.0368). Five patients in group I required redo surgery, whereas no patients required redo surgery in group II. Long-term patient satisfaction was significantly better in group II.

LIMITATIONS

It was a single-center experience, so longer follow-up was needed.

CONCLUSIONS

Stapled hemorrhoidopexy and stapled hemorrhoidopexy plus ligation anopexy were similar in short-term results with regard to complications rate, hemorrhoids symptoms score, return to work, and quality of life. Long-term results were significantly better with regard to recurrence of external swelling and/or prolapse and patient satisfaction after stapled hemorrhoidopexy plus ligation anopexy. See Video Abstract .

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry identifier PACTR20180100293130.

ECA PARA COMPARAR LA HEMORROIDOPEXIA CON GRAPAS MS ANOPEXIA POR LIGADURA CON LA HEMORROIDOPEXIA CON GRAPAS PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO III Y IV

ANTECEDENTES:A pesar de los beneficios de la hemorroidopexia con grapas a corto plazo, el manejo de las hemorroides prolapsadas, los resultados a largo plazo aún son insuficientes en cuanto al prolapso recurrente y la satisfacción del paciente, por lo que en nuestro estudio actual agregamos anopexia por ligadura a la hemorroidopexia con grapas.OBJETIVO:Valoración de añadir anopexia por ligadura a la hemorroidopexia con grapas para mejorar los resultados a corto y largo plazo en el tratamiento de las hemorroides grado III-IV.FUENTES DE DATOS:Entre enero de 2018 y enero de 2020 reclutamos a 124 pacientes con hemorroides de grado III-IV en el hospital universitario principal de Alexandria.SELECCIÓN DEL ESTUDIO:Ensayo controlado aleatorio PACTR201801002931307.INTERVENCIÓN(S):124 pacientes fueron asignados al azar de forma ciega a dos grupos iguales, hemorroidopexia con grapas (grupo I) y hemorroidopexia con grapas más anopexia por ligadura (grupo II).PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia de hemorroides y satisfacción del paciente después de un período de seguimiento de al menos dos años.RESULTADOS:El tiempo operatorio promedio fue notablemente menor en el grupo de hemorroidopexia con grapas. Mientras tanto, el dolor posoperatorio, la necesidad de analgesia, la puntuación de los síntomas de hemorroides, el regreso al trabajo, la tasa de complicaciones y la calidad de vida un mes después de la cirugía fueron similares. Después de un seguimiento medio de 36 meses (intervalo: 24-47), el Grupo I, 10 pacientes (16%) se quejaron de inflamación externa recurrente y/o prolapso en comparación con 3 pacientes (5%) en el Grupo II ( p = 0,0368) que requiere rehacer la cirugía. No fue necesaria una nueva cirugía en el grupo II; además, la satisfacción del paciente a largo plazo fue significativamente mejor en el grupo II.LIMITACIONES:Se necesita un seguimiento más prolongado y experiencia en un solo centro.CONCLUSIONES:La hemorroidopexia con grapas comparada con la hemorroidopexia con grapas más anopexia por ligadura fue similar en resultados a corto plazo en cuanto a tasa de complicaciones, puntuación de síntomas de hemorroides, regreso al trabajo y calidad de vida. Los resultados a largo plazo fueron significativamente mejores en cuanto a la recurrencia de la inflamación externa y/o el prolapso y la satisfacción del paciente después de la hemorroidopexia con grapas más anopexia por ligadura. (Traducción-Dr. Mauricio Santamaria ).

Top 100 most-cited articles on hemorrhoids: A bibliometric analysis and visualized study

Background

Hemorrhoids have a significant incidence in people and are becoming a common public health problem. This study provides a bibliometric and visualized analysis of the most influential literature in the field. The aim is to reveal trends in the field of hemorrhoids and to provide a reference for researchers.

Methods

The 100 most frequently cited studies in the field of hemorrhoids were collected from the Web of Science(WOS), and were analyzed in terms of the annual publication, types of literature, countries, institutions, authors, journals, and keywords. During the study, we used a combination of VosViewer, Carrot2, Microsoft Excel, and Tableau tools to better present the visual information.

Results

A total of 4,481 articles were retrieved, of which 3,592 were of the Article and Review types, among which we selected the 100 most frequently cited. A large amount of highly cited literature on hemorrhoid surgery emerged from 1990 to 2010, and the interest of researchers in hemorrhoid surgery seems to have waned after 2010. The sources of highly cited literature in the field of hemorrhoids are predominantly Western, with the United States. and the United Kingdom accounting for almost half of the publications worldwide. However, countries with higher prevalence populations do not have significant research on hemorrhoids. St. Mark's Hospital has published the largest number of influential articles in the field of hemorrhoid disease. Kamm MA and Phillips RKS are the most authoritative authors in the field. Diseases of the Colon & Rectum and the British Journal of Surgery are the most influential journals in this field. The highly cited literature covers a wide range of disciplines, with Thomson's classic “The nature of hemorrhoids” receiving the most attention among the studies focusing on hemorrhoids. Keyword and clustering analysis revealed that The most famous focus in the field of hemorrhoid research is the evolution of stapled hemorrhoidectomy (SH) and Milligan-morgan hemorrhoidectomy (MMH).

Conclusions

This study is the first to explore developments in the field of hemorrhoids, and it helps surgeons quickly understand global trends in the field of hemorrhoids. In recent years, the development of hemorrhoids seems to have hit a bottleneck, with scholarly interest in the field of waning, especially in surgery Procedures. The theory of inferior anal cushion migration has proven to be the most influential theory in the field, but after studies based on SH and MMH, more high-quality evidence is needed to continue advancing the field of hemorrhoids. The results of this study are intended to add to the attention and interest of scholars in this area and provide a reference for further research.

Medical insurance and physician-induced demand in China: the case of hemorrhoid treatments

In October 2015, the Guangdong government of China enacted a so-called unified medical insurance payment for patients residing in Guangdong province, which fundamentally simplifies reimbursement procedures of medical insurance for the involved cross-city in-patients. Using a unique confidential dataset from 2013 to 2018 on hemorrhoid treatments at a renowned hospital in Guangzhou, the provincial capital of Guangdong, and exploiting difference-in-differences estimations based on the abovementioned policy, we document that the physicians' incentives are a negative externality of the full medical insurance policy for cross-city in-patients and account for a 49% probability increase in improper treatments; and neither increasing the communication between physicians and patients nor enhancing the education level of patients reduces the physician-induced demand for improper treatments. A series of robustness tests indicate our findings are solid. In summary, we highlight the substantial roles of medical insurance as a driver of physician-induced demand in an emerging economy such as China.

