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

Comparison of Rubber Band Ligation and Hemorrhoidectomy in Patients With Symptomatic Hemorrhoids Grade III: A Multicenter, Open-Label, Randomized Controlled Noninferiority Trial

BACKGROUND

The optimal management strategy for grade III hemorrhoids remains a subject of ongoing debate. Hemorrhoidectomy is the criterion standard, but rubber band ligation offers a less invasive outpatient alternative. Treatment variability persists due to a lack of consensus on the preferred strategy.

OBJECTIVE

To directly compare the effectiveness of rubber band ligation and hemorrhoidectomy in the treatment of grade III hemorrhoids.

DESIGN

Open-label, parallel-group, randomized controlled noninferiority trial.

SETTINGS

Multicenter study across 10 Dutch hospitals from October 2019 to September 2022.

PATIENTS

Patients (aged 18 years or older) with symptomatic grade III (Goligher) hemorrhoids were included in this study. Exclusion criteria included prior rectal/anal surgery, more than 1 rubber band ligation/injection within the preceding 3 years, rectal radiation, preexisting sphincter injury, IBD, medical unfitness for surgery (ASA higher than 3), pregnancy, or hypercoagulability disorders.

INTERVENTIONS

Randomized 1:1 to rubber band ligation or hemorrhoidectomy, with up to 2 banding sessions allowed.

MAIN OUTCOME MEASURES

Primary outcomes included 12-month health-related quality of life and recurrence rate. Secondary outcomes included complications, pain, work resumption, and patient-reported outcome measures.

RESULTS

Eighty-seven patients were randomly assigned (47 rubber band ligation vs 40 hemorrhoidectomy). Rubber band ligation was not noninferior to hemorrhoidectomy in quality-adjusted life years (-0.045; 95% CI, -0.087 to -0.004). Recurrence rate was worse in the rubber band ligation group (47.5% vs 6.1%), with an absolute risk difference of 41% (95% CI, 24%-59%). Complication rates were comparable. Pain scores after hemorrhoidectomy were higher during the first week (visual analogue scale 4 vs 1; p = 0.002). Rubber band ligation group returned to work sooner (1 vs 9 days; p = 0.021). Patient-reported hemorrhoidal symptom scores favored hemorrhoidectomy.

LIMITATIONS

The primary limitation of the study was its early termination due to funding constraints, resulting in a relatively small sample size and limited statistical power. Patient recruitment was hindered by significant treatment preferences and the COVID-19 pandemic.

CONCLUSIONS

Hemorrhoidectomy may benefit patients with grade III hemorrhoids in terms of quality of life, recurrence risk, and symptom burden, whereas rubber band ligation allows faster recovery with less pain. These findings can guide clinical decision-making. See Video Abstract .

CLINICAL TRIAL REGISTRATION NUMBER

NCT04621695.

COMPARACIN DE LA LIGADURA CON BANDA ELSTICA Y LA HEMORROIDECTOMA EN PACIENTES CON HEMORROIDES SINTOMTICAS GRADO III ENSAYO MULTICNTRICO, ABIERTO, ALEATORIZADO, CONTROLADO Y DE NO INFERIORIDAD

