Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy

A Novel Therapeutic Approach of 980 nm Photobiomodulation Delivered with Flattop Beam Profile in Management of Recurrent Aphthous Stomatitis in Paediatrics and Adolescents-A Case Series with 3-Month Follow-Up

Background/Objectives: Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal lesions and a very debilitating lesion, especially in paediatric and adolescent patients. The current pharmacotherapy offers a pain relief but not without side effects, and therefore photobiomodulation (PBM) can be an alternative therapy. To the authors' best knowledge, no published study has explored the efficacy of λ 980 nm laser PBM in the management of all RAS subtypes in paediatric and adolescent patients, and therefore, this prospective observational clinical study was conducted to bridge this gap by evaluating λ 980 nm laser PBM efficacy in symptomatic RAS management in paediatric and adolescent patients. The objectives were to evaluate (1) pain intensity alleviation; (2) wound healing rate; (3) wound size closure; (4) a complete resolution; (5) evidence of recurrence; and (6) patients' treatment satisfaction. Methods: The study's variables were assessed at the following timepoints: T0: pre-treatment; T1: immediately after first PBM session; T2: 5 hours (h) post first PBM session (via telephone call); T3: immediately after second PBM session (three days post first PBM session); T4: three-day follow-up (after complete PBM treatments); T5: two-week follow-up; and T6: three-month follow-up. The following PBM dosimetry and treatment protocols were employed: λ 980 nm; 300 mW; 60 s; 18 J; CW; flattop beam profile of 1 cm2 spot size; 18 J/cm2; and twice-a-week irradiation (72 h interval). Results: At T1, significant immediate pain intensity relief was reported. 33.33% recorded "4" and 66.67% reported "5" on the quantitative numeric pain intensity scale (NPIS), and this continued to improve significantly (83.33%) at T2. All the subjects reported "0" on the NPIS at T3, T4, T5 and T6. There was a significant reduction in the lesion surface area (>50% complete healing) at T3 compared to T0. Complete healing (100%) with no evidence of scarring and lesion recurrence observed at T4, T5 and T6. Very good patients' satisfaction was reported at all timepoints. Conclusions: This is the first report demonstrating λ980 nm efficacy in all RAS subtype management in paediatric and adolescent patients with a 3-month follow-up, whereby its PBM dosimetry and treatment protocols were effective from scientific and practical standpoints, and hence multicentre RCTs with large data are warranted to validate its reproducibility and to enrich the knowledge of PBM application in all RAS subtypes.

Modified ultrasound scalpel haemorrhoidectomy versus conventional haemorrhoidectomy for mixed haemorrhoids: a study protocol for a single-blind randomised controlled trial

BACKGROUND

Haemorrhoids are common and frequently occurring diseases in the clinical setting, and severe haemorrhoids require surgical treatment. There are various surgical methods to treat haemorrhoids, but each has advantages and disadvantages. In recent years, ultrasonic scalpels have been used in haemorrhoid surgery and have achieved good results. Ultrasonic scalpel haemorrhoidectomy is safer and more effective in the surgical treatment of grade III and IV haemorrhoids, with less intraoperative bleeding, less postoperative pain, and fewer complications than diathermic therapy, electrosurgical haemorrhoidectomy, PROXIMATE® PPH haemorrhoidal circular stapler haemorrhoidopexy (PPH), and traditional haemorrhoidectomy. In previous reports, the majority of ultrasonic scalpel haemorrhoidectomies were performed as open procedures, with only the body of the haemorrhoid removed with the ultrasonic scalpel and the wound left open for drainage and natural healing. However, we performed a preliminary experiment with 12 patients who underwent open ultrasonic scalpel haemorrhoidectomy in the early stage. The results showed that 8 patients had different degrees of postoperative bleeding, and 4 of them required a second haemostatic surgery under anaesthesia. Therefore, we modified the open ultrasonic scalpel haemorrhoidectomy procedure by removing the mucosa of the internal haemorrhoid and closing the base of the incision with figure-eight penetrating sutures and designed this study protocol to evaluate its clinical efficacy and safety.

