Practice parameters for the management of hemorrhoids (revised 2010)

Outcomes of laser hemorrhoidoplasty for grade II-IV hemorrhoidal disease in Bangladesh

Background

Laser hemorrhoidoplasty is a minimally invasive procedure to treat hemorrhoids and has shown better outcomes. Less is known about its utility in a lower middle-income country; Bangladesh.

Method

Between March 2023 and December 2023, 86 patients with grade II-IV hemorrhoids underwent laser hemorroidoplasty. Follow up was assessed on 1st week, 2nd week, and 6th week including pain, satisfaction, symptom improvement, incapacity for work, complications, reduction, and recurrence.

Results

The study included 86 patients, with a higher proportion of male participants (73.3%) and a mean age of 55.43±13.6 years. The majority of subjects (68.60%) had grade 3 hemorrhoids. The average surgery duration was 14.70±4.70 minutes All individuals experienced substantial decreases in the size of their hemorrhoids (100%) and reported high levels of satisfaction after the operation (97.7%). The use of the Wilcoxon signed-rank test demonstrated a statistically significant reduction in both the Visual Analog Scale (VAS) and Patient Global Impression of Improvement (PGI-I) ratings during the three subsequent observation periods (1st week, 2nd week, and 6th week). The 6th week complication rate was 19.8%. Additional mucopexy was performed on all patients with grade IV and three patients with grade III hemorrhoids.

Conclusion

Laser hemorroidoplasty is a day-care procedure, that is safe and efficacious and can be used in rural area settings with good patient satisfaction. Mucopexy is required in some cases of large hemorrhoidal mass to prevent recurrence.

Exploring factors impacting patient decisions in hemorrhoid surgery: A questionnaire survey in Taiwan

Background

Minimally invasive hemorrhoid surgeries like Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL) and Stapled Hemorrhoidopexy (PPH) offer benefits over traditional methods. This study investigated public perceptions and attitudes towards these surgeries, exploring awareness, preferences, and influencing factors.

Methods

A detailed questionnaire was disseminated to 2011 participants from various regions of Taiwan in December 2023, gathering data on demographics, understanding of minimally invasive surgery, and attitudes towards hemorrhoid surgery. Chi-square tests were used for analysis (p < 0.05).

Results

Hemorrhoid prevalence was similar across sexes and age groups. About 70 % preferred medical centers or district hospitals for surgery. Postoperative complications were a primary concern, with significant sex differences. Approximately 70 % preferred minimally invasive surgery if costs were below NT$50,000. Medical personnel showed higher awareness of minimally invasive surgery benefits. Most participants relied on personal networks and medical social media for information.

Conclusions

The study revealed generally positive perceptions of minimally invasive hemorrhoid surgery, with cost being a significant factor. Knowledge gaps exist, particularly among non-medical personnel. Future initiatives should aim to enhance public awareness of minimally invasive surgery benefits, and policy considerations should address financial aspects of healthcare decisions.

Demography of Haemorrhoids in Jamhuriat Hospital, Kabul

Background

Hemorrhoids, common benign anorectal conditions, are associated with various factors, such as low fiber intake, constipation, and pregnancy. Treatment typically involves procedures such as banding and surgery.

Objective

This retrospective investigation aimed to assess the frequency and demography of hemorrhoids in Kabul, Afghanistan.

Materials and Methods

This study was conducted at Jamhuriat Hospital in Kabul, Afghanistan. Two hundred and fifty-two patients who were diagnosed with hemorrhoids were included. All pertinent demographic data were collected from the medical records and analyzed using IBM SPSS Statistics 25.

Results

Males composed 83.7% of the patients, and 32.9% were aged 30-40 years. A lower socioeconomic status was common (61.1%). Bleeding, prolapse, and pain were frequent symptoms. Surgical management was common for third- and fourth-degree hemorrhoids (51.6%).

Conclusion

This study found a high prevalence of hemorrhoids among males (83.7%) and low-income individuals (61.1%), highlighting the need for further research into risk factors for delayed presentation.

Natural Products with Potential Effects on Hemorrhoids: A Review

Hemorrhoid disease is a common anorectal disorder affecting populations worldwide, with high prevalence, treatment difficulties, and considerable treatment costs. Compared to other treatment options, medical therapy for hemorrhoids offers minimal harm, more dignity to patients, and is more economical. Unfortunately, there are few chemical hemorrhoid medications available clinically, which makes the search for efficacious, cost-effective, and environmentally friendly new medication classes a focal point of research. In this context, searching for available natural products to improve hemorrhoids exhibits tremendous potential. These products are derived from nature, predominantly from plants, with a minor portion coming from animals, fungi, and algae. They have excellent coagulation pathway regulation, anti-inflammatory, antibacterial, and tissue regeneration activities. Therefore, we take the view that they are a class of potential hemorrhoid drugs, prevention products, and medication add-on ingredients. This article first reviews the factors contributing to the development of hemorrhoids, types, primary symptoms, and the mechanisms of natural products for hemorrhoids. Building on this foundation, we screened natural products with potential hemorrhoid improvement activity, including polyphenols and flavonoids, terpenes, polysaccharides, and other types.

Laser hemorrhoidoplasty in the treatment of symptomatic hemorrhoids: a pilot Australian study

PURPOSE

Traditional therapeutic approaches to the surgical management of hemorrhoid disease such as hemorrhoidectomies are plagued with severe postoperative pain and protracted recovery. Our pilot study aims to the laser hemorrhoidoplasty (LH) patients with symptomatic hemorrhoid disease that have failed conservative management for the first time in an Australian population.

METHODS

Thirty patients were prospectively enrolled to undergo LH. Postoperative pain, time to return to function, and quality of life (QoL) were determined through the Hemorrhoid Disease Symptom Score and Short Health Scale adapted for hemorrhoidal disease and compared to a historical group of 43 patients who underwent a Milligan-Morgan hemorrhoidectomy by the same surgeon at 3, 6, and 12 months.

RESULTS

The LH group had significantly lower mean predicted pain scores on days 1 and 2 and lower defecation pain scores and lower opioid analgesia use on days 1, 2, 3, and 4. The median time to return to normal function was significantly lower in the LH group (2 days vs. 9 days, P<0.001). Similarly, the median days to return to the workplace was significantly lower in the LH group (6 days vs. 13 days, P=0.007). During long-term follow-up (12 months), hemorrhoid symptoms and all QoL measures were significantly improved, especially among those with grade II to III disease.

CONCLUSION

This pilot study demonstrates low pain scores with this revivified procedure in an Australian population, indicating possible expansion of the therapeutic options available for this common condition. Further head-to-head studies comparing LH to other hemorrhoid therapies are required to further determine the most efficacious therapeutic approach.

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial

BACKGROUND

Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events.

METHODS

This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no).

RESULTS

At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events.

CONCLUSIONS

LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Simple mucopexy and hemorrhoidal arterial ligation with and without Doppler guide: a randomized clinical trial for short-term outcome

PURPOSE

Hemorrhoids are the most common benign anorectal diseases. Mucopexy strengthens the anal canal mucosa, which can be performed alone or in combination with Doppler-guided hemorrhoidal artery ligation (DG-HAL). In this study, we compared the postoperative complications between simple mucopexy plus HAL with and without a Doppler guide.

METHODS

This study was performed as a single-blinded randomized clinical trial. Patients referred to a tertiary colorectal referral clinic with grades 3 and 4 hemorrhoids who were candidates for surgical intervention entered the study. Thirty-six patients were randomly divided into 2 groups. Group A including 18 patients underwent mucopexy and DG-HAL and the other 18 patients (group B) underwent standard mucopexy and HAL without a Doppler guide. Postoperative pain score and the duration of oral analgesic consumption were recorded. Additionally, postoperative symptoms and complications were recorded and compared between the 2 methods.