ANTECEDENTES:La estrategia óptima de tratamiento para las hemorroides grado III sigue siendo un tema de debate continuo. La hemorroidectomía es el estándar de oro, pero la ligadura con banda elástica ofrece una alternativa ambulatoria menos invasiva. La variabilidad del tratamiento persiste debido a la falta de consenso sobre la estrategia preferida.OBJETIVO:Comparar directamente la eficacia de la ligadura con banda elástica y la hemorroidectomía en el tratamiento de las hemorroides grado III.DISEÑO:Ensayo de no inferioridad, controlado, aleatorizado, de grupos paralelos y abierto.ENTORNO CLINICO:Estudio multicéntrico en 10 hospitales holandeses desde octubre de 2019 hasta septiembre de 2022.PACIENTES:Pacientes (≥18 años) con hemorroides sintomáticas grado III (Goligher). Exclusiones: cirugía rectal/anal previa, >1 ligadura con banda elástica/inyección en los tres años anteriores, radiación rectal, lesión preexistente del esfínter, enfermedad inflamatoria intestinal, incapacidad médica para la cirugía (ASA >3), embarazo o trastornos de hipercoagulabilidad.INTERVENCIONES:Aleatorización 1:1 para ligadura con banda elástica o hemorroidectomía, con hasta dos sesiones de ligadura permitidas.PRINCIPALES MEDIDAS DE RESULTADOS:Primarias: calidad de vida relacionada con la salud a los 12 meses y tasa de recurrencia. Secundarias: complicaciones, dolor, reanudación del trabajo y medidas de resultados informadas por el paciente.RESULTADOS:Se aleatorizaron ochenta y siete pacientes (47 ligadura con banda elástica frente a 40 hemorroidectomía). La ligadura con banda elástica no fue no inferior a la hemorroidectomía en años de vida ajustados por calidad (-0,045, intervalo de confianza del 95 %: -0,087 a -0,004). La tasa de recurrencia fue peor en el grupo de ligadura con banda elástica (47,5 % frente a 6,1 %), con una diferencia de riesgo absoluto del 41 % (intervalo de confianza del 95 %: 24 %-59 %). Las tasas de complicaciones fueron comparables. Las puntuaciones de dolor posthemorroidectomía fueron más altas durante la primera semana (escala analógica visual 4 frente a 1; p = 0,002). El grupo de ligadura con banda elástica volvió al trabajo antes (1 frente a 9 días; p = 0,021). Las puntuaciones de síntomas hemorroidales notificadas por los pacientes favorecieron a la hemorroidectomía.LIMITACIONES:La principal limitación del estudio fue su finalización temprana debido a las limitaciones de financiación, lo que dio lugar a un tamaño de muestra relativamente pequeño y a un poder estadístico limitado. El reclutamiento de pacientes se vio obstaculizado por las preferencias significativas de tratamiento y la pandemia de COVID-19.CONCLUSIONES:La hemorroidectomía puede beneficiar a los pacientes con hemorroides de grado III en términos de calidad de vida, riesgo de recurrencia y carga de síntomas, mientras que la ligadura con banda elástica permite una recuperación más rápida con menos dolor. Estos hallazgos pueden orientar la toma de decisiones clínicas. (Traducción- Dr. Francisco M. Abarca-Rendon )NÚMERO DE REGISTRO DEL ENSAYO CLÍNICO:NCT04621695.

Development of a Core Outcome Set for Studies Assessing Interventions for Diabetes-Related Foot Ulceration

OBJECTIVE

Diabetes affects 537 million people globally, with 34% expected to develop foot ulceration in their lifetime. Diabetes-related foot ulceration causes strain on health care systems worldwide, necessitating provision of high-quality evidence to guide their management. Given heterogeneity of reported outcomes, a core outcome set (COS) was developed to standardize outcome measures in studies assessing treatments for diabetes-related foot ulceration.

RESEARCH DESIGN AND METHODS

The COS was developed using Core Outcome Measures in Effectiveness Trials (COMET) methodology. A systematic review and patient interviews generated a long list of outcomes that were rated by patients and experts using a nine-point Likert scale (from 1 [not important] to 9 [critical]) in the first round of the Delphi survey. Based on predefined criteria, outcomes without consensus were reprioritized in a second Delphi round. Critical outcomes and those without consensus after two Delphi rounds were discussed in the consensus meeting where the COS was ratified.

RESULTS

The systematic review and patient interviews generated 103 candidate outcomes. The two consecutive Delphi rounds were completed by 336 and 176 respondents, resulting in an overall second round response rate of 52%. Of 37 outcomes discussed in the consensus meeting (22 critical and 15 without consensus after the second round), 8 formed the COS: wound healing, time to healing, new/recurrent ulceration, infection, major amputation, minor amputation, health-related quality of life, and mortality.