METHODS

A randomised single-blind parallel-controlled trial is proposed for this project, and patients who meet the inclusion criteria will be divided into a test group and a control group, with 39 patients in each group. The experimental group will be treated with modified ultrasonic scalpel haemorrhoidectomy, and the control group will be treated with the Milligan-Morgan operation. The effectiveness of modified ultrasonic scalpel haemorrhoidectomy for haemorrhoids will be objectively evaluated, including the incision healing time and the time for patients to return to normal activities, postoperative complications, evaluations of anal function 3 months and 6 months after surgery, an evaluation of quality of life 6 months after surgery, and an evaluation of the patient satisfaction rate 6 months after surgery. The safety assessment will consider all adverse and serious adverse events associated with the study treatment.

DISCUSSION

The study was approved by the ethics committee. The first patient was registered on July 1 2021. The purpose of this trial will be to evaluate the clinical efficacy and safety of the modified ultrasonic scalpel haemorrhoidectomy procedure for the treatment of mixed haemorrhoids and to provide an evidence base for the clinical promotion and application of the procedure. A limitation of this study is that only the patients will be single-blinded because the researchers and the patients cannot be blinded at the same time, which may produce certain bias in the results. In addition, the sample size of this study will be small, and the test results will only represent the findings from this clinical trial. In later stages, the sample size needs to be further expanded to improve the level of evidence. Despite its limitations, we hope the present study will help provide a more optimised surgical approach in the selection of haemorrhoid surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration ID: ChiCTR2100047229). Registered on June 11, 2021.

A Novel Concept of Combined High-Level-Laser Treatment and Transcutaneous Photobiomodulation Therapy Utilisation in Orthodontic Periodontal Interface Management

This case report is aimed to demonstrate the synergetic effects of λ940 nm laser photobiomodulation (PBM) therapy in augmenting the advantages of high-level-laser treatment (HLLT)-mediated reaction orthodontic periodontal interface management. Materials and Methods: A 32-year-old female who presented with a persistent gummy smile of upper incisors and low upper midline frenum attachment post-orthodontic treatment, was seeking a better smile appearance. She had a history of delayed wound healing without underlying medical conditions; otherwise, she was fit and healthy. She underwent laser ablation of the upper midline frenum and gingivoplasty of the upper incisors region with λ940 nm and λ2780, respectively, as well as transcutaneous PBM therapy (λ940 nm) to accelerate wound healing. The laser protocols were as follows: λ2780 nm: power output—2 W, pulse width—60 μs, free running pulse (FRP), spot area—0.0016 cm², pulse repetition rate—25 pulses per second (s), 80 mJ/pulse, 90 s, λ940 nm: 1.2 W, continuous wave (CW) emission mode, 300 μm, 60 s; whereas the adjunctive λ940 nm induced-PBM parameters were as follows: power output—1.4 W, CW—120 s, single application, spot area—2.8 cm². An acceleration of the wound healing was observed on the 4th day of treatment with no immediate or post-operative complications. The results showed no functional or aesthetic relapses at a long-term follow-up of 6 months. The authors concluded that λ940 nm laser-PBM can provide a synergetic effect to HLLT in accelerating wound healing and offering a precision smile with minimal to none post-operative complications. It is safe and justifiable to utilise dual therapy over the conventional methods, which serves our patients’ needs in our daily practice and in various clinical indications. The concept and laser protocols of this clinical case report can pave the roadmap for future extensive studies.

Comparison of the reliability and efficacy of LigaSure hemorrhoidectomy and a conventional Milligan-Morgan hemorrhoidectomy in the surgical treatment of grade 3 and 4 hemorrhoids

Objective

The aim of this study was to compare the clinical results of LigaSure-assisted hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy as a conventional method in our clinic.

Materials and Methods

Patients who underwent LigaSure-assisted hemorrhoidectomy or conventional hemorrhoidectomy for grade 3 and 4 hemorrhoids in our clinic between 2009 and 2014 were included in this study. The patient data were reviewed by screening records. Gender, age, preoperative hemoglobin and hematocrit levels, operation time, presence of thrombosis, number of packages, hospitalization time, early and late postoperative complications, prolonged pain presence, and follow-up period were recorded.