RESULTS

There was no significant difference between the 2 groups in terms of pain score and the duration of postoperative analgesic consumption as well as the incidence of postoperative complications. Besides, the primary grade of hemorrhoids was not significantly associated with recurrence, but there was a significant association between body mass index and Wexner score (WS) with recurrence. The mean WS of patients showed a significant decrease in both groups postoperatively. However, the rate of WS reduction was not remarkably different between the 2 groups.

CONCLUSION

Simple mucopexy with blind HAL (without Doppler guide) might be considered for the treatment of grades 3 and 4 hemorrhoids effectively.

Regional Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem

INTRODUCTION

Hemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period.

METHODS

Using Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL.

RESULTS

1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL.

CONCLUSIONS

While continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted.

The role of the Rafaelo procedure in the management of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to summarize the current evidence regarding the role of the Rafaelo procedure in the management of hemorrhoidal disease (HD).

METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed (Medline, Scopus, CENTRAL, and Web of Science) from inception to 25/09/2022. Grey literature databases were also reviewed. The primary endpoint was the pooled complications rate of the Rafaelo procedure in patients with HD. Secondary endpoints included short- (bleeding, pain, thrombosis, necrosis, urinary retention, fever, oedema, anal fissure, and readmission) and long-term (stenosis, meteorism, constipation, anal tags, anal hyposensibility, reoperation, and recurrence) postoperative complication rates. Both prospective and retrospective studies were considered. Quality evaluation was performed via the ROBINS-I tool. Certainty of Evidence was based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

Overall, 6 non-randomized studies and 327 patients were included. The overall complication rate was 17.6% (95% CI 8.8-26.3%). Short-term complications were bleeding (7.5%, 95% CI 2.5-12.5%), thrombosis (2.2%, 95% CI 0.4-4.8%), and pain (1.6%, 95% CI 0.2-3.3%). Reoperation and recurrence rates were 1.8% (95% CI 0.3-3.4%) and 4.8% (95% CI 1.2-8.4%), respectively. A significant improvement in the presenting symptoms was noted. Method approval and patient satisfaction rates were 89.1% (95% CI 81.7-96.6%) and 95% (95% CI 89.8-100%), correspondingly. Overall CoE was "Very Low".

CONCLUSIONS

Further randomized controlled trials are required to delineate the exact role of the Rafaelo procedure in HD.

Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis

PURPOSE

This study compared the short- and long-term clinical outcomes of laser hemorrhoidoplasty (LH) vs. conventional hemorrhoidectomy (CH) in patients with grade II/III hemorrhoids.

METHODS

PubMed/Medline and the Cochrane Library were searched for randomized and nonrandomized studies comparing LH against CH in grade II/III hemorrhoids. The primary outcomes included postoperative use of analgesia, postoperative morbidity (bleeding, urinary retention, pain, thrombosis), and time of return to work/daily activities.

RESULTS

Nine studies totaling 661 patients (LH, 336 and CH, 325) were included. The LH group had shorter operative time (P<0.001) and less intraoperative blood loss (P<0.001). Postoperative pain was lower in the LH group, with lower postoperative day 1 (mean difference [MD], -2.09; 95% confidence interval [CI], -3.44 to -0.75; P=0.002) and postoperative day 7 (MD, -3.94; 95% CI, -6.36 to -1.52; P=0.001) visual analogue scores and use of analgesia (risk ratio [RR], 0.59; 95% CI, 0.42-0.81; P=0.001). The risk of postoperative bleeding was also lower in the LH group (RR, 0.18; 95% CI, 0.12- 0.28; P<0.001), with a quicker return to work or daily activities (P=0.002). The 12-month risks of bleeding (P>0.999) and prolapse (P=0.240), and the likelihood of complete resolution at 12 months, were similar (P=0.240).

CONCLUSION

LH offers more favorable short-term clinical outcomes than CH, with reduced morbidity and pain and earlier return to work or daily activities. Medium-term symptom recurrence at 12 months was similar. Our results should be verified in future well-designed trials with larger samples.

Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review

BACKGROUND

Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure.

METHODS

Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2 weeks, 1 month and 6 months after surgery.

RESULTS

Forty-seven out of 75 patients were male, and the mean age was 50 (± 17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%.

CONCLUSIONS

THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.

Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study

Background

Massive, delayed bleeding (DB) is the most common major complication of Rubber Band Ligation (RBL) for internal hemorrhoids caused by premature band slippage. In this study we modified conventional RBL to prevent early rubber band slippage and evaluated its clinical efficacy and safety.

Methods

Study participants were consecutive patients with grade II or III internal hemorrhoids treated with RBL at Ningbo Medical Center of Lihuili Hospital from January 2019 to December 2020. Postoperative minor complications such as pain, swelling, anal edema, prolapse recurrence and major complications like DB were retrospectively reviewed.

Results

A total of 274 patients were enrolled, including 149 patients treated with modified RBL and 125 treated with conventional RBL. There was no statistically significant difference between the two groups at baseline. Five cases of postoperative DB have been observed in the conventional RBL group, compared to none in the modified ones, with a significant difference (P < 0.05). Within three months after surgery, 8 cases in the modified RBL group experienced a recurrence rate of 5.4%, whereas 17 patients in the conventional RBL group experienced a recurrence rate of 13.6%. The difference was statistically significant (P < 0.05). The VAS score, edema, and incidence of sensation of prolapse between the two groups were not significantly different at 3 and 7 days after surgery (P < 0.05). There were also no significant differences in HDSS and SHS scores between the two groups after surgery (P > 0.05).

Conclusion

Modified RBL may be associated with a lower rate of complications, especially with lower DB rate in comparison with standard RBL. Further studies in larger samples and different design are necessary to confirm these results.

Comparison of the outcomes of hemorrhoidectomy and PPH in the treatment of grades III and IV hemorrhoids

ABSTRACT

To investigate the clinical effect and outcome of traditional hemorrhoidectomy and procedures for prolapse and hemorrhoid (PPH) for the treatment of grades III and IV hemorrhoids.We retrospectively reviewed 1003 grades III and IV hemorrhoid patients who presented to our hospital. A total of 585 patients underwent PPH, and 418 patients underwent hemorrhoidectomy. The outcomes were 1-year recurrence, postoperative complications, surgery-related complications, and indicators.No significant difference between the 2 treatment groups regarding patient demographics. All patients underwent more than 12months of postoperative follow-up. No significant difference between the 2 treatment groups in 1-year recurrence. PPH can markedly improve anal pain, postoperative bleeding, difficult urination, and postoperative resting anal pressure. The operative blood loss, operative time, wound healing time, and wound infection rates were decreased significantly in the PPH group compared with the traditional hemorrhoidectomy group.Our data suggest that PPH is useful and safe for grades III and IV hemorrhoids. It can reduce postoperative and surgery-related complications. However, this was a single-hospital retrospective study. Therefore, well-designed, multicenter, randomized controlled trials are needed to evaluate the value of PPH for grades III and IV hemorrhoids.

Sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy) for the Treatment of Second- and Third-Degree Hemorrhoidal Disease: Feasibility and Short-Term Outcomes

BACKGROUND

Sclerobanding is a novel technique combining rubber band ligation with 3% polidocanol foam sclerotherapy for the treatment of hemorrhoidal disease (HD). The aim of this study is to evaluate the feasibility, safety and short-term outcomes of sclerobanding in the treatment of second- and third-degree HD.

METHODS

A retrospective analysis of second- and third-degree HD cases from November 2017 to August 2021 was performed. Patients on anticoagulants or with other HD degrees were excluded. Follow-up was conducted at 1 month, 3 months, 6 months, 1 year and then every 12 months.