CONCLUSIONS

The proposed COS for studies assessing treatments for diabetes-related foot ulceration was developed using COMET methodology. Its adoption by the research community will facilitate assessment of comparative effectiveness of current and evolving interventions.

Global International Society of University Colon and Rectal Surgeons in collaboration with European Society of Coloproctology audit on office-based and surgical treatment of haemorrhoidal disease: Study protocol

AIM

Haemorrhoidal disease (HD) is one of the most common anal disorders in the adult population. Despite that, treatment options differ among different countries and specialists, even for the same grade of HD. The aim of this study is to evaluate the differences in patient demographics, surgeon preference for the treatment option, outcomes as well as patient satisfaction rate for the procedure using an office-based or surgical approach for the treatment of HD among International Society of University Colon and Rectal Surgeons (ISUCRS) and European Society of Coloproctology (ECSP) fellows.

METHOD

A panel of the ISUCRS and ECSP members will answer questions that are included in a questionnaire about the treatment of HD. The questionnaire will be distributed electronically to ISUCRS and ECSP fellows included in our database and will remain open from 1 April 2024 to 31 May 2024.

CONCLUSION

This multicentre, global prospective audit will be delivered by consultant colorectal and general surgeons as well as trainees. The data obtained will lead to a better understanding of the incidence of HD, treatment and diagnostic possibilities. This snapshot audit will be hypothesis generating and inform areas the need future prospective study.

Analgesic effect of local anaesthetic in haemorrhoid banding: systematic review and meta-analysis

PURPOSE

Rubber band ligation of haemorrhoids can be,painful and there is no consensus regarding the optimal analgesic strategy. This study aims to determine whether there is a difference in post-procedural pain in adults undergoing haemorrhoid banding who have received local anaesthetic, a pudendal nerve block or no regional or local analgesia.

METHODS

MEDLINE, Embase, Google Scholar and clinical trial registries were searched for randomised trials of local anaesthetic or pudendal nerve block use in banding. Primary outcomes were patient-reported pain scores. The quality of the evidence was assessed using the GRADE approach.

RESULTS

Seven studies were included in the final review. No articles were identified that studied pudendal nerve blocks. The difference in numerical pain scores between treatment groups favoured the local anaesthetic group at all timepoints. The mean difference in scores on a 10-point scale was at 1 h,-1.43 (95% CI-2.30 to-0.56, p < 0.01, n = 342 (175 in treatment group)); 6 h,-0.52 (95% CI-1.04 to 0.01, p = 0.05, n = 250 (130 in treatment group)); and 24 h,-0.31 (95% CI-0.82 to 0.19, p = 0.86, n = 247 (127 in treatment group)). Of reported safety outcomes, vasovagal symptoms proceeded to meta-analysis, with a risk ratio of 1.01 (95% CI 0.64-1.60). The quality of the evidence was rated down to 'low' due to inconsistency and imprecision.

CONCLUSION

This review supports the use of LA for reducing early post-procedural pain following haemorrhoid banding. The evidence was limited by small sample sizes and substantial heterogeneity across studies.

REGISTRATION

PROSPERO (ID CRD42022322234).

Current status and implementation strategies of patient education in core outcome set development

OBJECTIVE

Patient participation is essential for Core Outcome Set (COS) development studies. Patient education during participation may help patients better express their views in COS studies. This study aimed to investigate the current status of patient participation and the specified educational information in COS studies.

METHODS

We conducted a systematic review of COS development studies. Information on patient participation in COS research, and especially details of patient education, was analyzed.

RESULTS

In total, 146 COS development studies were included in this review. Of these, 125 studies (85.6%) mentioned patient participation. Most studies did not provide explicit information on patient participation. Some studies mentioned recruiting patients, but ultimately, none of them responded. Six studies reported conducting patient education through workshops, creating patient forums, or providing videos and slides. However, these studies did not provide details on education. Twenty-three studies used the plain language to explain patient outcomes.