Hemoroidlerin Cerrahi Tedavisinde Ferguson Hemoroidektomi

Amaç: Prolabe hemoroidal hastalık nedeniyle ameliyat edilen hastalarımızın ameliyatında geleneksel Ferguson yaklaşımının sonucunu değerlendirmek amaçlanmıştır.Yöntem: Mart 2007-Ocak 2017 tarihleri arasında Ferguson tekniği ile tedavi edilen 769 hasta çalışmaya dahil edildi. Hastaların tıbbi dosyaları değerlendirilerek başvuru şikayetleri, anorektal komorbiditeler, ameliyat bulguları ve postoperatif erken ve geç komplikasyon verileri kaydedildi.Bulgular: Hastaların% 65'i erkekti ve ortalama yaş 39 (18-81) idi. Şikayet süreleri bir hafta ile 5 yıl arasında değişiyordu. Şikayetler sık görülenden az görülene doğru sırasıyla ele gelen pake, kanama ve ağrı idi. Paker'l2r, hastaların %69'unda klasik konumdaydı (saat 3,5,7,11). Vakaların çoğu (% 65) 4. derece hemoroiddi. Hastaların%19'unda anorektal komorbidite olarak anal fissür vardı. Tüm hastalar litotomi pozisyonunda spinal anestezi altında ameliyat edildi. Ferguson tekniği için ameliyat süresi ortalama 20 dakika ve ameliyat sonrası hastanede kalış süresi ortalama bir gündü. Postoperatif dönemde 55 hastada erken komplikasyonlar gelişti. Bunlar 25 hastada (%3-25) şiddetli karın ağrısı, 3 hastada (% 0.4) kanama ve 28 hastada (% 3.60) idrar retansiyonu idi. Yedi hastada geç komplikasyonlar gelişti. 1 hastada anal stenoz, 3 hastada anal fissür ve 2 hastada apse ile fistül gelişti. Hiçbir hastada inkontinans ve nüks görülmedi.Sonuç: Ferguson tekniği halen hemoroid cerrahisinde kullanılmaktadır. Çalışmamızın sonuçları, güvenilir bir tercih yöntemi olarak Ferguson hemoroidektomisini desteklemektedir.

STAPLED HEMORRHOIDOPEXY: RESULTS, LATE COMPLICATIONS, AND DEGREE OF SATISFACTION AFTER 16 YEARS OF FOLLOW-UP

Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids, but concerns about complications and recurrences after prolonged follow-up are still under debate.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis

Background

Multiple treatments for early–moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II–III haemorrhoids.

Methods

A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II–III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.

Results

Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.

Conclusion

Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The aim of this study was to review clinical outcome of haemorrhoidectomy and rubber band ligation in grade II-III haemorrhoids.

METHODS

A systematic review was conducted. Medline, Embase, Cochrane Library, Clinicaltrials.gov, and the WHO International Trial Registry Platform were searched, from inception until May 2018, to identify randomised clinical trials comparing rubber band ligation with haemorrhoidectomy for grade II-III haemorrhoids. The primary outcome was control of symptoms. Secondary outcomes included postoperative pain, postoperative complications, anal continence, patient satisfaction, quality of life and healthcare costs were assessed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Three hundred and twenty-four studies were identified. Eight trials met the inclusion criteria. All trials were of moderate methodological quality. Outcome measures were diverse and not clearly defined. Control of symptoms was better following haemorrhoidectomy. Patients had less pain after rubber band ligation. There were more complications (bleeding, urinary retention, anal incontinence/stenosis) in the haemorrhoidectomy group. Patient satisfaction was equal in both groups. There were no data on quality of life and healthcare costs except that in one study patients resumed work more early after rubber band ligation.

CONCLUSIONS

Haemorrhoidectomy seems to provide better symptom control but at the cost of more pain and complications. However, due to the poor quality of the studies analysed/it is not possible to determine which of the two procedures provides the best treatment for grade II-III haemorrhoids. Further studies focusing on clearly defined outcome measurements taking patients perspective and economic impact into consideration are required.

Experiences of patients with haemorrhoidal disease – a qualitative study

Purpose To obtain a better understanding of the patients’ experiences with haemorrhoidal disease’ impact on their daily life and results of treatment by performing a qualitative study.

Method Individually interviews were conducted among patients with haemorrhoidal disease between 2016 and 2017. Each interview was recorded using an audio recorder and transcribed verbatim. A semi-structured interview guide was used with pre-specified topics, based on a previous conducted literature review. Transcripts were coded and the analysis consisted highlighting passages in the text and assigning each passage a code representing the predefined themes from the interview guide. This resulted in a three-level theme hierarchy: overarching theme, mid-level sub-theme and issues.

Results Fifteen participants underwent individual interviews of whom thirteen were conducted by telephone. The mean age was 60.7 years (35–78); five of them were female (33.3%). Pain and blood loss were the most frequently reported symptoms. Participants indicated that these symptoms were directly associated with emotional burden, daily adjustments and social impact. Before diagnosis with haemorrhoidal disease blood loss resulted in feelings of fear and next in embarrassment during social activities. In daily life participants needed to get up early, used sanitary pads for blood loss and anal ice sticks to reduce pain. Participants were often not completely satisfied with the process and outcome of treatment.

Conclusion This first qualitative study provides detailed insight into the patients’ experiences with haemorrhoidal disease, impact on daily life and results of treatment. This information may be used in daily practice to create awareness among clinicians.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

European Society of ColoProctology: guideline for haemorrhoidal disease

AIM

The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD.

METHODS

The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE.

RESULTS

There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated.

CONCLUSION

This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Pre-operative assessment of internal mucosal rectal prolapse in internal hemorrhoids: technical details and results from a single institution

Background:

The aim of the study was to assess safety and efficacy of pre-operative assessment for internal mucosal rectal prolapse (IMRP) in internal hemorrhoids, in order to achieve a tailored transanal stapled surgery.

Methods:

All consecutive patients (January 2011 to December 2014; age 18-80 years), affected by prolapses with II-IV degrees hemorrhoids that underwent Longo procedure with EEA® Auto Suture stapler (Covidien) were included in the present study.