Results

In this period, surgical interventions were performed on 365 patients diagnosed with hemorrhoids. Among these, 159 underwent LigaSure-assisted operations, while 206 were operated on by conventional methods. One hundred forty-four (39.5%) cases were female, while 221 (60.5%) cases were male. The median age of the patients was 40 (19-82) years in the LigaSure group and 41 (16-78) years in the conventional method group. The operation time was 15 (4-60) min in the LigaSure group and 20 (6-40) min in the conventional method group. Postoperative analgesics were given to the 182 (88.3%) cases in the conventional group and 107 (67.3%) cases in the LigaSure group. The time required for returning to normal daily activity was 6 (1-15) days in the LigaSure group and 7 (1-30) days in the conventional method group.

Conclusion

In this study, LigaSure was determined to be superior to a conventional method in terms of operation time, hospitalization period, postoperative analgesic requirements, time required for returning to normal daily activity, and postoperative bleeding.

Surgical outcomes of total thyroidectomy using the LigaSure™ Small Jaw versus LigaSure Precise™: A retrospective study of 2000 consecutive patients

BACKGROUND

We compared surgical outcomes of LigaSure™ Small Jaw, which is a multifunctional thermal device that incorporates a tissue divider versus LigaSure Precise™ in thyroid surgery.

METHODS

A retrospective, single-center study was carried out in an acute-care teaching hospital in Barcelona, Spain. Between January 2008 and June 2015, consecutive patients scheduled for total thyroidectomy were included in the study. Surgical outcomes were operative time, length of skin incision, use of a suction drain, intraoperative bleeding, postoperative complications and length of hospital stay.

RESULTS

A total of 2000 patients were included (LigaSure™ Small Jaw, n = 1000; LigaSure Precise™, n = 1000). Demographics and indication for surgery were similar in both groups. A significant and independent shorter operative time (median 40 vs. 65 min, P = 0.002), smaller length of the skin incision (mean [SD] 4 [2] vs. 7 [3] cm, P = 0.031), lower percentages of patients with suction drain (15% vs. 66%, P = 0.012) and intraoperative bleeding (4% vs. 9%, P = 0.045) and reduced length of stay (median 1 vs. 3 days, P = 0.039) were found in the LigaSure™ Small Jaw than in the LigaSure Precise™. Postoperative complications including haematoma, hypoparathyroidism and recurrent laryngeal nerve injury were similar.

CONCLUSIONS

The LigaSure™ Small Jaw in thyroid surgery results in significant less blood loss and operative time as well as shorter hospital stay compared to LigaSure Precise™. These findings could have direct application in daily practice.

Comparison of hemorrhoidectomy by LigaSure with conventional Milligan Morgan's hemorrhoidectomy

Objective:

To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy.

Methods:

This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A (Haemorrhoidectomy by Ligasure) and group B (Milligan Morgan Haemorrhoiectomy). Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7^th post operative day.

Results:

Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 – 60 years. Third degree Heamorrhoids were present in 37 (67.3%) of patients while remaining 18 (32.7%) had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6± 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34±25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method.

Conclusion:

The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups.

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.

Hemorrhoidectomy - making sense of the surgical options

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Randomized single-blind clinical trial of intradermal methylene blue on pain reduction after open diathermy haemorrhoidectomy

BACKGROUND

Open haemorrhoidectomy has been associated with considerable postoperative pain and discomfort. Perianal intradermal injection of methylene blue has been shown to ablate perianal nerve endings and may bring about temporary pain relief after haemorrhoidectomy. We hypothesized that the administration of intradermal methylene blue would reduce postoperative pain during the initial period after surgery.

METHOD

A randomized, prospective, single-blind placebo-controlled trial was conducted. Patients were randomized to intradermal injection at haemorrhoidectomy of either 4 ml 1% methylene blue and 16 ml 0.5% marcaine or of 16 ml 0.5% marcaine and 4 ml saline prior to surgical dissection. Patients were asked to fill in a pain diary with a visual analogue scale. The primary outcome measure was pain score and analgesic use. Secondary outcomes were complications.