CONCLUSION

COS developers are increasingly focusing on patient participation. However, only a few COS studies have explicitly reported conducting measures related to patient education. Further patient education is necessary when they participate in the development of a new Core Outcome Set.

PRACTICE IMPLICATION

This article provides implementation strategies related to patient education for future COS development studies.

Time to change? Present and prospects of hemorrhoidal classification

As a common benign anal condition, the high incidence and recurrence of hemorrhoids pose challenges for both patients and doctors. The classification of hemorrhoids plays a crucial role in assessing, diagnosing, and treating the condition. By using appropriate classification and corresponding treatment strategies, we can achieve higher cure rates and lower recurrence rates of hemorrhoids. Since the introduction of the Miles classification in 1919, various classifications have been developed, which include objective classifications based on anatomical or instrumental assessment and subjective classifications based on symptoms and patient sensations. These classifications aim to accurately evaluate the condition. In this study, we discuss the evaluation values of each classification in terms of their advantages, disadvantages, treatment relevance, reproducibility, practicality, and assessment value. We also analyze the significant and essential factors, principles of use, and components of assessment indicators of hemorrhoidal classification. This study proposes several strategies to address the limitations of current hemorrhoidal assessment methods. All these will provide a reference for the development regarding the assessment and classification of hemorrhoids and clinical diagnosis and management of hemorrhoids.

Responsiveness of the Patient-Reported Outcome Measure-Haemorrhoidal Impact and Satisfaction Score in patients with haemorrhoidal disease

AIM

In this study we aimed to assess the responsiveness of the symptom score of the recently developed Patient-Reported Outcome Measure-Haemorrhoidal Impact and Satisfaction Score (PROM-HISS). Furthermore, the minimally relevant difference (MRD) was determined.

METHOD

The responsiveness of PROM-HISS was tested using a criterion-based (i.e. anchor) and construct-based (i.e. hypotheses testing) approach. Patients with haemorrhoidal disease (HD) completed the PROM-HISS before and 1 week after treatment in hospital. A global self-assessment of change question (SCQ) was administered 1-week after treatment and functioned as the criterion. The following analyses were performed: (1) correlation between the PROM-HISS symptom score and the criterion (SCQ) and (2) hypotheses testing. The MRD was determined as change in symptoms of the subgroup reporting 'somewhat fewer complaints' on the SCQ.

RESULTS

Between February and August 2022, 94 patients with grade II-IV HD from three hospitals were included. The correlation between the SCQ and a change on the PROM-HISS symptom score was 0.595 indicating that an improvement on the SCQ corresponds to an improvement on the PROM-HISS symptom score. As hypothesized, the mean change in PROM-HISS scores was significantly different between subgroups of patients based on their SCQ responses. Patients reporting a small change in HD symptoms on the SCQ corresponded to a mean change of 0.3 on the PROM-HISS symptom score.

CONCLUSION

The PROM-HISS symptom score is a responsive instrument as it identifies change in HD symptoms because of treatment. The estimated MRD of 0.3 can be used to inform clinical research and practice.

English translation and cross-cultural validation of the patient-reported outcome measurement-haemorrhoidal impact and satisfaction score (PROM-HISS)

AIM

The aim of this study was to translate the Dutch patient-reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS) to English and perform a cross-cultural validation.

METHOD

The ISPOR good practice guidelines for the cross-cultural validation of PROMs were followed and included two steps: (1) Two forward and two backward translations. The forward translation concerned the translation from the source language (Dutch) to the target language (English), performed by two independent English speakers, one medical doctor and one nonmedical. Subsequently, a discussion about discrepancies in the reconciled version was performed by a stakeholder group. (2) Cognitive interviews were held with patients with haemorrhoidal disease (HD), probing the comprehensibility and comprehensiveness of the PROM-HISS.