Results:

A total of 100 consecutive patients (38 females) were enrolled in the study. Preoperative Visual Analogue Scale pain assessment was 7.33±2.68. The mean duration of the procedure was 34.1±17.8 min, and the median hospital stay was 2 days (range 2-6). No major complication occurred, including relapses of mucosal prolapse. Preoperative prolapse measurement with EEA® EEA® Auto Suture stapler (2.3±0.5 cm) was well correlated direct assessment (2.4±0.6, p<0.001), but a proportional bias was identified, with significant preoperative underestimation of IMRP, particularly for lesions larger than 3 cm (around 10% of actual extent).

Conclusions:

EEA® Auto Suture stapler seems to be safe and effective for a tailored approach to anorectal prolapse due to hemorrhoids. However, it reasonable that its actual impact may have been overestimated, beneficing of the repetitive, direct assessment of the operatory field guaranteed by preoperative IMRP measurement. (www.actabiomedica.it)

European Society of Coloproctology Core Outcome Set for haemorrhoidal disease: an international Delphi study among healthcare professionals

AIM

There is considerable heterogeneity in outcomes in studies reporting on the treatment of haemorrhoidal disease (HD). The aim of this study was to develop a Core Outcome Set (COS) for HD in cooperation with the European Society of Coloproctology.

METHOD

A Delphi study was performed according to the Outcome Measures in Rheumatology (OMERACT) methodology. In total 38 healthcare professionals and 30 patients were invited to the panel. Previously, 10 outcome domains and 59 outcomes were identified through a systematic literature review. In this study, these domains and outcomes were formed into one questionnaire for healthcare professionals and a separate questionnaire for patients. Sequential questionnaire rounds prioritizing the domains and outcomes were conducted. Panel members were asked to rate the appropriateness of each domain and outcome on a nine-point Likert scale. During a face-to-face meeting, healthcare professionals agreed on the primary and secondary end-points of the COS for HD. Finally, a short survey was sent to the healthcare professionals in order to reach consensus on how the chosen end-points should be assessed and at which time points.

RESULTS

The response rate in questionnaire round 1 for healthcare professionals was 44.7% (n = 17). Sixteen out of 17 healthcare professionals also completed the questionnaire in round 2. The response rate for the patient questionnaire was 60% (n = 18). Seventeen healthcare professionals participated in the face-to-face meeting. The questionnaire rounds did not result in a clear-cut selection of primary and secondary end-points. Most domains and outcomes were considered important, and only three outcomes were excluded. During the face-to-face meeting, agreement was reached to select the domain 'symptoms' as primary end-point, and 'complications', 'recurrence' and 'patient satisfaction' as secondary end-points in the COS for HD. Furthermore, consensus was reached that the domain 'symptoms' should be a patient reported outcome measure and should include the outcomes 'pain' and 'prolapse', 'itching', 'soiling' and 'blood loss'. The domain 'complications' should include the outcomes 'incontinence', 'abscess', 'urinary retention', 'anal stenosis' and 'fistula'. Consensus was reached to use 'reappearance of initial symptoms' as reported by the patient to define recurrence. During an additional short survey, consensus was reached that 'incontinence' should be assessed by the Wexner Fecal Incontinence Score, 'abscess' by physical examination, 'urinary retention' by ultrasonography, 'anal stenosis' by physical examination, and 'fistula' by physical examination and MR imaging if inconclusive. During follow-up, the outcome 'symptoms' should be assessed at baseline, 7 days, 6 weeks and 1 year post-procedure. The outcomes 'abscess' and 'urinary retention' should be assessed 7 days post-procedure and 'incontinence', 'anal stenosis' and 'fistula' 1 year post-procedure.

CONCLUSIONS

We developed the first European Society of Coloproctology COS for HD based on an international Delphi study among healthcare professionals. The next step is to incorporate the patients' perspective in the COS. Use of this COS may improve the quality and uniformity of future research and enhance the analysis of evidence.

Partial Stapled Hemorrhoidopexy Versus Circumferential Stapled Hemorrhoidopexy for Grade III to IV Prolapsing Hemorrhoids: A Randomized, Noninferiority Trial

BACKGROUND

Long-term outcomes and efficacy of partial stapled hemorrhoidopexy are not known.

OBJECTIVE

The purpose of this study was to compare the long-term clinical efficacy and safety of partial stapled hemorrhoidopexy with circumferential stapled hemorrhoidopexy.

DESIGN

This was a parallel group, randomized, noninferiority clinical trial.

SETTINGS

The study was conducted at a single academic center.

PATIENTS

Patients with grade III/IV hemorrhoids between August 2011 and November 2013 were included.

INTERVENTIONS

Three hundred patients were randomly assigned to undergo either partial stapled hemorrhoidopexy (group 1, n = 150) or circumferential stapled hemorrhoidopexy (group 2, n = 150).

MAIN OUTCOME MEASURES

The primary outcome was the rate of recurrent prolapse at a median follow-up period of 5 years with a predefined noninferiority margin of 3.75%. Secondary outcomes included incidence and severity of postoperative pain, fecal urgency, anal continence, and the frequency of specific complications, including anorectal stenosis and rectovaginal fistula.

RESULTS

The visual analog scores in group 1 were less than those in group 2 (p < 0.001). Fewer patients in group 1 experienced postoperative urgency compared with those in group 2 (p = 0.001). Anal continence significantly worsened after both procedures, but the difference between preoperative and postoperative continence scores was higher for group 2 than for group 1. Postoperative rectal stenosis did not develop in patients in group 1, although it occurred in 8 patients (5%) in group 2 (p = 0.004). The 5-year cumulative recurrence rate between group 1 (9% (95% CI, 4%-13%)) and group 2 (12% (95% CI, 7%-17%)) did not differ significantly (p = 0.137), and the difference was within the noninferiority margin (absolute difference, -3.33% (95% CI, -10.00% to 3.55%)).

LIMITATIONS

The study was limited because it was a single-center trial.

CONCLUSIONS

Partial stapled hemorrhoidopexy is noninferior to circumferential stapled hemorrhoidopexy for patients with grade III to IV hemorrhoids at a median follow-up period of 5 years. However, partial stapled hemorrhoidopexy was associated with reduced postoperative pain and urgency, better postoperative anal continence, and minimal risk of rectal stenosis. See Video Abstract at http://links.lww.com/DCR/A790.Trial registration (chictr.org) identifier is chiCTR-trc-11001506.

Stapled Hemorrhoidopexy: Results at 10-Year Follow-up

BACKGROUND

Despite the advantages of stapled hemorrhoidopexy reported in the literature in terms of postoperative pain, hospital stay, and duration of convalescence, it was described to have a higher recurrence rate compared with conventional hemorrhoidectomy.