RESULTS

There were 37 patients in the methylene blue arm and 30 patients in the placebo arm. There were no statistically significant differences in the sex, type of haemorrhoid, number of haemorrhoids excised, duration of surgery or hospital stay. The mean pain scores were significantly lower and the use of paracetamol was also significantly less in the methylene blue group during the first three postoperative days. The risk ratio of acute urinary retention occurring when methylene blue was not used was 2.320 (95% CI 1.754-3.067). Other complication rates were not significantly different.

CONCLUSION

Perianal intradermal injection of methylene blue was useful in reducing the initial postoperative pain of open haemorrhoidectomy.

Functional and structural abnormalities after milligan hemorrhoidectomy: a comparison with healthy subjects

BACKGROUND

Fecal incontinence is a rare but well-known adverse effect of hemorrhoidectomy.

OBJECTIVE

The objective of this study was to identify possible reasons for incontinence after hemorrhoidectomy.

DESIGN

We conducted a retrospective comparative study.

SETTINGS

The study was performed in 1 university hospital and 1 general district hospital serving 2 counties in central Sweden.

PATIENTS

In a cohort of 418 patients with consecutive Milligan hemorrhoidectomies, 40 reported fecal incontinence that was attributed to surgery. Of these, 19 patients agreed to participate. Fifteen age- and sex-matched patients from the same cohort who were operated on, but without symptoms of incontinence, were also studied, as was a third reference group of 19 age- and sex-matched persons serving as a population-based control group.

INTERVENTION

All of the participants answered a bowel function questionnaire and underwent clinical evaluation, including rectoscopy, anal manometry, saline infusion test, and endoanal ultrasound.

MAIN OUTCOME MEASURES

We evaluated anal resting and squeeze pressures, sphincter defects, and continence function.

RESULTS

The symptomatic patients had higher incontinence scores than the control groups (p = 0.00002). The mean resting pressure at the high-pressure zone was also reduced in this group (p = 0.047). External sphincter injuries were detected in 4 (20%) of 19 subjects compared with none in the control group (p = 0.11). Saline infusion test in the patients reporting incontinence showed reduced ability to hold liquids compared with healthy controls (p = 0.004).

LIMITATIONS

This study was limited by selection bias and limited numbers in the groups.

CONCLUSIONS

In the group of patients reporting incontinence after hemorrhoidectomy, there was a proportion with sphincter defects and impaired sphincter function. These results indicate a need for cautious patient selection and improved or alternative surgical techniques.

Comparison of vessel sealing systems with conventional

Background

Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Haemorrhoidal disease is a common anorectal disorder which has symptoms of bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Haemorrhoidectomy is one of most frequently performed anorectal operation worldwide.

Objectives

The aim of this study was to compare the effectiveness of the LigaSure tissue sealing device, Harmonic Scalpel and conventional MM open haemorrhoidectomy.

Materials and Methods

Sixty-nine patients with newly diagnosed symptomatic grade three or grade four haemorrhoidal disease, from July 2011 to December 2011 were recruited for the study. Patients were prospectively randomized to LigaSure, Harmonic Scalpel and conventional haemorrhoidectomy. Patients were evaluated on the basis of the mean operative time, postoperative pain, day of discharge, early and late complications.

Results

Each group has twenty-three patients. Ten (14.5 %) were female and fifty-nine (85.5 %) were male. Mean age were 44.5 ± 10.8 for LigaSure group, 39.5±14.4 for Harmonic Scalpel group and 39.8 ± 13.6 for conventional haemorrhoidectomy group. Mean operative time was 12.6 ± 2.9 for LigaSure group, 12.6 ± 2.5 for Harmonic Scalpel group and 22.3 ± 4.5 for conventional haemorrhoidectomy group. Postoperative pain and required analgesic dose were significantly lower for conventional haemorrhoidectomy. Wound healing was also more rapid in conventional haemorrhoidectomy than both LigaSure and Harmonic Scalpel.

Conclusions

Lateral heat dissipation of energy based cautery such as Harmonel Scalpel and LigaSure is considerably high when compared with conventional methods. More thermal damage which is generated on tissue seems to be the reason for increased degree of postoperative pain and delay in wound healing.