RESULTS

97 patients with second- (20 pts; 20.6%) and third-degree (77 pts; 79.4%) HD with a mean age of 52 years (20-84; SD ± 15.5) were included. Fifty-six patients were men (57.7%) and forty-one women (42.3%). Median follow-up was 13 months (1-26 months). No intraoperative adverse events or drug-related side effects occurred. Minor complications occurred in four patients (4.1%) in the first 30 postoperative days and all resolved after conservative treatment at the 3-month follow-up visit. No mortality or readmissions were observed.

CONCLUSIONS

Sclerobanding is a safe technique with a low rate of minor postoperative complications. Further studies on larger samples are necessary to establish the effectiveness and long-term outcomes of the technique.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Influence of Bowel Habit and Hormonal Changes on the Development of Hemorrhoidal Disease During Pregnancy and the Postdelivery Period: A Prospective Cohort Study

BACKGROUND

Hemorrhoidal disease in women during pregnancy is common in clinical practice. However, prospective data on its real prevalence and women's demographics are scarce.

OBJECTIVE

The aim of this study was to determine the prevalence of hemorrhoidal disease during pregnancy and to assess its impact on quality of life. In addition, this study aimed to identify the relationship between patients' characteristics, bowel habits, hormonal changes, and the presence of symptomatic hemorrhoids.

DESIGN

This is a prospective longitudinal cohort study.

SETTING

This study was conducted in the Obstetrics Department for pregnancy follow-up.

PATIENTS

The patients evaluated were a cohort of pregnant women.

INTERVENTION

The study was designed to follow a homogeneous cohort of women for 15 months. Visits took place in the first and third trimesters of pregnancy, and 3 and 6 months after delivery. Women's demographics (age, medical history, bowel habit, Bristol stool scale) and serum determination of pregnancy-related hormones (estrogen, progesterone, and relaxin) were determined.

MAIN OUTCOME MEASURES

The primary outcome was the development of hemorrhoidal disease.

RESULTS

Overall, 109 women (mean age, 31.2 ± 5.4 years) were included in the study. The prevalence of symptoms and physical findings of hemorrhoidal disease was present in 11% in the first trimester, 23% in the third trimester, 36.2% at 1 month after delivery, and 16.9% at 3 months after delivery. A medical history of hemorrhoidal disease was significantly associated with the diagnosis of hemorrhoids in the first trimester (p < 0.0001) and third trimester (p = 0.005). Symptoms of constipation were associated with this clinical disorder in the first trimester (p = 0.011) and the third trimester of pregnancy (p = 0.022). No association was found between hormonal changes and the development of hemorrhoidal disease.

LIMITATIONS

A larger sample would provide more information.

CONCLUSIONS

The prevalence of women with hemorrhoidal disease increases during pregnancy and after delivery. A history of hemorrhoidal disease and constipation is significantly associated with the diagnosis of symptomatic hemorrhoidal disease. See Video Abstract at http://links.lww.com/DCR/B504.

INFLUENCIA DEL HBITO INTESTINAL Y LOS CAMBIOS HORMONALES EN EL DESARROLLO DE LA ENFERMEDAD HEMORROIDAL DURANTE EL EMBARAZO Y EL PERODO POSTERIOR AL PARTO UN ESTUDIO DE COHORTE PROSPECTIVO

ANTECEDENTES:La enfermedad hemorroidal en mujeres durante el embarazo es común en la práctica clínica. Sin embargo, hay escasos datos prospectivos sobre su prevalencia real y la demografía de las mujeres.OBJETIVO:El objetivo fue determinar la prevalencia de enfermedad hemorroidal durante el embarazo y evaluar su impacto en la calidad de vida. Además, identificar la relación entre las características de los pacientes, los hábitos intestinales, los cambios hormonales y la presencia de hemorroides sintomáticas.DISEÑO:Estudio prospectivo de cohorte longitudinal.AJUSTE:Este estudio se realizó en el Departamento de Obstetricia para el seguimiento del embarazo.PACIENTES:Una cohorte de mujeres embarazadas.INTERVENCIÓN:El estudio se diseñó para realizar un seguimiento de una cohorte homogénea de mujeres durante 15 meses. Las visitas se realizaron en el primer y tercer trimestre del embarazo, y a los 3 y 6 meses después del parto. Se determinaron los datos demográficos de las mujeres (edad, antecedentes médicos, hábito intestinal, escala de heces de Bristol) y la determinación sérica de hormonas relacionadas con el embarazo (estrógeno, progesterona y relaxina).PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el desarrollo de enfermedad hemorroidal.RESULTADOS:Se incluyó en el estudio a 109 mujeres (edad media, 31,2 ± 5,4 años). La prevalencia de síntomas y hallazgos físicos de enfermedad hemorroidal estuvo presente en 11% en el primer trimestre, 23% en el tercer trimestre, 36,2% 1 mes después del parto y 16,9% 3 meses después del parto. Un historial médico previo de enfermedad hemorroidal se asoció significativamente con el diagnóstico de hemorroides en el primer trimestre (p <0,0001) y tercer trimestre (p = 0,005). Los síntomas de estreñimiento se asociaron con este trastorno clínico en el primer trimestre (p = 0,011) y el tercer trimestre del embarazo (p = 0,022), respectivamente. No se encontró asociación entre los cambios hormonales y el desarrollo de enfermedad hemorroidal.LIMITACIONES:Una muestra más grande proporcionaría más información.CONCLUSIONES:La prevalencia de mujeres con enfermedad hemorroidal aumentó durante el embarazo y el posparto. El antecedente de enfermedad hemorroidal y estreñimiento se asociaron significativamente con el diagnóstico de enfermedad hemorroidal sintomática. Consulte Video Resumen en http://links.lww.com/DCR/B504.

Clinical study of herbal mixture "Diding Oral Medicine" as an alternative to preventative antibiotics in perioperative hemorrhoids: A CARE-compliant article

To study the clinical effects of Diding Oral Medicine as an alternative to preventative antibiotics in perioperative hemorrhoids.From August 2017 to February 2018, a total of 214 patients who were treated with external exfoliation and internal ligation of mixed hemorrhoids in our hospital were divided into the control group and experimental group by way of stratified random (107 cases in each group). Patients in the control group were given antibiotics preventatively before operation, while patients in the experimental group took Diding Oral Medicine before operation, and the white blood cell count, neutrophil count, wound recovery, pain score, anal bulge score, and pathogen culture of wound secretions were compared between the 2 groups.There was no significant difference in white blood cell count and neutrophil count between both groups before and after operation (P > .05). The wound seepage score, wound edema score, and wound area score in the experimental group were lower than those in the control group, and the wound healing in the experimental group was shorter than that in the control group (all P < .05). The pain score and anal bulge score of the experimental group were decreased significantly compared to the control group (P < .05). In addition, the detection rate of pathogenic bacteria in the experimental group was downregulated significantly compared to the control group (P < .05).The Diding Oral Medicine has prominent bacteriostatic and antibacterial effects on patients with hemorrhoids during perioperative period, and promotes wound healing, reduces pain stress, and anal bulge.

A Prospective Study on the Efficacy of Two Different Phlebotonic Therapies as a Bridge to Surgery in Patients with Advanced Hemorrhoidal Disease

The aims of this study were to evaluate the efficacy of two different phlebotonic therapies, preoperatively administered in advanced hemorrhoidal disease (HD) patients with recommendation for surgery, and to assess patient satisfaction after treatment. In this prospective observational study, 100 patients were preoperatively treated either with micronized purified flavonoid fraction (group A) or sublingual nano-emulsion flavonoid (group B). HD symptoms, local inflammation signs and patients' satisfaction were evaluated at baseline visit (T0), after 4 weeks of therapy (T1) and 8 weeks after its discontinuation (T2). In group A, a significant improvement for all HD symptoms and inflammation signs was observed after therapy (T1), followed by a reduction of efficacy in T2, except for itching and edema. In group B, therapy had a significant benefit on symptoms and local inflammation at T1, which persisted after its discontinuation for all symptoms, and edematous hemorrhoids. In both groups, the satisfaction rate was "good" in 60% of patients and patients were statistically significant more satisfied at T1 compared with T2 (p = 0.0001). No adverse events were recorded. Preoperative treatment was safe and useful to optimize patients' clinical condition prior to surgery.