RESULTS

Discrepancies in the reconciled forward translation concerned the terminology of HD symptoms. Furthermore, special attention was paid to the response options, ranging from "not at all", indicating minor symptoms, to "a lot", implying many symptoms. Consensus among the stakeholder group about the final version of the translated PROM-HISS was reached. Interviews were conducted with 10 native English-speaking HD patients (30% female), with a mean age of 44 years (24-83) and primarily diagnosed with grade II HD (80%). The mean time to complete the PROM-HISS was 1 min 43 s. Patients showed a good understanding of the questions and response options, found all items relevant and did not miss important symptoms or topics.

CONCLUSION

The translated English language PROM-HISS is a valid tool to assess symptoms of HD, its impact on daily activities and patient satisfaction with HD treatment.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease

PURPOSE

The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores.

METHODS

This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications.

RESULTS

A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%).

CONCLUSION

Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Treatment of haemorrhoids: rubber band ligation or sclerotherapy (THROS)? Study protocol for a multicentre, non-inferiority, randomised controlled trial

INTRODUCTION

Haemorrhoidal disease (HD) is a common condition with significant epidemiologic and economic implications. While it is possible to treat symptomatic grade 1-2 haemorrhoids with rubber band ligation (RBL) or sclerotherapy (SCL), the effectiveness of these treatments compatible with current standards has not yet been investigated with a randomised controlled trial. The hypothesis is that SCL is not inferior to RBL in terms of symptom reduction (patient-related outcome measures (PROMs)), patient experience, complications or recurrence rate.

METHODS AND ANALYSIS

This protocol describes the methodology of a non-inferiority, multicentre, randomised controlled trial comparing rubber band ligation and sclerotherapy for symptomatic grade 1-2 haemorrhoids in adults (> 18 years). Patients are preferably randomised between the two treatment arms. However, patients with a strong preference for one of the treatments and refuse randomisation are eligible for the registration arm. Patients either receive 4 cc Aethoxysklerol 3% SCL or 3 × RBL. The primary outcome measures are symptom reduction by means of PROMs, recurrence and complication rates. Secondary outcome measures are patient experience, number of treatments and days of sick leave from work. Data are collected at 4 different time points.

DISCUSSION

The THROS trial is the first large multicentre randomised trial to study the difference in effectivity between RBL and SCL for the treatment of grade 1-2 HD. It will provide information as to which treatment method (RBL or SCL) is the most effective, gives fewer complications and is experienced by the patient as the best option.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers, location AMC (nr. 2020_053). The gathered data and results will be submitted for publication in peer-reviewed journals and spread to coloproctological associations and guidelines.

TRIAL REGISTRATION

Dutch Trial Register NL8377 . Registered on 12-02-2020.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial)

INTRODUCTION

Rubber band ligation ('banding') is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the optimal analgesic strategy. In practice, patients may receive submucosal local anaesthetic, pudendal nerve block or routine periprocedural analgesia. The aim of this study is to compare the efficacy of submucosal local anaesthetic, pudendal nerve block and routine analgesia for postprocedural pain in patients undergoing haemorrhoid banding.

METHODS AND ANALYSIS

This is a multicentre, prospective, three-arm, double-blind randomised controlled trial of adults booked for haemorrhoid banding. Participants will be randomised to one of three groups in a 1:1:1 ratio: (1)submucosal bupivacaine injection; (2) pudendal nerve ropivacaine injection and (3) no local anaesthetic. The primary outcome is patient reported postprocedural pain (scored 0-10) from 30 min to 2 weeks. Secondary outcomes include postprocedural analgesia use, time to discharge, patient satisfaction, time to return to work and complications. A sample size of 120 patients is required to achieve statistical significance.

ETHICS AND DISSEMINATION

This study received Human Research Ethics Approval from the Austin Health Human Research Ethics Committee (March 2022). Trial results will be submitted to a peer-reviewed journal, and presented at academic meetings. A summary of the trial results will be made available to study participants on request.