Randomized clinical trial of vessel sealing system (LigaSure) in esophagogastric devascularization and splenectomy in patients with portal hypertension

BACKGROUND

The LigaSure vessel sealing system (Valleylab, Boulder, CO) has been tested, with excellent results, in different fields of surgery. However, no study has evaluated the efficiency of the LigaSure in open esophagogastric decongestion and splenectomy in a randomized trial to date.

METHODS

Patients scheduled to undergo esophagogastric decongestion and splenectomy were assigned to the use of either the LigaSure or a conventional clamp-and-tie technique. Primary outcome measures were operating time and intraoperative blood loss. Secondary outcome measures were postoperative drainage volume, complications such as spleen fever, bleeding, portal vein thrombosis, length of incision, pain, and time to discharge.

RESULTS

Sixty patients were randomized to the LigaSure (n = 30) and clamp-and-tie (n = 30) groups. The groups were well matched with respect to liver function, associated illnesses, and grading of esophageal varices. Postoperative outcomes in drainage and major complications did not differ between the groups, while operative time and the volume of blood loss were significantly decreased in the LigaSure group compared with the clamp-and-tie group (P < .001).

CONCLUSIONS

The use of the LigaSure is safe and effective in vessel division and homeostasis in the esophagogastric decongestion and splenectomy, with statistically significant decreases in operative time and intraoperative blood loss and without significantly modifying postoperative results.

Effects of a tissue sealing-cutting device versus monopolar electrocautery on early pilonidal wound healing: a prospective randomized controlled trial

BACKGROUND

Monopolar electrocauterization produces thermal effects on neighboring tissues, causing tissue damage. Recently, tissue sealing-cutting devices, which are easy to use and achieve simultaneous selective sealing and cutting with less production of heat, have been used.

OBJECTIVE

The aim of this study was to investigate the effects of a tissue sealing-cutting device vs monopolar electrocautery on wound healing in the early postoperative period after pilonidal sinus surgery.

DESIGN

This study was a prospective randomized clinical trial.

SETTING

This study was conducted at Military Hospital, Eskisehir, Turkey.

PATIENTS

In total, 128 patients with chronic pilonidal disease were randomly assigned into 2 clinically comparable groups between December 2009 and June 2010.

INTERVENTION

Pilonidal sinus excision was performed with monopolar electrocautery in the control group (n = 64) and with a tissue sealing-cutting device in the study group (n = 64). Data regarding wound healing, demographic variables, history, physical examination findings, defect dimensions, and scores for a visual analog scale were recorded.

MAIN OUTCOME MEASURES

The main outcomes measured were surgical site infection, early wound failure (dehiscence), and unhealed wound rate.

RESULTS

: Wound infection and dehiscence rates were significantly lower (P = .01 and .02), but the duration of surgery was significantly longer (P < .01) in the tissue sealing-cutting group. The unhealed wound rate was 12.5% in the electrocautery group and 4.7% in the tissue sealing-cutting group (P = .01). When the distance from the lowest margin to the anus was 5 cm or less, wound infection and dehiscence rates were lower in the tissue sealing-cutting group (P < .01 and .03).

LIMITATIONS

We could not obtain data regarding the cost-effectiveness of the instruments.

CONCLUSIONS

A tissue sealing-cutting device in pilonidal sinus surgery yields better wound healing than monopolar electrocautery.

LigaSure hemorrhoidectomy versus stapled hemorrhoidopexy: a prospective, randomized clinical trial

PURPOSE

This study was designed to compare the outcome of LigaSure hemorrhoidectomy and stapled hemorrhoidopexy for prolapsed hemorrhoids.

METHODS

Consecutive patients with grade III or IV hemorrhoids were randomly assigned to undergo either LigaSure hemorrhoidectomy or stapled hemorrhoidopexy. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, number of parenteral analgesic injections, duration of hospital stay, and time to return to work were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. Patients were regularly followed for a total period of 12 months.

RESULTS

A total of 68 patients completed the study (34 per group). Patient demographic and clinical characteristics were similar in the 2 groups. No significant differences between LigaSure hemorrhoidectomy and stapled hemorrhoidopexy were observed in mean operating time, postoperative pain score, number of parenteral analgesic injections, duration of hospital stay, or time to return to work. The groups were also similar regarding postoperative complications, except that at 4 weeks postoperatively, residual prolapse was observed in 8 patients (23.5%) in the stapled hemorrhoidopexy group vs. 2 patients (5.9%) in the LigaSure group (P = .040). Rate of recurrence of prolapse at 1 year was higher with stapled hemorrhoidopexy (4 patients, 11.8%) than with the LigaSure procedure (1 patient, 2.9%), but the difference was not significant (P = .163).