OBJECTIVE

The aim of this study was to evaluate clinical outcomes and patient satisfaction after stapled hemorrhoidopexy at 10-year follow-up.

DESIGN

This was a retrospective cohort analysis conducted on prospectively collected data.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included.

MAIN OUTCOME MEASURES

Patients satisfaction and recurrence rates were measured.

RESULTS

Eighty-six patients (45 men and 41 women; median age, 49 y (range, 31-74 y)) underwent stapled hemorrhoidopexy. Eight patients had urinary retention during the immediate postoperative period, and 2 patients required a reoperation for suture line bleeding. The median hospital stay was 12 hours (range, 12-96 h). No suture line dehiscence, rectovaginal fistula, pelvic sepsis, anal abscess, or anal stenosis was recorded during the follow-up. Seventy-seven patients (90%) completed the expected follow-up, with a median duration of 119.0 months (range 115.4-121.8 mo). Among them, 30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation. Thirty-four patients (44%) reported urge to defecate with a median visual analog scale of 1 (range, 1-7). Six patients (8%) reported gas leakage at the last follow-up visit, whereas no liquid or solid stool leakage was recorded. Satisfaction rate at 10-year follow-up was 68%.

LIMITATIONS

The study was limited by its small sample size and lack of a control group.

CONCLUSIONS

The high recurrence rate and low patient satisfaction rate showed that stapled hemorrhoidopexy reduces its efficacy in the long-term. See Video Abstract at http://links.lww.com/DCR/A510.

Towards a core outcome set for hemorrhoidal disease-a systematic review of outcomes reported in literature

PURPOSE

Previously published literature regarding treatment of hemorrhoidal disease (HD) revealed a lack of uniform defined outcomes. These differences between outcomes among studies limit transparency and lead to incomparability of results. The aim of this study was to systematically list the types of outcomes used in HD studies. This list will be used to develop a core outcome set.

METHODS

We searched Medline (Pubmed), Embase (OVID), and Cochrane for interventional studies for adult patients with HD. Two authors independently identified and reviewed eligible studies. This resulted in a list of outcomes reported by each clinical trial. All outcomes were categorized using the conceptual framework OMERACT filter 2.0.

RESULTS

A total of 34 randomized controlled trials and prospective observational studies were included in this study. A total of 59 different types of outcomes were identified. On average, 5.8 different outcomes (range 2-8) were used per study. The outcomes were structured into three core areas and10 ten domains. The most commonly reported core area was pathophysiological manifestations including the domain symptoms, complications, and recurrence. The most frequently reported outcomes were pain (91%), blood loss (94%), prolapse (71%), and incontinence (56%). There was a high variation in definitions of the common outcomes. And often there was no definition at all.

CONCLUSION

This study shows a substantial heterogeneity in the types of outcomes in HD studies. We provided an overview of the types of outcomes reported in HD studies and identified a list of potentially relevant outcomes required for the development of a COS.

A pragmatic multicentre randomised controlled trial comparing stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease: the eTHoS study

BACKGROUND

Haemorrhoids are a benign anorectal condition and are highly prevalent in the UK population. Treatments involve clinic-based procedures and surgery. The surgical procedures available include stapled haemorrhoidopexy (SH) and traditional haemorrhoidectomy (TH), and over 25,000 operations are performed for haemorrhoids annually in the UK. The disease is therefore important both to patients and to health service commissioners. Debate remains as to which of these surgical procedures is the most clinically effective and cost-effective.

OBJECTIVE

The aim of this study was to compare the clinical effectiveness and cost-effectiveness of SH with that of TH.

DESIGN

A large, open two-arm parallel-group pragmatic multicentre randomised controlled trial involving 32 UK hospitals and a within-trial cost-benefit analysis. A discrete choice experiment was conducted to estimate benefits (willingness to pay).

PARTICIPANTS

Patients with grades II-IV haemorrhoids who had not previously undergone SH or TH were included in the study.

INTERVENTIONS

Participants were randomised to receive either SH or TH. Randomisation was minimised at 1 : 1, in accordance with baseline EuroQol-5 Dimensions, three-level version (EQ-5D-3L) score, haemorrhoid grade, sex and centre, via an automated system.

MAIN OUTCOME MEASURES

The primary outcome was area under the quality-of-life curve measured using the EQ-5D-3L descriptive system over 24 months, and the primary economic outcome was the incremental cost-effectiveness ratio. Secondary outcomes included disease-specific quality of life, recurrence, complications, further interventions and costs.

RESULTS

Between January 2011 and August 2014, 777 patients were randomised (389 to receive SH and 388 to receive TH). There were 774 participants included in the analysis as a result of one post-randomisation exclusion in the SH arm and two in the TH arm. SH was less painful than TH in the short term. Surgical complications were similar in both arms. EQ-5D-3L score was higher for the SH arm in the first 6 weeks after surgery, but over 24 months the TH group had significantly better EQ-5D-3L scores (-0.073, 95% confidence interval -0.140 to -0.006; p = 0.0342). Symptoms and further interventions were significantly fewer in the TH arm at 24 months. Continence was better in the TH arm and tenesmus occurred less frequently. The number of serious adverse events reported was 24 out of 337 (7.1%) for participants who received SH and 33 out of 352 (9.4%) for those who received TH. There were two deaths in the SH arm, both unrelated to the eTHoS (either Traditional Haemorrhoidectomy or Stapled haemorrhoidopexy for haemorrhoidal disease) study. Patient preference did not seem to influence the treatment difference. SH was dominated by TH as it cost more and was less effective. The net benefit for the TH arm was higher than that for the SH arm.

LIMITATIONS

Neither the participants nor the assessors were masked to treatment assignment and final recruitment was slightly short of the total target of 800. There were also substantial missing follow-up data.

CONCLUSIONS

While patients who received SH had less short-term pain, after 6 weeks, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured TH. In addition, TH is cheaper. As part of a tailored management plan for haemorrhoids, TH should be considered over SH as the surgical treatment of choice for haemorrhoids refractory to clinic-based interventions.

FUTURE WORK

Perform an updated meta-analysis incorporating recently conducted European trials [eTHoS, HubBLe (haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids) and LingaLongo (Cost-effectiveness of New Surgical Treatments for Haemorrhoidal Disease)].

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80061723.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 70. See the NIHR Journals Library website for further project information.

Step by step guide to do a systematic review and meta-analysis for medical professionals

INTRODUCTION

Systematic review and meta-analysis are statistical tools used to review researches performed on a same topic. They extract the collective effect of the studies performed on the topic of interest after statistically analysing the data of all the studies included.