Analysis of risk factors for delayed bleeding after semi-closed hemorrhoidectomy

PURPOSE

The aim of this study was to determine the incidence of delayed post-hemorrhoidectomy bleeding (DPHB) after hemorrhoidectomy using a semi-closed procedure. We also investigated risk factors associated with DPHB.

METHODS

This retrospective study enrolled a total of 1645 consecutive patients with symptomatic grade II to IV hemorrhoids who underwent a semi-closed procedure at the Seoul Songdo Hospital between September 2018 and May 2019. All patients underwent a semi-closed procedure with submucosal feeding vessel ligation, a method commonly performed at our institution.

RESULTS

A total of 1645 patients (mean age: 48.67 (±14.38) years, 823 (50.0%) male/822 (50.0%) female) underwent semi-closed hemorrhoidectomy. Critically, 24 (1.5%) patients experienced DPHB. Of these patients, 13 (0.8%) experienced stump bleeding, whereas 11 (0.7%) experienced marginal bleeding. The mean bleeding period was 8.21±4.45 days. Multivariate analysis showed that male sex, drinking history, more than four hemorrhoid piles, and laxative agents were independent risk factors for DPHB. The risk of stump bleeding was significantly associated with male sex (OR=5.55, 95% CI 1.23-25.14, p=0.026), more than four hemorrhoid piles (OR=5.90, 95% CI 1.62-21.53, p=0.007), and laxative usage (OR=3.92, 95% CI 1.31-11.74, p=0.015). Conversely, the risk of marginal bleeding were significantly associated with drinking history (OR=10.48, 95% CI 1.34-82.03, p=0.025) and more than four hemorrhoid piles (OR=4.71, 95% CI 1.24-17.81, p=0.023).

CONCLUSION

Male sex, drinking history, more than four hemorrhoid piles, and laxative usage were independent risk factors for DPHB in patients undergoing semi-closed hemorrhoidectomy. The risk factors for stump bleeding included male sex, more than four hemorrhoid piles, and laxative usage. In contrast, the risk factors for marginal bleeding were drinking history and more than four hemorrhoid piles.

Non-Doppler hemorrhoidal artery ligation and hemorrhoidopexy combined with pudendal nerve block for the treatment of hemorrhoidal disease: a non-inferiority randomized controlled trial

BACKGROUND

In this study, we proposed a combined outpatient treatment modality for hemorrhoidal disease.

METHODS

This study was a prospective non-inferiority randomized controlled trial (RCT). The experimental group included the dearterialization and hemorrhoidopexy under pudendal nerve block, whereas the comparator consisted of the standard Doppler guided hemorrhoidal artery ligation and hemorrhoidopexy, under spinal anesthesia. As primary hypothesis, we considered the non-inferiority of the proposed modality in terms of the presenting symptom remission rate (non-inferiority margin: 10%). Randomization was based on a 1:1 ratio. Blinding was confined to the patient and the investigator.

RESULTS

Overall, 60 patients were enrolled. The primary hypothesis of this RCT (96.7% vs 73.3%) was validated. The experimental group was associated with a lower operation duration and an expedited onset of mobilization and feeding. Moreover, a favorable profile regarding short-term morbidity and analgesia was identified. The control group displayed a higher pile recurrence rate and a suboptimal patient satisfaction. A significant effect of the treatment modality in most of the SF-36 components was confirmed.

CONCLUSIONS

The proposed treatment modality was associated with favorable short and long-term outcomes. Due to specific limitations, further RCTs, with a larger sample size, are required. Trial Registration ClinicalTrials.gov : NCT03298997.

Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review

BACKGROUND

Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment.

METHODS

We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed.

RESULTS

Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis.

CONCLUSION

Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

The novel BPRST classification for hemorrhoidal disease: A cohort study and an algorithm for treatment

BACKGROUND

The classification for HD was developed by Goligher in 1980 and does not contemplate important aspects of this disease, which limits its use in guiding treatment. The aim of this study if to apply in clinical practice the new classification for hemorrhoids named BPRST (bleeding, prolapse, reduction, skin tags, thrombosis), to compare it with the original classification proposed by Goligher and to propose an algorithm for treatment.

MATERIALS AND METHODS

This is a prospective study conducted at the University of São Paulo's teaching hospital and Hospital 9 de Julho. Patients with HD treated from March 2011 to July 2013 were included. Patients were classified according to BPRST and Goligher classifications and treated according to personal experience and most updated guidelines. The association between both classifications and the treatment adopted was compared and an algorithm for treatment was developed.

RESULTS

229 patients were included in this study and 28 patients were lost due to follow-up. According to Goligher, 29, 61, 85 and 26 were classified as grades I, II, III and IV, respectively. According to the BPRST, 23 were classified as stage I, 95 as stage II and 83 as stage III. Six patients classified as Goligher I were reclassified as BPRST stage III and required conventional hemorrhoidectomy, either due to thrombosis (n = 4) or intolerable skin tags (n = 2). The BPRST classification was more closely associated with the type of treatment employed and had few outliers than Goligher (p < 0.001).

CONCLUSION

There are limitations to the use of Goligher's classification in clinical practice. The novel BPRST classification includes important aspects of HD that should be considered when deciding the best treatment option. Our algorithm for treatment contemplates the most commonly used techniques and can help to guide the treatment of this complex disease.

Trends Associated with Hemorrhoids in Japan: Data Mining of Medical Information Datasets and the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan

Hemorrhoids are a common anorectal disease. Epidemiological studies on medication trends and risk factors using information from real-world databases are rare. Our objective was to analyze the relationship between hemorrhoid treatment prescription trends and several risk factors using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan and related medical information datasets. We calculated the standardized prescription ratio (SPR) based on the 2nd NDB Open Data Japan from 2015. The correlation coefficients between the SPR of antihemorrhoidals and those of "antispasmodics," "antiarrhythmic agents," "antidiarrheals, intestinal regulators," "purgatives and clysters," "hypnotics and sedatives, antianxietics," "psychotropic agents," and "opium alkaloids preparations" were 0.7474, 0.7366, 0.7184, 0.6501, 0.6320, 0.4571, and 0.4542, respectively. The correlation coefficient between the SPR of antihemorrhoidals and those of "average annual temperature," "percentage of people who were smokers," and "percentage of people who drank regularly" were -0.7204, 0.6002, and 0.3537, respectively. The results of cluster analysis revealed that Hokkaido and Tohoku regions tended to have low average annual temperature values and high percentage of people who were smokers and had comparatively high SPRs of "antispasmodics," "antiarrhythmic agents," "antidiarrheals, intestinal regulators," "purgatives and clysters," "hypnotics and sedatives, antianxietics," "psychotropic agents," and "opium alkaloids preparations." Antihemorrhoidals are frequently used in Hokkaido and Tohoku, Japan; thus, it is important for these prefectural governments to focus on these factors when taking measures regarding health promotion.

Effectiveness and cost-effectiveness of rubber band ligation versus sutured mucopexy versus haemorrhoidectomy in patients with recurrent haemorrhoidal disease (Napoleon trial): Study protocol for a multicentre randomized controlled trial

BACKGROUND

Currently, there is no consensus regarding the best treatment option in recurrent haemorrhoidal disease (HD), due to a lack of solid evidence. The Napoleon trial aims to provide high-level evidence on the comparative effectiveness and cost-effectiveness of repeat rubber band ligation (RBL) versus sutured mucopexy versus haemorrhoidectomy in patients with recurrent HD.