CONCLUSIONS

LigaSure hemorrhoidectomy and stapled hemorrhoidopexy yield comparable good results, with a short operative time and minimal side effects in the treatment of grade III and IV hemorrhoids, but with a lower rate of residual prolapse for the LigaSure procedure. Both procedures offer low levels of postoperative pain and therefore are excellent therapeutic options for prolapsed grade III and IV hemorrhoids. A larger controlled study is needed to reach solid conclusions regarding risk of postoperative recurrence of hemorrhoidal prolapse.

LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial

BACKGROUND

The present study was conducted to compare operative time, postoperative course and outcome of LigaSure hemorrhoidectomy (LH), and conventional open hemorrhoidectomy (OH) for prolapsed hemorrhoids.

METHODS

Eighty-four patients with grade III and IV hemorrhoids were randomized into two groups of 42 patients each; group 1 patients underwent LH whereas group 2 patients underwent OH. Data regarding patient demographics, operative details, postoperative pain score, amount of parenteral analgesics required, length of hospital stay, and time until return to work or normal physical activity were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. All patients had regular follow-ups every 2 weeks for the first 8 weeks postoperatively, and at 2-month intervals thereafter, for a total period of 12 months.

RESULTS

Patient demographics, clinical characteristics, and length of hospital stay were similar in both groups (P > 0.05). The mean operative time, postoperative pain score (up to 48 h), amount of parenteral analgesics required, time off work, and time needed for complete wound healing were significantly less in patients who underwent LH (P < 0.001). Both groups had similar postoperative complications except for delayed wound healing that was observed at 4 weeks postoperatively, in seven patients (16.67%) in the LH group compared to 17 patients (40.48%) in the OH group (chi(2) = 5.83, P = 0.016). Although hemorrhoid recurrence, at 1 year, was also lower among the LH group compared to the OH group (2.38 vs. 9.14%, respectively), the difference was not statistically significant (P = 0.167).

CONCLUSIONS

LH is a better alternative than conventional OH in treating prolapsed hemorrhoids (grades III and IV) since it reduces operating time, postoperative pain, and time off work, and allows surgical wounds to heal faster, with minimal comparable side effects and a low recurrence rate.

Diagnosis and management of symptomatic hemorrhoids

Hemorrhoidal disease is a common problem that is managed by various physicians, ranging from primary care providers to surgeons. This article reviews the pathophysiology, clinical presentation, and updated treatment of hemorrhoids, including nonoperative options, office-based procedures, and surgical interventions from standard excision to stapled hemorrhoidopexy and Doppler-guided ligation. The article also covers complications and provides guidance for special circumstances, such as pregnancy, hemorrhoidal crisis, and inflammatory bowel disease.

Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids

BACKGROUND

Hemorrhoidectomy is a frequently performed surgical procedure and associated with postprocedural pain. The use of the Ligasure could result in a decreased incidence of pain as coagulation with high frequency currency and active feedback control over the power output has minimal thermal spread and limited tissue charring.

OBJECTIVES

To compare patient tolerance focussing on pain following Ligasure and conventional hemorrhoidectomy in patients with symptomatic hemorrhoids.

SEARCH STRATEGY

A multi-database (MEDLINE, EMBASE, CENTRAL and CINAHL) systematic search was conducted. Key journals were handsearched. There was no restriction on language.

SELECTION CRITERIA

Randomized controlled trials comparing hemorroidectomy using the Ligasure-technique with conventional diathermy techniques for symptomatic hemorrhoids in adult patients were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, assessed trial quality and resolved discrepancies together with a third party. Odd Ratios were generated for dichotomous variables. Weight Mean Differences were used for analysing continuous variables. Only random effects models were used. Heterogeneity was explored by sensitvity analysis.