AIMS AND OBJECTIVES

Systematic reviews and meta-analysis are getting more and more popular in the medical field. Statistics is never the strong aspect of medical professionals, and facing a large number of statistical tests and values could be quite confusing for them. The aim of this article is to simplify these two very important research modalities for medical professionals.

CONCLUSION

This article will provide a step-to-step guide for the medical colleagues to perform a meta-analysis if they are interested.

LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY

Background:

Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients.

Aim:

To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique.

Method:

In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up.

Results:

The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97).

Conclusion:

Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.

Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III-IV Prolapsing Hemorrhoids

PURPOSE

Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III-IV hemorrhoids because of less pain and short hospital stay. However, this procedure is associated with some complications, such as urge to defecate, anal stenosis, staple line dehiscence, abscess and sepsis. To avoid these complications, surgeons perform a partial stapled hemorrhoidopexy (PSH). The aim of this study is to present our early experience with the PSH.

METHODS

We retrospectively reviewed the medical records of 58 patients with hemorrhoids who were treated with a PSH at Busan Hang-Un Hospital from January 2016 to June 2016. A specially designed tri-window anoscope was used, and a purse string suture was made at the mucosae of the protruding hemorrhoids through the window of the anoscope. The hemorrhoidopexy was done by using a circular stapler.

RESULTS

Of the 58 patients included in this study, 34 were male and 24 were female patients (mean age, 50.4 years). The mean operation time was 12.4 minutes, and the mean postoperative hospital stay was 3.8 days. Three patients experienced bleeding (5.1%) 5 urinary retention (8.6%) and 5 skin tags (8.6%). Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur.

CONCLUSION

PSH is a minimally invasive, feasible, and safe technique for treating patients with grades III-IV hemorrhoids. A PSH, instead of a CSH, can be used to treat certain patients with hemorrhoids.

[Not Available]

Zusammenfassung. Der auf Höhe der Linea dentata gelegene Corpus cavernosum recti spielt eine tragende Rolle bei der Regulierung der Feinkontinenz. Kommt es zu einer pathologischen Vergrösserung des Corpus cavernosum verbunden mit Symptomen, spricht man von einem Hämorrhoidalleiden. Das Hämorrhoidalleiden ist eine Volkskrankheit mit einer Inzidenz von ca. 40 %, wobei die Rate an Selbsttherapien hoch ist. Im klinischen Alltag fällt der stadienadaptierten Therapie eine wichtige Rolle zu: Hämorrhoiden Grad I sind die Domäne der konservativen Therapie, Hämorrhoiden Grad II können in Abhängigkeit der Schwere der Symptome konservativ oder operativ angegangen werden. Hämorrhoiden Grad III und Grad IV sollten einer Operation zugeführt werden.

A Case Report of Acute Diverticulitis in "Pseudodiverticulosis" after Hemorpex System® Procedure

Introduction. In the last years many mini-invasive approaches were developed in order to reduce postoperative pain and complication after haemorrhoid surgery: one of these alternatives is represented by Hemorpex System, a relatively young technique that combines transanal dearterialization with mucopexy through a dedicated proctoscope. Case Presentation. A 78-year-old male patient was admitted to the Emergency Department for acute urinary retention and elevated temperature. Hemorpex procedure was performed 4 years before. Clinical, endoscopic, and radiological findings demonstrated the presence of multiple diverticula-like structures fulfilled by purulent fluid and a deep alteration of the normal anatomy of the rectum. He was treated following the standard protocol of acute diverticulitis and full recovery from symptoms was achieved. Discussion. Hemorpex System is a young technique, and nowadays-available studies lack long-term follow-up data. Anatomical changes induced by the procedure are consistent and definitive. Our patient luckily demonstrated a prompt response to conservative treatment, but it must be taken into account that, in case of medical treatment failure, surgical approach would be necessary and the actual patient anatomical changes could lead the surgeon to unavoidable threatening maneuvers.

Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Two commonly performed surgical interventions are available for severe (grade II-IV) haemorrhoids; traditional excisional surgery and stapled haemorrhoidopexy. Uncertainty exists as to which is most effective. The eTHoS trial was designed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery.

METHODS

The eTHoS trial was a large, open-label, multicentre, parallel-group, pragmatic randomised controlled trial done in adult participants (aged 18 years or older) referred to hospital for surgical treatment for grade II-IV haemorrhoids. Participants were randomly assigned (1:1) to receive either traditional excisional surgery or stapled haemorrhoidopexy. Randomisation was minimised according to baseline EuroQol 5 dimensions 3 level score (EQ-5D-3L), haemorrhoid grade, sex, and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery. The primary outcome was area under the quality of life curve (AUC) measured with the EQ-5D-3L descriptive system over 24 months, assessed according to the randomised groups. The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables. This trial is registered with the ISRCTN registry, number ISRCTN80061723.

FINDINGS

Between Jan 13, 2011, and Aug 1, 2014, 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery). Stapled haemorrhoidopexy was less painful than traditional excisional surgery in the short term and surgical complication rates were similar between groups. The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months; mean difference -0·073 (95% CI -0·140 to -0·006; p=0·0342). EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery, the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group. 24 (7%) of 338 participants who received stapled haemorrhoidopexy and 33 (9%) of 352 participants who received traditional excisional surgery had serious adverse events.

INTERPRETATION

As part of a tailored management plan for haemorrhoids, traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice.

FUNDING

National Institute for Health Research Health Technology Assessment programme.

Doppler-Guided Transanal Hemorrhoidal Dearterialization (DG-THD) Versus Stapled Hemorrhoidopexy (SH) in the Treatment of Third-Degree Hemorrhoids: Clinical Results at Short and Long-Term Follow-Up

INTRODUCTION

The stapled hemorrhoidopexy (SH) and the Doppler-guided transanal hemorrhoidal dearterialization (DG-THD) are minimally invasive procedures for the surgical treatment of hemorrhoids. This study aims to verify the efficacy of the DG-THD versus the SH in the treatment of third-degree hemorrhoids.

METHOD

One hundred consecutive patients were causally allocated to either procedure, obtaining two groups of 50 pts. A clinical examination was performed at 3, 7, 15, and 30 days after the operation. Quality of life, anal symptoms, recurrence of hemorrhoids, and reoperation were assessed by means of a questionnaire and of a clinical examination at long-term follow-up (7.0 year average).