METHODS

This is a multicentre randomized controlled trial. Patients with recurrent HD grade II and III, ≥18 years of age and who had at least two RBL treatments in the last three years are eligible for inclusion. Exclusion criteria include previous rectal or anal surgery, rectal radiation, pre-existing sphincter injury or otherwise pathologies of the colon and rectum, pregnancy, presence of hypercoagulability disorders, and medically unfit for surgery (ASA > III). Between June 2020 and May 2022, 558 patients will be randomized to receive either: (1) RBL, (2) sutured mucopexy, or (3) haemorrhoidectomy. The primary outcomes are recurrence after 52 weeks and patient-reported symptoms measured by the PROM-HISS. Secondary outcomes are impact on daily life, treatment satisfaction, early and late complication rates, health-related quality of life, costs and cost-effectiveness, and budget impact. Cost-effectiveness will be expressed in societal costs per Quality Adjusted Life Year (QALY) (based on EQ-5D-5L), and healthcare costs per recurrence avoided.

DISCUSSION

The best treatment option for recurrent HD remains unknown. The comparison of three generally accepted treatment strategies in a randomized controlled trial will provide high-level evidence on the most (cost-) effective treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04101773.

The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey

Background: This international study assessed the characteristics and treatment of individuals with hemorrhoids. Materials & methods: Online survey among nationally representative populations of adults from Brazil, Czech Republic, France, Hungary, Italy, Romania, Russia and Spain, that identified participants who self-reported having hemorrhoidal disease. Results: Hemorrhoid prevalence was 11% (1725/16015); most respondents had low-severity disease (71%). Compared with the general population, participants with hemorrhoidal disease had more comorbidities (mean 3.1 vs 1.3) and included more women who had been pregnant (81 vs 68%). Common initial signs/symptoms were pain (60%), bleeding (47%) and discomfort (43%). Hemorrhoid respondents who consulted a physician were more likely to undergo interventions and take medications. Conclusion: The prevalence of hemorrhoidal disease in the adult population is 11%, mostly low-severity disease.

Excisional haemorrhoidectomy: is it safe in patients with an ileal pouch-anal anastomosis?

AIM

Excisional haemorrhoidectomy in patients with ulcerative colitis (UC), especially those undergoing an ileal pouch-anal anastomosis (IPAA), remains controversial. The aim of our study was to determine the safety of excisional haemorrhoidectomy in UC patients with and without an IPAA.

METHOD

A retrospective review of all adult UC patients undergoing excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019 at a tertiary inflammatory bowel disease referral centre was performed. Data collected included patient demographics, clinical characteristics of UC, prior surgical intervention for UC (colectomy, IPAA) and complications after haemorrhoidectomy.

RESULTS

Forty-one adult patients [50% male; median age 52 (range 25-79) years] with UC underwent excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019. The majority (n = 23) had not previously undergone surgery for UC. However, eight had already undergone construction of an IPAA at the time of haemorrhoidectomy, seven had IPAA at the time of haemorrhoidectomy and three had an IPAA constructed subsequent to haemorrhoidectomy. Two (4.9%) patients need to go back to theatre for postoperative bleeding. There were no further 30-day complications or long-term nonhealing of the surgical site. There were no pouch complications in those who had haemorrhoidectomy at the time of IPAA construction or in the presence of an IPAA.

CONCLUSION

Our data suggest that excisional haemorrhoidectomy may be performed safely in carefully selected UC patients with symptomatic haemorrhoids with or without IPAA and even at the time of IPAA construction.

Excisional Hemorrhoidectomy: Safe in Patients With Crohn's Disease?

INTRODUCTION

Due to concerns over wound healing, hemorrhoidectomy in patients with Crohn's disease (CD) remains controversial. We sought to ascertain safety and efficacy of excisional hemorrhoidectomy in CD.

METHODS

A retrospective review of all adult CD patients undergoing excisional hemorrhoidectomy between January 1, 1995, and January 1, 2019, at 2 IBD referral centers was performed. Data collected included patient demographics, clinical characteristics of CD (anorectal symptoms; prior nonoperative hemorrhoidal therapy; presence of other perianal disease; and activity, duration, and anatomic location of CD), and postoperative complications including bleeding, wound healing, and need for further therapy or surgical intervention after surgery.

RESULTS

A total of 36 adult patients with Crohn's disease with symptomatic hemorrhoidal disease were included. The study cohort included 16 males (44%), and median age was 49 (range, 21 to 77) years. Predominant symptoms included pain (n = 16; 44%), prolapse (n = 8; 22%), and bleeding (n = 12; 33%). Sixteen patients (44%) had nonoperative therapy before surgery. Twenty-four patients (67%) had other perianal disease. At the time of hemorrhoidectomy, 9 patients (25%) were exposed to corticosteroids, 8 patients (25%) to immunomodulators, and 9 patients (25%) to biologics. During a median follow-up time of 31.5 (range, 1 to 255) months after hemorrhoidectomy, 4 patients (11%) had complications (1 developed a stricture, 1 developed a perianal abscess/fistula, 1 had a nonhealing wound, and 1 had hemorrhoidal recurrence).

CONCLUSION

Our data suggest that excisional hemorrhoidectomy may be performed safely in CD patients who have failed nonoperative hemorrhoidal therapy without concern for de novo perianal disease or need for proctectomy.Hemorrhoidal disease is common in patients with Crohn's disease. This study sought to understand the outcomes of surgically treating hemorrhoids in patients with Crohn's disease.

Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial

Phlebotonics’ effects were evaluated to reduce time-to-stop bleeding and anal irritation in 130 patients who complained of hemorrhoidal disease (HD); bleeding and pain after hemorrhoidectomy (31 patients) and hemorrhoidal thrombosis (34 patients) in the short time. Sixty patients were randomized to receive the routine treatment (both conservative and surgical) (control Group C). The treated group (both conservative and surgical) was divided into two subgroups: one treated with flavonoids (Group A, n = 73), the other with Centella (Group B, n = 66). Time-to-stop bleeding was checked at baseline and checkups (0 up to day 42). Healing was estimated with Kaplan-Meier method, the Kruskal-Wallis test estimated changes in the VAS scores. The HD median time-to-stop bleeding was 2 weeks for Groups A and B; 3 weeks for Group C. VAS scores comparison among Groups (irritation): A vs C, p = 0.007; B vs C, p = 0.041; and A vs B, p = 0.782 resulted respectively. As for operated hemorrhoids, the time-to-stop bleeding was 3 and 4 weeks in Groups A and B and 5 in Group C. Histopathology showed an association between flavonoids and piles’ fibrosis (p = 0.008). Phlebotonics in HD, as well as after surgery, showed significant beneficial effects. Flavonoids are the most effective phlebotonics against bleeding and anal irritation.

Minimal Open Hemorrhoidectomy Versus Transanal Hemorrhoidal Dearterialization: The Effect on Symptoms: An Open-Label Randomized Controlled Trial

BACKGROUND

There is limited evidence on the long-term efficacy of transanal hemorrhoidal dearterialization compared with hemorrhoidectomy. Most studies investigated short-term effects with postoperative pain as the primary outcome. Being a benign disease, the long-term goal of treatment for hemorrhoids is the resolution of symptoms and improvement of quality of life.

OBJECTIVE

The purpose of this study was to compare the effect of minimal open hemorrhoidectomy versus transanal hemorrhoidal dearterialization on patient-reported symptoms.

DESIGN

This was an open-label randomized controlled trial.

SETTINGS

This was a single-center study.

PATIENTS

Patients with symptomatic hemorrhoids grade II to IV (Goligher's classification) were included.

INTERVENTIONS

Patients were randomly allocated to minimal open hemorrhoidectomy or transanal hemorrhoidal dearterialization.

MAIN OUTCOME MEASURES

The primary outcome was symptoms assessed by the Hemorrhoidal Disease Symptom Score 1 year postoperatively. Secondary outcomes included health-related quality of life, patient satisfaction, postoperative pain and recovery, adverse events, recurrence, and hospital costs.