TRIAL REGISTRATION NUMBER

ACTRN12622000006741p.

Sclerotherapy with 3% polidocanol foam to treat second-degree haemorrhoidal disease: Three-year follow-up of a multicentre, single arm, IDEAL phase 2b trial

BACKGROUND

Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I-II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow-up of more than 1 year. The purpose of this study was to analyse the long-term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II-degree HD.

METHODS

This was an open label, single-arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS-HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score.

RESULTS

The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow-up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow-up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p < 0.001) from a median preoperative value of 11 (10-13) and 18 (15-20) to 0 (0-2) and 4 (0-4), respectively. Symptom-free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo-sclerotherapy nor additional adverse events (AEs) compared to the first 12 months.

CONCLUSIONS

Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate.

Hemorrhoid laser dearterialization: systematic review and meta-analysis

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

Picking Up the Threads: Long-Term Outcomes of the Sutured Haemorrhoidopexy: A Retrospective Single-Centre Cohort Study

BACKGROUND

This study aimed to assess the short- and long-term safety and efficacy of the sutured haemorrhoidopexy (SH) in patients with haemorrhoidal disease (HD).

METHODS

A retrospective study was performed, assessing the following treatment characteristics: number of sutures needed; operation time; perioperative complications; postoperative pain; hospital stay. The short- and long-term postoperative complications, HD recurrence and data on current HD symptoms were assessed according to the Core Outcome Set for HD.

RESULTS

Between January 2009 and December 2021, 149 patients with HD underwent a SH. One-hundred and forty-five patients were included, with a mean age of 61 years (±12.8), of which 70 were women (48.3%). Patients were predominantly diagnosed with grade III (37.2%) HD and the median follow-up was nine years (5-11). Perioperative complications occurred in four cases (2.8%). In two patients (1.4%), short-term postoperative complications were reported, and in seven patients (6.2%), long-term complications were reported. The cumulative efficacy in terms of freedom of recurrence was 88.3% (95% CI, 83.1-93.5) at six months, 80.0% (95% CI, 73.5-86.5) at one year, and 67.7% (95% CI, 59.7-75.7) at five years.

CONCLUSIONS

Sutured haemorrhoidopexy is a safe treatment for patients with HD and can be proposed as a minimally invasive surgical treatment if basic and outpatient procedures fail.

Patient reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS): Development, reliability and construct validity

AIM

Haemorrhoidal disease (HD) is a frequently occurring disorder with a significant negative impact on a patient's quality of life. Here, we describe the development and validation of the Dutch patient reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS).

METHODS

The development of the PROM-HISS followed recommended guidelines. Face and content validity, structural properties, reliability and construct validity were evaluated in a HD population. Reliability was tested by assessing the test-retest reliability, defined by the intraclass correlation coefficient (ICC), and internal consistency measured with Cronbach's alpha. Construct validity was evaluated using confirmatory factor analysis (CFA) and hypotheses testing.

RESULTS

The PROM-HISS consists of three domains: (1) HD symptoms (blood loss; pain; prolapse; soiling; itching), (2) impact of symptoms on daily activities, and (3) satisfaction with treatment. The PROM-HISS showed good face and content validity. The PROM-HISS was completed by 102 patients (65% male), with a mean age of 58 years (23-81 years). The ICCs of the different items in the domain HD symptoms ranged between 0.56 and 0.79 and were interpreted as good. The Cronbach's alpha value was 0.80 and considered satisfactory. The CFA provided further evidence for construct validity with a good model fit. A high score on the symptoms of HD correlated with a high impact of HD on daily activities (Pearson's r = 0.632, p < 0.01) and a low degree of satisfaction (Pearson's r = 0.378, p < 0.01).

CONCLUSION

The PROM-HISS is a reliable and valid instrument to evaluate symptoms of HD, impact on daily activities and satisfaction with treatment.

Is the Goligher classification a valid tool in clinical practice and research for hemorrhoidal disease?