RESULTS

At short-term follow-up, the median postoperative pain score was significantly lower in DG-THD group compared to SH group, (V.A.S 2 vs 6; t = 2.65, p < 0.01). The morbidity rate and the return to normal life and work were similar after the two procedures. At long-term follow-up, the incidence of piles was not statistically different between the two groups (DG-THD 10.0 %; SH 14.0 %). No differences were reported by patients in terms of satisfaction for surgery.

CONCLUSION

SH and DG-THD procedures do not show significantly different results with regard to the patients outcome. However, considering the lower p. o. pain, the DG-THD might be proposed as the first line treatment in third-degree hemorrhoids.

Early complications after stapled hemorrhoidopexy: a retrospective study comparing three different circular staplers

BACKGROUND

A retrospective analysis was performed to assess differences between three devices used for stapled hemorrhoidopexy (SH) in terms of early complications and complaints and the volume of excised tissue.

MATERIALS AND METHODS

All patients who underwent an elective SH from January 2008 to December 2014 were included. Three different devices were used: the PPH03 stapler (Ethicon EndoSurgery, Diegem, Belgium) and the Chex^TM CPH32 and CPH34 staplers (Frankenman International Ltd, Hong Kong, China). The demographic data were reviewed as well as indications for surgery. The volume of the excised tissue was determined by reviewing the anatomopathologic reports. We assessed early postoperative complications and complaints and compared the rate of complications between the three used devices.

RESULTS

From 1 January 2008 to 30 December 2014, 253 patients underwent a SH using three different devices. One hundred and seventy-four patients were treated with the PPH03 stapler, 51 with the Chex^TM CPH32 stapler and 28 with the Chex^TM CPH34 stapler. Postoperatively, 28.5% of patients experienced minor early complications. There was no difference in complication rates between the three different devices, except for the occurrence of postoperative stenosis with more stricture formation when using the CPH32 stapler (p < 0.0001). The volume of tissue excised by the Chex^TM CPH32 and CPH34 staplers was significantly larger than in the PPH03 group (18.19 ± 9.67 mL; 25.53 ± 13.99 mL; 11.63 ± 5.66 mL; p < 0.0001).

CONCLUSIONS

Postoperative anal stenosis was more common after circular stapled hemorrhoidopexy with the ChexTM CPH32 stapler.

Transanal anopexy with HemorPex System (HPS) is effective in treating grade II and III hemorrhoids: medium-term follow-up

BACKGROUND

Hemorrhoidal disease is a common proctologic disorder. The HemorPex System(®) (HPS) (Angiologica, S. Martino Siccomario PV, Italy) is an innovative surgical technique based on muco-hemorrhoidopexy without Doppler guidance. The aim of this study was to evaluate the efficacy of HPS in on the treatment of grade II and III hemorrhoids.

METHODS

One hundred patients with grade II and III hemorrhoidal disease were included in the study and operated on using HPS without Doppler guidance. The procedure consists of a mucopexy carried out by means of a dedicated rotating anoscope in the 6 relatively constant positions of the terminal branches of the superior hemorrhoidal artery. A direct follow-up was carried out on 100 patients for up to 3 months. A late analysis (>12 months postoperatively) was conducted by telephone interview. At follow-up the following parameters were considered: pain, bleeding, prolapse, difficulties with hygiene and patient satisfaction with treatment.

RESULTS

Operative time was 16 ± 5 min. Three-month follow-up showed significant improvement of symptoms: pain was present in 10 (10 %) patients versus 45 (45 %) preoperatively; bleeding in 13 (13 %) of patients versus 57 (57 %) preoperatively; prolapse in 13 (13 %) of patients versus 45 (45 %) preoperatively and difficulties with hygiene in 1 (1 %) versus 24 (24 %) preoperatively (all p < 0.05). At longer follow-up which was available in 67 patients, 5 patients (7.5 %) had recurrence and were reoperated on at 8, 10, 24, 26 and 36 months, respectively after the first procedure. As regards patient satisfaction, complete satisfaction was reported by 95/100 patients (95 %) at 3 months, 62/67 (92.5 %) at 12 months and 8/56 (85.7 %) at 24 months; partial satisfaction was reported by 3/100 patients (3 %) with intermittent bleeding at 3 months, 3/67 (4.4 %) patients at 12 months and 6/56 (10.7 %) patients at 24 months, all with either intermittent bleeding or prolapse. Dissatisfaction with the procedure was reported by in 1/100 (1 %) patient at 3 months, 2/67 (2.9 %) at 12 months and 2/56 (3.6 %) at 24 months including patients who underwent reintervention.

CONCLUSIONS

HPS can be used in the treatment of grade II and III hemorrhoidal disease. Our results show that this simple technique may be an effective but due to the important limitations of this study (loss to follow-up, non-comparative study) further studies are required.

Circular mucosal anopexy: Experience and technical considerations

INTRODUCTION

Circular mucosal anopexy (CMA) achieves a more comfortable postoperative period than resective techniques. But complications and recurrences are not infrequent. This study aims to evaluate of the efficacy of CMA in the treatment of hemorrhoids and rectal mucosal prolapse (RMP).

METHOD

From 1999 to 2011, 613 patients underwent surgery for either hemorrhoids or RMP in our hospital. CMA was performed in 327 patients. Gender distribution was 196 male and 131 female. Hemorrhoidal grades were distributed as follows: 28 patients had RMP, 46 2nd grade, 146 3rd grade and 107 4th grade. Major ambulatory surgery (MAS) was performed in 79.9%. Recurrence of hemorrhoids was studied and groups of recurrence and no-recurrence were compared. Postoperative pain was evaluated by Visual Analogical Scale (VAS) as well as early complications.

RESULTS

A total of 31 patients needed reoperation (5 RMP, 2 with 2nd grade, 17 with 3rd grade,/with 4th grade). No statistically significant differences were found between the non-recurrent group and the recurrent group with regards to gender, surgical time or hemorrhoidal grade, but there were differences related to age. In the VAS, 81.3% of patients expressed a postoperative pain ≤ 2 at the first week. Five patients needed reoperation for early postoperative bleeding. Six patients needed admission for postoperative pain.

CONCLUSIONS

Recurrence rate is higher in CMA than in resective techniques. CMA is a useful technique for the treatment of hemorrhoids in MAS. Pain and the rate of complications are both low.

[Comparison of Doppler-assisted dearterialization with mucopexy and hemorrhoidectomy]

AIM

To compare two methods of hemorrhoid treatment.