RESULTS

Forty-eight patients received minimal open hemorrhoidectomy, and 50 patients received transanal hemorrhoidal dearterialization. No difference in symptom score at 1-year follow-up was found. Median (range) symptom score was 3 (0-17) after minimal open hemorrhoidectomy and 5 (0-17) after transanal hemorrhoidal dearterialization (median difference = -1.0 (95% CI, -3.0 to 0.0); p = 0.15). Residual hemorrhoidal prolapse was reported more frequently (p = 0.008), and more patients had treatment for recurrence after transanal hemorrhoidal dearterialization (7 vs 0 patients; p = 0.013). Patient satisfaction was higher after minimal open hemorrhoidectomy (p = 0.049). No differences were found in the impact on health-related quality of life, average and peak postoperative pain, recovery, or adverse events (p > 0.05). Transanal hemorrhoidal dearterialization was more expensive (median difference = &OV0556;555 (95% CI, &OV0556;472-&OV0556;693); p < 0.001).

LIMITATIONS

No blinding was included in this study.

CONCLUSION

No difference was found in symptom score 1 year postoperatively. Minimal open hemorrhoidectomy had a better effect on the hemorrhoidal prolapse and higher patient satisfaction. More patients needed treatment for recurrence after transanal hemorrhoidal dearterialization. Minimal open hemorrhoidectomy has an immediate postoperative course similar to transanal hemorrhoidal dearterialization. See Video Abstract at http://links.lww.com/DCR/B152.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02061176. HEMORROIDECTOMíA MíNIMA ABIERTA VERSUS DESARTERIALIZACIóN HEMORROIDAL TRANSANAL: EL EFECTO SOBRE LOS SíNTOMAS: UN ESTUDIO ABIERTO CONTROLADO Y ALEATORIZADO: Hay evidencia limitada sobre la eficacia a largo plazo de la desarterialización hemorroidal transanal en comparación con la hemorroidectomía. La mayoría de los estudios han investigado los efectos a corto plazo con el dolor postoperatorio como el resultado primario. Al ser una enfermedad benigna, el objetivo a largo plazo del tratamiento de la enfermedad hemorroidal es la resolución de los síntomas y la mejora en la calidad de vida.Comparar el efecto de la hemorroidectomía abierta mínima versus la desarterialización hemorroidal transanal en los síntomas reportados por el paciente.Ensayo controlado aleatorizado abierto.Estudio en sede única.Pacientes con enfermedad hemorroidal sintomática de grado II-IV (clasificación de Goligher).Los pacientes fueron asignados aleatoriamente a hemorroidectomía mínima abierta o desarterialización hemorroidal transanal.El resultado primario fueron los síntomas evaluados por el Score de Síntomas de Enfermedad Hemorroidal un año después de la operación. Los resultados secundarios incluyeron calidad de vida relacionada con la salud, satisfacción del paciente, dolor y recuperación postoperatorios, eventos adversos, recurrencia y costos hospitalarios.Cuarenta y ocho pacientes recibieron hemorroidectomía abierta mínima y cincuenta pacientes recibieron desarterialización hemorroidal transanal. No se encontraron diferencias en la puntuación de los síntomas al año de seguimiento. La puntuación mediana (rango) de síntomas fue 3 (0-17) después de una hemorroidectomía mínima abierta y 5 (0-17) después de la desarterialización hemorroidal transanal (diferencia mediana [IC95%]: -1.0 [-3.0-0.0], p = 0.15). El prolapso hemorroidal residual se informó con mayor frecuencia (p = 0.008) y más pacientes recibieron tratamiento por recurrencia después de la desarterialización hemorroidal transanal (7 frente a 0 pacientes, p = 0.013). La satisfacción del paciente fue mayor después de una hemorroidectomía abierta mínima (p = 0.049). No se encontraron diferencias en el impacto sobre la calidad de vida relacionada con la salud, el dolor postoperatorio promedio y máximo, la recuperación o los eventos adversos (p> 0.05). La desarterialización hemorroidal transanal fue más costosa (diferencia mediana [IC95%]: &OV0556; 555 [472-693], p <0.001).Estudio sin cegamiento.No se encontraron diferencias en la puntuación de los síntomas a un año después de la operación. La hemorroidectomía mínima abierta tuvo un mejor efecto sobre el prolapso hemorroidal y una mayor satisfacción del paciente. Más pacientes necesitaron tratamiento para la recurrencia después de la desarterialización hemorroidal transanal. La hemorroidectomía abierta mínima tiene un curso postoperatorio inmediato similar a la desarterialización hemorroidal transanal. Consulte Video Resumen en http://links.lww.com/DCR/B152. (Traducción-Dr. Jorge Silva Velazco).ClinicalTrials.gov Identifier: NCT02061176.

Management of haemorrhoids: protocol of an umbrella review of systematic reviews and meta-analyses

INTRODUCTION

The prevalence of haemorrhoidal diseases was high in general population, and many treatments are proposed for the management of haemorrhoids. The treatments include conservative and surgical interventions; the credibility and strength of current evidence of their effectiveness are not comprehensively evaluated. We aim to evaluate the credibility of systematic reviews and meta-analyses that assess the effectiveness of the treatments for haemorrhoidal diseases through an umbrella review.

METHODS AND ANALYSIS

We will search Ovid Medline, Embase, Cochrane library and Web of Science from inception to March 2020 without any language restriction. We will include meta-analyses that examine the effectiveness of treatments in the management of haemorrhoids. Two reviewers will independently screen the titles and abstracts of retrieved articles, and they will extract data from the included meta-analyses. For each meta-analysis, we will estimate the effect size of a treatment through the random-effect model and the fixed-effect model, and we will evaluate between-study heterogeneity (Cochrane's Q and I2 statistics) and small-study effect (Egger's test); we will also estimate the evidence of excess significance bias. Evidence of each treatment will be graded according to prespecified criteria. Methodological quality of each meta-analysis will be evaluated by using Assessment of Multiple Systematic Reviews 2. The corrected cover area method will be used to assess the impact of overlap in reviews on the findings of the umbrella review.

ETHICS AND DISSEMINATION

We will present the results of the umbrella review at conferences and publish the final report in a peer-reviewed journal. The umbrella review does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42019140702.

Comparison of the short-term outcomes of using DST and PPH staplers in the treatment of grade III and IV hemorrhoids

Stapled hemorrhoidopexy has a few advantages such as less postoperative pain and faster recovery compared with conventional hemorrhoidectomy. There are two major devices used for stapled hemorrhoidopexy, PPH stapler (Ethicon EndoSurgery) and DST stapler (Covidien). This study was conducted to investigate the postoperative outcomes among patients with grade III and IV hemorrhoids who underwent hemorrhoidopexy with either of these two devices. A total of 242 consecutive patients underwent stapled hemorrhoidopexy with either PPH stapler (110 patients) or DST stapler (132 patients) at a single center in 2017. We performed a retrospective case–control study to compare the short-term postoperative outcomes and the complications between these two groups. After matching the cases in terms of age, gender, and the grade of hemorrhoids, there were 100 patients in each group (PPH versus DST). There were no significant differences in the postoperative visual analog scale (VAS) score and analgesic usage. Among complications, the incidence of anorectal stricture was significantly higher in the DST group (p = 0.02). Evaluation of the mucosal specimen showed that the total surface area, the muscle/mucosa ratio and the surface area of the muscle were also significantly higher in the DST group (p = 0.03). Further analysis of the DST group demonstrated that patients with anorectal stricture after surgery are younger than patients without anorectal stricture, and higher muscle/mucosa ratio (p = 0.03) and a higher surface area of the muscle (p = 0.03) also measured in the surgical specimen. The two devices provide similar outcomes of postoperative recovery. Patients who underwent DST stapled hemorrhoidopexy had a higher incidence rate of stricture, larger area of muscle excision, and higher muscle/mucosa ratio in the surgical specimen. Further investigation is warranted for a better understanding of the correlation between muscle excision and anorectal stricture.