BACKGROUND

The most widely used classification for hemorrhoidal disease (HD) is the Goligher classification, which ranks presence and severity of prolapse in four grades. Since physicians base this gradation on medical history and physical examination, it might be prone to interobserver variability. Furthermore, the gradation impacts the treatment of choice which makes reproducibility of utmost importance. The aim of this study was to determine the interobserver variability of Goligher classification among surgeons in the Netherlands.

METHODS

A single-choice survey was used. The first part consisted of questions concerning baseline characteristics and the use of the Goligher classification in routine clinical practice. In the second part, to assess interobserver variability, we asked gastrointestinal surgeons and residents who routinely treat HD to review 25 photographs (with given timing as during rest or push) of patients with HD and classify the gradation using the Goligher classification. The survey was sent by email on April 19, 2021 and was available online until July 5, 2021. Interobserver variability was assessed using Fleiss' Kappa test.

RESULTS

A total of 329 gastrointestinal surgeons, fellows and residents were sent an invitation email, of whom 95 (29%) completed the survey. Among the respondents, 87% indicated that they use the Goligher classification in clinical practice. Eighty-one percent found the classification helpful and 63% classified HD according to Goligher and followed the guidelines for treatment of HD accordingly. The interobserver variability showed an overall fair strength of agreement, with a Fleiss' Kappa (κ) of 0.376 (95% CI 0.373-0.380). There was a moderate agreement for grade I and IV HD with a κ statistic of 0.466 and 0.522, respectively. For grades II and III, there was a lower (fair) strength of agreement with 0.206 and 0.378, respectively.

CONCLUSIONS

The fair interobserver variability is disappointing and demonstrates the need for a more reliable, and internationally accepted, classification for HD. A new classification should enable more uniformity in treating HD and in comparing outcomes of future trials and prospective registries. The protocol for a Delphi study for a new classification system is currently being prepared and led by an international research group.

Hemorrhoidectomy versus rubber band ligation in grade III hemorrhoidal disease: a large retrospective cohort study with long-term follow-up

PURPOSE

Standard therapy for grade III hemorrhoids is rubber band ligation (RBL) and hemorrhoidectomy. The long-term clinical and patient-reported outcomes of these treatments in a tertiary referral center for proctology were evaluated.

METHODS

A retrospective analysis was performed in all patients with grade III hemorrhoids who were treated between January 2013 and August 2018. Medical history, symptoms, reinterventions, complications, and patient-reported outcome measurements (PROM) were retrieved from individual electronic patient files, which were prospectively entered as standard questionnaires in our clinic.

RESULTS

Overall, 327 patients (163 males) were treated by either RBL (n=182) or hemorrhoidectomy (n=145). The median follow-up was 44 months. The severity of symptoms and patient preference led to the treatment of choice. The most commonly experienced symptoms were prolapse (83.2%) and blood loss (69.7%). Hemorrhoidectomy was effective in 95.9% of the cases as a single procedure, while a single RBL procedure was only effective in 51.6%. In the RBL group, 34.6% received a second RBL session. Complications were not significantly different, 11 (7.6%) after hemorrhoidectomy versus 6 (3.3%) after RBL. However, 4 fistulas developed after hemorrhoidectomy and none after RBL (P<0.05). The pre-procedure PROM score was higher in the hemorrhoidectomy group whereas the post-procedure PROM score did not significantly differ between the groups.

CONCLUSION

Treatment of grade III hemorrhoids usually requires more than one session RBL whereas 1-time hemorrhoidectomy suffices. Complications were more common after hemorrhoidectomy. The patient-related outcome did not differ between procedures.

Polidocanol foam sclerotherapy in the treatment of hemorrhoidal disease in patients with bleeding disorders: a multicenter, prospective, cohort study

Background

The management of hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. Polidocanol foam sclerotherapy (PFS) is associated with a low rate of bleeding complications. The aim of this study was to compare the efficacy and safety of PFS in the treatment of HD in patients with and without BD.