MATERIAL AND METHODS

This prospective study included 240 patients with hemorrhoids stage III-IVA. Stages III and IVA were diagnosed in 156 (65%) and 84 (35%) patients respectively. Randomization was performed using envelopes method in one to one distribution. In group 1 (n=120) Doppler-assisted dearterialization of internal hemorrhoids with mucopexy was performed (DDM), in group 2 (n=120) - hemorrhoidectomy using harmonic scalpel (HE).

RESULTS

Duration of surgery was 17.9±6.1 and 34.5±10.1 minutes in DDM and HE groups respectively (p<0.01). Postoperative pain severity was higher in group 2 (4.8 compared with 2.5 scores of the first group (p<0.01). Narcotic analgesics were used less often in DDM group (1.3 doses compared with 6.1 doses in HE group (p<0.01). Disability period was 14.4±5.2 and 30.3±5.4 days in both groups respectively (p<0.01). Immediate postoperative complications occurred in 9 (7.5%) and 19 (15.8%) patients of DDM and HE groups respectively. Recurrent prolapse of internal hemorrhoids was diagnosed in 2 (1.7%) patients of the 1st group in terms of up to 45 days.

CONCLUSION

DDM is reliable minimally invasive method of hemorrhoids stage III-IVA treatment and has similar efficacy with HE. DDM reduces postoperative pain severity, hospital stay and disability period.

Complications Following Anorectal Surgery

Anorectal surgery is well tolerated. Rates of minor complications are relatively high, but major postoperative complications are uncommon. Prompt identification of postoperative complications is necessary to avoid significant patient morbidity. The most common acute complications include bleeding, infection, and urinary retention. Pelvic sepsis, while may result in dramatic morbidity and even mortality, is relatively rare. The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain.

High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study

The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012–2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (p < 0.001). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (p = 0.000), Pescatori's degree (p = 0.000), Goligher's grade (p = 0.003), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (p = 0.000), and higher volume of prolapsectomy (p = 0.000). At regression analysis, only the preoperative CSS, Pescatori's degree, Goligher's grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; p < 0.001) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates.

Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids

BACKGROUND

The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids.

METHODS

Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.

RESULTS

Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags.

CONCLUSION

Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.

Gabapentin significantly decreases posthemorrhoidectomy pain: a prospective study

PURPOSE

Surgery for hemorrhoidectomy remains a painful procedure despite advances in pain management. Gabapentin is widely used for control of acute and chronic pain. Our aim was to evaluate the effect of gabapentin on posthemorrhoidectomy pain and opioid use.

METHODS

A prospective, open-label study. Patients requiring hemorrhoid surgery were recruited to be in control (standard of care) or treatment group (standard of care plus daily gabapentin).

RESULTS

Twenty-one treatment and 18 control patients were recruited. One patient from study group and two patients from control group were excluded due to failure to follow up. Pain levels for gabapentin group were significantly lower on postoperative days 1, 7, and 14 compared to the standard treatment group (3.68 vs. 6.82 p < 0.01, 2.68 vs. 5 p = 0.02 and 0.75 vs. 3.64 p < 0.001 respectively). There was a trend toward less opioids taken in gabapentin group for postoperative days 1, 7, and 14 (4.69 vs. 6.36; 2.13 vs. 2.73, and 0.125 vs. 0.9) but it did not reach statistical significance. The average hemorrhoidal grade and number of hemorrhoidal complexes removed was slightly higher in gabapentin group. Five control group patients experienced postoperative complications versus two gabapentin group patients. No gabapentin related complications were seen in the treatment group. The average cost of gabapentin course was $5.34 per patient.

CONCLUSIONS

Daily use of gabapentin in perioperative period significantly decreased reported levels of postoperative pain. This effective, inexpensive addition improves pain after hemorrhoid surgery. Randomized placebo-controlled studies would better define the usefulness of this medication for posthemorrhoidectomy pain.

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

A pragmatic, multicentre, randomised controlled trial comparing stapled haemorrhoidopexy to traditional excisional surgery for haemorrhoidal disease (eTHoS): study protocol for a randomised controlled trial

BACKGROUND

Current interventions for haemorrhoidal disease include traditional haemorrhoidectomy (TH) and stapled haemorrhoidopexy (SH) surgery. However, uncertainty remains as to how they compare from a clinical, quality of life (QoL) and economic perspective. The study is therefore designed to determine whether SH is more effective and more cost-effective, compared with TH.

METHODS/DESIGN

eTHoS (either Traditional Haemorrhoidectomy or Stapled Haemorrhoidopexy for Haemorrhoidal Disease) is a pragmatic, multicentre, randomised controlled trial. Currently, 29 secondary care centres are open to recruitment. Patients, aged 18 year or older, with circumferential haemorrhoids grade II to IV, are eligible to take part. The primary clinical and economic outcomes are QoL profile (area under the curve derived from the EuroQol Group's 5 Dimension Health Status Questionnaire (EQ-5D) at all assessment points) and incremental cost per quality adjusted life year (QALY) based on the responses to the EQ-5D at 24 months. The secondary outcomes include a comparison of the SF-36 scores, pain and symptoms sub-domains, disease recurrence, complication rates and direct and indirect costs to the National Health Service (NHS). A sample size of n =338 per group has been calculated to provide 90% power to detect a difference in the mean area under the curve (AUC) of 0.25 standard deviations derived from EQ-5D score measurements, with a two-sided significance level of 5%. Allowing for non-response, 400 participants will be randomised per group. Randomisation will utilise a minimisation algorithm that incorporates centre, grade of haemorrhoidal disease, baseline EQ-5D score and gender. Blinding of participants and outcome assessors is not attempted.

DISCUSSION

This is one of the largest trials of its kind. In the United Kingdom alone, 29,000 operations for haemorrhoidal disease are done annually. The trial is therefore designed to give robust evidence on which clinicians and health service managers can base management decisions and, more importantly, patients can make informed choices.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80061723 (assigned 8 March 2010).

Is Stapled Hemorrhoidectomy a Safe Procedure for Third and Fourth Grade Hemorrhoids? An Experience at Civil Hospital Karachi

Hemorrhoids are amongst the most frequent anorectal conditions affecting approximately 4-36 % of the general population. The study was carried out to assess the clinical consequences of stapled hemorrhoidectomy comparing results with other published literature regarding postoperative pain, bleeding, incontinence, and other complications. A total of 120 patients were included in this study with symptomatic grade 3 or 4 prolapsed hemorrhoids, who underwent stapled hemorrhoidectomy from January 2006 to January 2012 at the Civil Hospital Karachi, Pakistan. In 92 patients (76.6 %), proctological examination showed grade 3 hemorrhoids. Fourth degree hemorrhoids were found in 28 cases (23.4 %). Hospitalization time ranged between 1 and 3 days (median time was 34 h). Seventy-eight patients were discharged on the first postoperative day, without severe pain, and the remaining 42 patients were discharge on the third day. Two cases of postoperative pain and thrombosis were found as postoperative complications. Stapled hemorrhoidectomy is a safe and quick procedure associated with less pain, better outcome, and early recovery with shorter hospital stay.