MAIN RESULTS

Twelve studies with 1142 patients met the inclusion criteria. The pain score at the first day following surgery was significantly less in the Ligasure group (10 studies, 835 patients, WMD -2.07 CI -2.77 to -1.38). Most outcomes concerning analgesics used (7 studies) and pain scores up to 7 days (5 studies) favoured the Ligasure-technique. The benefit was diminished at day 14 (VAS pain score, 4 studies, 183 patients, WMD -0.12 CI -0.37 to 0.12). The conventional technique took significantly longer to complete (11 trials, 9.15 minutes, CI 3.21 to 15.09). There was no relevant difference in postoperative complications, symptoms of recurrent bleeding or incontinence at final follow-up. Hospital stay was similar for both groups (6 reports, 525 patients, WMD -0.19 CI -0.63 to 0.24). Patients treated with the Ligasure-technique returned to work significantly earlier (4 studies, 451 patients, 4.88 days, CI 2.18 to 7.59). Sensitivity analysis on high quality studies, fixed effects models, open or closed conventional techniques revealed no clinical relevant different results.

AUTHORS' CONCLUSIONS

Since the usage of the Ligasure technique results in significantly less immediate postoperative pain after hemoroidectomy without any adverse effect on postoperative complications, convalescence and incontinence-rate, this technique is superior in terms of patient tolerance. Although there was a tendency for equal efficacy, more evaluation of the long-term risk of recurrent hemorrhoidal disease is required.

Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids

BACKGROUND

Hemorrhoidectomy is a frequently performed surgical procedure and associated with postprocedural pain. The use of the Ligasure could result in a decreased incidence of pain as coagulation with high frequency currency and active feedback control over the power output has minimal thermal spread and limited tissue charring.

OBJECTIVES

To compare patient tolerance focussing on pain following Ligasure and conventional hemorrhoidectomy in patients with symptomatic hemorrhoids.

SEARCH STRATEGY

A multi-database (MEDLINE, EMBASE, CENTRAL and CINAHL) systematic search was conducted. Key journals were handsearched. There was no restriction on language.

SELECTION CRITERIA

Randomized controlled trials comparing hemorroidectomy using the Ligasure-technique with conventional diathermy techniques for symptomatic hemorrhoids in adult patients were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, assessed trial quality and resolved discrepancies together with a third party. Odd Ratios were generated for dichotomous variables. Weight Mean Differences were used for analysing continuous variables. Only random effects models were used. Heterogeneity was explored by sensitvity analysis.

MAIN RESULTS

Twelve studies with 1142 patients met the inclusion criteria. The pain score at the first day following surgery was significantly less in the Ligasure group (10 studies, 835 patients, WMD -2.07 CI -2.77 to -1.38). Most outcomes concerning analgesics used (7 studies) and pain scores up to 7 days (5 studies) favoured the Ligasure-technique. The benefit was diminished at day 14 (VAS pain score, 4 studies, 183 patients, WMD -0.12 CI -0.37 to 0.12). The conventional technique took significantly longer to complete (11 trials, 9.15 minutes, CI 3.21 to 15.09). There was no relevant difference in postoperative complications, symptoms of recurrent bleeding or incontinence at final follow-up. Hospital stay was similar for both groups (6 reports, 525 patients, WMD -0.19 CI -0.63 to 0.24). Patients treated with the Ligasure-technique returned to work significantly earlier (4 studies, 451 patients, 4.88 days, CI 2.18 to 7.59). Sensitivity analysis on high quality studies, fixed effects models, open or closed conventional techniques revealed no clinical relevant different results.

AUTHORS' CONCLUSIONS

Since the usage of the Ligasure technique results in significantly less immediate postoperative pain after hemoroidectomy without any adverse effect on postoperative complications, convalescence and incontinence-rate, this technique is superior in terms of patient tolerance. Although there was a tendency for equal efficacy, more evaluation of the long-term risk of recurrent hemorrhoidal disease is required.

Evidence based treatment of hemorrhoids

A number of different hemorrhoids' treatment modalities were introduced and discussed during last two decades. Different level of evidence supports one or another approach and new data emerge constantly. Decision to apply particular method of treatment force clinicians to make thorough judgment. The article presents the newest data about different aspects of hemorrhoids management focusing on proof of efficacy.