Portuguese Society of Gastroenterology Consensus on the Diagnosis and Management of Hemorrhoidal Disease

Hemorrhoidal disease (HD) is a frequent health problem with considerable repercussions on patients' quality of life. However, much of the clinical practice related to HD is based on knowledge without scientific evidence and supported largely by empirical experience of the physician who deals with this pathology. As in other countries, the goal of this consensus is to establish statements supported by solid scientific evidence and whose purpose will be to standardize and guide the diagnosis and management of HD both in the general population and in some particular groups of patients.

Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand

BACKGROUND

Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention.

AIM

To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand.

METHODS

An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios.

RESULTS

There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain.

CONCLUSION

Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.

Short-term Outcomes of Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: A Prospective Randomized Multicenter Trial

BACKGROUND

Transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy seem to reduce postoperative pain compared with classic excisional hemorrhoidectomy, but whether one of them is superior remains unclear.

OBJECTIVE

We compared transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy.

DESIGN

This was a multicenter, randomized controlled trial.

SETTING

The study was conducted at 6 Spanish centers.

PATIENTS

Patients aged ≥18 years with grade III to IV hemorrhoids were included.

INTERVENTIONS

Patients were randomly assigned to transanal hemorrhoidal dearterialization with mucopexy (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41).

MAIN OUTCOME MEASURES

Primary outcome was the mean postoperative number of days in which patients needed nonsteroidal anti-inflammatory drugs. Secondary outcomes were postoperative pain, 30-day morbidity, patient satisfaction, Vaizey score, hemorrhoid symptoms score, return to work, and quality of life.

RESULTS

More patients were still taking analgesia in the vessel-sealing device hemorrhoidectomy group during the second postoperative week compared with the transanal hemorrhoidal dearterialization with mucopexy group (87.8% vs 53.8%; p = 0.002). For the transanal hemorrhoidal dearterialization with mucopexy group, analgesia consumption continued until day 10.1 (mean; SD = 7.22 d), whereas in the vessel-sealing device hemorrhoidectomy group it continued until day 15.2 (mean; SD = 8.70 d; p = 0.006). The mean daily average pain was similar during the first (p = 0.900) and second postoperative weeks (p = 0.265). Mean operative time was higher for the transanal hemorrhoidal dearterialization with mucopexy group versus the vessel-sealing device hemorrhoidectomy group (45 min; range, 40-60 vs 20 min; range, 15-41 min; p < 0.001). Postoperative complications rate, use of laxatives, patient satisfaction, Vaizey score, hemorrhoids symptoms score, return to work, and quality of life at 1 month after surgery were similar between groups.

LIMITATIONS

The main limitation of this study was that the 2 groups did not contain equal numbers of grade III and IV hemorrhoids.

CONCLUSIONS

Transanal hemorrhoidal dearterialization with mucopexy is associated with a shorter need for postoperative analgesia compared with vessel-sealing device hemorrhoidectomy. See Video Abstract at http://links.lww.com/DCR/A915.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02654249.

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.

Burden and Cost of Outpatient Hemorrhoids in the United States Employer-Insured Population, 2014

INTRODUCTION

Although hemorrhoids are a common indication for seeking health care, there are no contemporary estimates of burden and cost. We examined data from an administrative claims database to estimate health care use and aggregate costs.

METHODS

We conducted a cross-sectional study using the MarketScan Commercial Claims and Encounters Database for 2014. The analysis included 18.9 million individuals who were aged 18-64 and continuously enrolled with prescription coverage. Outpatient hemorrhoid claims were captured using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in the first position, as well as Common Procedural Terminology codes. Prescription medications were identified using National Drug Codes. Annual prevalence and costs were determined by summing gross payments for prescription medications, physician encounters, and facility costs. We used validated weights to standardize annual cost estimates to the US employer-insured population.

RESULTS

In 2014, we identified 227,638 individuals with at least one outpatient hemorrhoid-related claim (annual prevalence, 1.2%). Among those, 119,120 had prescription medication claims, 136,125 had physician claims, and 28,663 had facility claims. After standardizing, we estimated that 1.4 million individuals in the US employer-insured population sought care for hemorrhoids in 2014 for a total annual cost of $770 million. This included $322 million in physician claims, $361 million in outpatient facility claims, and $88 million in prescription medication claims.

CONCLUSIONS

The estimated economic burden of hemorrhoids in the employer-insured population approaches $800 million annually. Given the substantial and rising burden and cost, expanded research attention should be directed to hemorrhoidal etiology, prevention, and treatment.

Risk of delayed bleeding after hemorrhoidectomy

PURPOSE

Delayed post-hemorrhoidectomy bleeding (DPHB) is a rare but serious complication. We investigated the incidence and risk factors of DPHB in patients undergoing hemorrhoidectomy using the LigaSure device or the Ferguson procedure.

METHODS

This retrospective study included 382 consecutive patients with symptomatic grades II to IV hemorrhoids who received either LigaSure (184 patients) or Ferguson (198 patients) hemorrhoidectomy procedures. Thirty-two patients who experienced DPHB after discharge were followed up.

RESULTS

Significantly fewer Ferguson group patients had DPHB compared to the LigaSure group (5.1% vs. 11.9%; P = 0.015). In the overall population, the risk of DPHB was higher in (1) males compared to that of females (OR = 3.39; 95% CI 1.50-7.69, P = 0.003); (2) in the LigaSure group compared to the Ferguson group (OR = 2.77; 95% CI 1.23-6.24, P = 0.01); and (3) in patients with constipation (OR = 6.59; 95% CI 2.73-15.89, P < 0.0001). Males in the LigaSure group had a significantly higher rate of delayed bleeding than those in the Ferguson group (20% vs. 5.8%, P = 0.004); no significant differences were found in females (4.9% vs. 4.5%, P = 0.878). Subgroup analysis showed that in males, risk of DPHB increased significantly with postoperative constipation (OR = 4.73, 95% CI 1.45-15.43, P = 0.010) and the LigaSure procedure (OR = 3.99, 95% CI 1.37-11.62, P = 0.011). In females, the risk of DPHB was significantly associated with postoperative constipation (OR = 8.80, 95% CI 2.24-34.54, P = 0.002).

CONCLUSIONS

The LigaSure procedure and constipation are independent risk factors for DPHB in patients undergoing hemorrhoidectomy and can be used as predictors of outcome.

[Prospects for stimulation in early rehabilitation of patients and restoration of bowel function after proctological operations]

RELEVANCE

The leveling of postoperative pain, early activation of patients are the leading components of the fast-track program, providing fast recovery with good quality of life, minimizing postoperative problems. In colorectal surgery, the most important factor determining the early recovery of patients is the normalization of bowel function, the restoration of defecation rhythm.

AIM

To assess the possibility of using dietary fiber (arabinogalactan) in combination with lactoferrin (the drug Fibraxin, Alfa Sigma) in the complex postoperative therapy of proctologic patients, as well as to determine the effectiveness of their influence on the dynamics of rehabilitation.

MATERIAL AND METHODS

A non-randomized cohort comparative prospective study was conducted in two clinical groups of 100 patients operated on for proctological pathology. In the first (control) group, after the operation, venotonics were prescribed for 2-3 weeks, as well as topical preparations - for 2.5 weeks. In the second (main) group, this treatment is supplemented with the use of Fibraxin, at a dosage of 6g 1 time per day, the observation period is 4 weeks. A comparative analysis of the rates of relief of postoperative defecation disorders, as well as the effect of the drug on the dynamics of the relief of leading postoperative complaints, has been carried out.