Residual Prolapse in Patients with III-IV Degree Haemorrhoids Undergoing Stapled Haemorrhoidopexy with CPH34 HV: Results of an Italian Multicentric Clinical Study

CPH34 HV, a high volume stapler, was tested in order to assess its safety and efficacy in reducing residual/recurrent haemorrhoids. The clinical charts of 430 patients with third- to fourth-degree haemorrhoids undergoing SH in 2012-2013 were consecutively reviewed, excluding those with obstructed defecation (rectocele >2 cm; Wexner's score >15). Follow-up was scheduled at six and 12 months. Rectal prolapse exceeding more than half of CAD was reported in 341 patients (79.3%); one technical failure was reported (0.2%) without any serious untoward effect; and 1.3 stitch/patient (SD, 1.7) was required to achieve complete haemostasis. Doughnuts volume was higher (13.8 mL; SD, 1.5) in patients with a large rectal prolapse than with smaller one (8.9 mL; SD, 0.7) (P value <0.05). Residual and recurrent haemorrhoids occurred in 8 of 430 patients (1.8%) and 5 of 254 patients (1.9%), respectively. A high index of patient satisfaction (visual analogue scale = 8.9; SD, 0.9) coupled with a persistent reduction of constipation scores (CSS = 5.0, SD, 2.2) was observed. The wider prolapse resection well correlated with a clear-cut reduction of haemorrhoidal relapse, a high index of patient satisfaction, and clinically relevant reduction of constipations scores coupled with satisfactory haemostatic properties of CPH34 HV.

Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review

Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.

Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations?

BACKGROUND

Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line.

OBJECTIVE

This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital.

PATIENTS

All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples.

INTERVENTIONS

If identified, the retained staples were removed endoscopically or transanally.

MAIN OUTCOME MEASURES

After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms.

RESULTS

From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms.

LIMITATIONS

The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement.

CONCLUSIONS

The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.

Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux

OBJECTIVES

To determine the prevalence of haemorrhoids in women with pelvic vein reflux, identify which pelvic veins are associated with haemorrhoids and assess if extent of pelvic vein reflux influences the prevalence of haemorrhoids.

METHODS

Females presenting with leg varicose veins undergo duplex ultrasonography to assess all sources of venous reflux. Those with significant reflux arising from the pelvis are offered transvaginal duplex ultrasound (TVS) to evaluate reflux in the ovarian veins and internal Iliac veins and associated pelvic varices in the adnexa, vulvar/labial veins and haemorrhoids. Patterns and severity of reflux were evaluated.

RESULTS

Between January 2010 and December 2012, 419 female patients with leg or vulvar varicose vein patterns arising from the pelvis underwent TVS. Haemorrhoids were identified on TVS via direct tributaries from the internal Iliac veins in 152/419 patients (36.3%) and absent in 267/419 (63.7%). The prevalence of the condition increased with the number of pelvic trunks involved.

CONCLUSION

There is a strong association between haemorrhoids and internal Iliac vein reflux. Untreated reflux may be a cause of subsequent symptomatic haemorrhoids. Treatment with methods proven to work in conditions caused by pelvic vein incompetence, such as pelvic vein embolisation and foam sclerotherapy, could be considered.

A prospective and comparative study between stapled hemorrhoidopexy and hemorrhoidal artery ligation with mucopexy

AIM

The aim of this study was to compare the efficacy between stapled hemorrhoidopexy (Longo technique) and transanal hemorrhoidal artery ligation with mucopexy (THDm) in the treatment of hemorrhoidal disease.

PATIENTS AND METHODS

From June 2009 to January 2011, 81 patients having grade II or III hemorrhoidal disease underwent prospective evaluation followed by surgery at two centers (27 Longo and 54 THDm). Symptoms (bleeding, tenesmus, prolapse, fecal incontinence, pain) and the satisfaction score were compared on the first post-operative day and at 1, 6, 12, and 24 months thereafter. The follow-up was 24 months.

RESULTS

There was no difference in mean length of stay. One complication (recto-vaginal fistula) was observed after Longo. The prolapse score was significantly lower after THDm than after Longo on the first post-operative day (P < 0.0015). Bleeding score after THDm was significantly lower on the first post-operative day (P = 0.04), but higher thereafter (P = 0.03 and P = 0.04). Tenesmus score after THDm was significantly lower for the first three months (P < 0.06 and 0.001). On the first post-operative day and at one month, the visual analog pain score was significantly lower after THDm than that after Longo (P < 0.0003 et P < 0.01). On the first post-operative day and at one month, the satisfaction score was higher after THDm than after Longo (P < 0.001).

CONCLUSION

THDm was safe and effective. Short-term outcomes after THDm were better than after Longo but long-term results seemed to be similar.

Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials

BACKGROUND

Although surgery is the gold standard treatment for anal fissure, the main concern remains its side effects and complications. Botulinum toxin injection and lateral internal sphincterotomy are technical options for patients suffering from chronic anal fissure. However, little is known about the efficacy of these two techniques. The aim of this meta-analysis was to compare the outcomes of botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure.

METHODS

Original studies in English were searched from the MEDLINE database, PubMed, Web of Science, and the Cochrane Library database. Randomized control trials that compared botulinum toxin injection with lateral internal sphincterotomy were identified. Data were independently extracted for each study, and a meta-analysis was performed using fixed and random effects models.

RESULTS

Four hundred and eighty-nine patients from seven trials met the inclusion criteria. Patients undergoing lateral internal sphincterotomy had a higher-healing and incontinence rate. No statistically significant differences were noted in total complications between botulinum toxin injection and lateral internal sphincterotomy. Patients treated with lateral internal sphincterotomy had a significantly lower recurrence rate than the patients treated with botulinum toxin injection.

CONCLUSIONS

Our meta-analysis shows that lateral internal sphincterotomy was superior to botulinum toxin injection in terms of healing rate and lower recurrence rate. Botox, however, is safe associated with a lower rate of incontinence and could be used in certain situations. Further studies with a long-term follow-up are required to confirm our observations.