RESULTS

In the main group, the best results were obtained for the main parameters analyzed, early normalization of the frequency and rhythm of bowel movements was achieved, with adequate relief of complaints of pain during bowel movements and after it. Intolerance to the drug and pathological reactions associated with its use was not. The positive effect of Fibraxin in patients with concomitant diseases of the colon, including colitis, irritable bowel syndrome, diverticular disease and chronic colonic stasis, was noted.

CONCLUSION

The use of the drug Fibraxin at a dose of 6g per day allows a significant influence on the course of the postoperative period in proctological patients. The inclusion of Fibraxin in the scheme of rehabilitation treatment allows to stabilize the immediate results of treatment and reliably improve long-term, due to the correction of rectal dysfunction, elimination of dysbiosis, normalization of motility, as well as potentiation of reparative and restorative processes.

[Experience of using an individual approach in the anal fissures treatment]

AIM

To objectify the criteria for choosing the method of treatment of anal fissures, to determine the indications for surgery and sphincterotomy.

MATERIAL AND METHODS

The results of treatment of 206 patients with chronic and acute anal fissures between the ages of 17 to 75 years are analyzed. The posterior anal fissure was detected in 175 (84.9%) patients, the front - in 18 (8.7%), the combination of fissures was noted 13 (6.3%) times. The history of the disease - from 1 month to 12 years. The examination included analysis of clinical data, indicators of pre- and postoperative anorectal manometry, endorectal ultrasound. The period of postoperative monitoring is from 6 to 12 months, control examinations with a functional study of the anal sphincters were carried out 1 and 2 months after healing. Concomitant hemorrhoids were noted in 65 (31.5%) patients, of which 20 (9.7%) patients were simultaneously hemorrhoidectomized. In 11 (5.3%) patients, simultaneous operations were performed in the presence of paraproctitis, rectal fistula.

RESULTS

In 77.8% of patients with acute fissures, the use of conservative therapy, which included myotropic antispasmodics and local application of glycerol trinitrate made it possible to achieve healing of fissures without surgery. Operated 185 (89.8%) patients. With an increase in the basal anal pressure at the level of the internal sphincter, an increase in the average pressure in the anal canal, a decrease in the amplitude and duration of the rectoanal reflex, the indications for dosed sphincterotomy were determined in 167 patients. At the same time, in 117 persons, the excision of fissures was supplemented with a lateral 'closed' sphincterotomy, in 50 cases the posterior 'open' dosed sphincterotomy was performed. In 18 (9.7% of the operated ones) patients in the absence of sphincter hypertonus, the fissures were excised without sphincterotomy. The best functional results were obtained after performing the lateral 'closed' subcutaneous sphincterotomy. It was noticed that in the absence of characteristic complaints and clinical manifestations of incontinence, in 14 patients there was a decrease in the average pressure in the anal canal at rest and with volitional contraction. At the same time, 6 patients out of 14 belonged to the older age groups, and in 9 women there was a rectocele, pelvic floor prolapse. Postoperative incontinence was not observed. Recovery with complete epithelialization of the anoderm defect and the absence of complaints was achieved in 191 (92.7%) patients, satisfactory results (healing of fissures in the presence of pain or proctitis) - in 8 (3.9%) and in 7 (3.4%) patients relapse of the disease was noted with the ineffectiveness of therapy.

CONCLUSION

The ineffectiveness of complex conservative treatment for more than two weeks, with a history of more than 3 months, is an indication for surgical treatment. Preoperative functional and clinical and physiological examination of patients allows the formation of surgical tactics. A differentiated approach to the choice of treatment method, as well as individual determination of indications for surgery and sphincterotomy can improve long-term results. The technique of simultaneous operations with the combination of anal fissure and other proctological diseases needs to be improved.

What every PA needs to know about anorectal pain

Anorectal pain is common but often misdiagnosed, and patients may suffer in silence if they are too uncomfortable discussing the topic with their healthcare provider. This article reviews rectal anatomy and the signs and symptoms of several common anorectal conditions and how to manage them.

Rethinking What We Know About Hemorrhoids

Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visits annually. The etiology of hemorrhoids is speculative. A low-fiber diet and constipation have historically been thought to increase the risk for hemorrhoids, but not proven. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. Research has found that these symptoms were equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber where the results have been inconsistent. A number of office-based interventions such as rubber band ligation and infrared coagulation are widely used and economically favorable for practitioners. Surgical procedures are effective at eliminating hemorrhoids but may be painful. Given the burden of disease and numerous gaps in our understanding, the time has come for targeted research to understand the cause, symptoms, and best treatment for patients with symptomatic hemorrhoids.

Transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) in treatment of internal hemorrhoids: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Although conventional hemorrhoidectomy proved effective in treatment of hemorrhoidal disease, postoperative pain remains a vexing problem. Alternatives to conventional hemorrhoidectomy as transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidopexy (SH) were described. The present meta-analysis aimed to review the randomized trials that compared THD and SH to determine which technique is superior in terms of recurrence of hemorrhoids, complications, and postoperative pain.

METHODS

Electronic databases were searched for randomized trials that compared THD and SH for internal hemorrhoids. The PRISMA guidelines were followed when reporting this meta-analysis. The primary endpoint of the analysis was persistence or recurrence of hemorrhoidal disease. Secondary endpoints were postoperative pain, complications, readmission, return to work, and patients' satisfaction.

RESULTS

Six randomized trials including 554 patients (THD = 280; SH = 274) were included. The mean postoperative pain score of THD was significantly lower than SH (2.9 ± 1.5 versus 3.3 ± 1.6). 13.2% of patients experienced persistent or recurrent hemorrhoids after THD versus 6.9% after SH (OR = 1.93, 95%CI = 1.07-3.51, p = 0.029). Complications were recorded in 17.1% of patients who underwent THD and 23.3% of patients who underwent SH (OR = 0.68, 95%CI 0.43-1.05, p = 0.08). The average duration to return to work after THD was 7.3 ± 5.2 versus 7.7 ± 4.8 days after SH (p = 0.34). Grade IV hemorrhoids was significantly associated with persistence or recurrence of hemorrhoidal disease after both procedures.

CONCLUSION

THD had significantly higher persistence/recurrence rate compared to SH whereas complication and readmission rates, hospital stay, return to work, and patients' satisfaction were similar in both groups.

Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years

AIM

The management of haemorrhoids has changed significantly in the last two decades as a result of new insights into their pathophysiology and the availability of new surgical devices. The aim of this survey was to evaluate changes in the management of haemorrhoids in Italy over the last 17 years.

METHOD

An electronic database which recorded details of management relating to the severity of haemorrhoids between 2000 and 2016 was obtained from 18 of 34 colorectal surgeons who were invited to participate.

RESULTS

A total of 32 458 patients were treated for haemorrhoids by 18 expert coloproctologists during a 17-year period. Patients were classified as Grade II (7542, 23.2%), Grade III(15 360, 47.3%) and Grade IV (9556, 29.4%). Grade II haemorrhoids were treated with rubber band ligation in over 90% of the cases, and patients with Grade IV had a Milligan-Morgan (MM) haemorrhoidectomy in over 90% of the cases. In Grade III, the use of stapled haemorrhoidopexy progressively decreased from 30% to 35% (between 2000 and 2007) to 5% of the cases. Meanwhile, commencing from 2006 the use of Doppler-guided haemorrhoid artery ligation (DGHAL) with mucopexy increased progressively from 6% to 24%. Over the years, the percentage of MM haemorrhoidectomy remained consistent at between 65% and 70% of the cases.

CONCLUSION

Relevant changes in the surgical choice of haemorrhoid treatment have occurred in Italy over the last 17 years. MM haemorrhoidectomy remains the most frequently performed procedure for Grade III haemorrhoids. Stapled haemorrhoidopexy has become much less popular in contrast to DGHAL with mucopexy which is being performed much more frequently.