Methods

This prospective, multicenter, cohort study enrolled patients with (group B) and without (group A) BD, with symptomatic internal HD grades I–III over an 18-month period. All patients were treated with PFS. Patients with congenital BD did not undergo prior replacement therapy and those with acquired BD due to antithrombotic drugs, did not discontinue therapy. Efficacy outcomes included therapeutic success and HD recurrence during a 1-year follow-up period. To evaluate safety the complications related to PFS were recorded.

Results

We included 228 patients (group A: 155, group B: 73; male/female: 114/114; mean age: 59.4 ± 15.9 years). The baseline hemorrhoidal disease bleeding grade (p < 0.001) and Sodergren hemorrhoidal symptom severity score (p = 0.019) were higher for group B. The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51 ± 0.74, significantly higher for group B (1.68 ± 0.86 vs 1.43 ± 0.65, p = 0.013). Complications occurred in 11.4% of the patients, with bleeding reported in 4.8%. The majority of complications were mild (96.2%). No significant differences between the two groups were observed for therapeutic success, recurrence, or complication rate.

Conclusions

Patients with BD may have more symptomatic HD at baseline. Even so, PSF showed similar effectiveness and safety in patients with BD compared to patients without BD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02600-5.

Making Use of Patient-Reported Outcome Measures for Haemorrhoidal Disease in Clinical Practice: A Perspective

Haemorrhoidal disease (HD) affects millions of people around the world and for most it is a recurring problem. Increasingly, clinicians broaden their focus on the patient's experiences with haemorrhoidal symptoms, including their impact on daily life. The patient's experience can be assessed using a patient-reported outcome measure (PROM). A PROM facilitates a deeper understanding of the disease-burden and allows a clinician to obtain information directly from the patients about their experiences with the ailment. Over the last years, PROMs have shown their additional role to traditional outcomes for several diseases and have earned their place in the daily consultation room. In order to improve and personalize the treatment of HD, we endorse the use of validated PROMs in clinical care.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HollAND trial: comparison of rubber band ligation and haemorrhoidectomy in patients with symptomatic haemorrhoids grade III: study protocol for a multicentre, randomised controlled trial and cost–utility analysis

Introduction

Haemorrhoidal disease is one of the most common anorectal disorders, which affects nearly half of the general population. Treatment of grade III haemorrhoids consists initially of conservative measures, followed by rubber band ligation and haemorrhoidectomy when unsuccessful. Given the current guidelines and numerous modalities the obvious question which needs to be answered is which treatment is the best for grade III haemorrhoids. There is a need for evaluating treatment from the patient’s point of view and transparency in surgical and non-surgical treatment outcome.

Methods and analysis

This multicentre, randomised controlled, non-inferiority trial with cost–utility analysis compares haemorrhoidectomy with rubber band ligation. Patients aged 18 years and older with symptomatic haemorrhoids grade III are recruited. Primary outcome measure is quality of life at 24 months measured with the EQ-5D-5L and in-hospital (in)direct costs and out-of-hospital postoperative costs. A key secondary outcome is recurrence at 1-year postprocedure. Secondary outcomes are complaint reduction with proctology-specific patient-reported outcome measurements (Haemorrhoid Severity Score, ProctoPROM, PROM-HISS, vaizey score), resumption of work, pain and complication rates. Data are collected at seven different time points. Standard postprocedural care is followed.

A sample size has been calculated using a one sided alpha of 0.025 and a power of 80% with an SD of 0.15 and a non-inferiority limit of 0.05. With stratification by centre and to adjust for 10% lost to follow-up the total sample size will be 360 patients in total (180 per group).

Data will be analysed according to the intention-to-treat and the per-protocol principle.

Ethics and dissemination

The protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centres, location AMC. Findings will be disseminated in peer-reviewed journals and presented at conferences, whether they are positive, negative or inconclusive.

Trial registration numbers

NCT04621695, NTR8020

Symptom-based scoring for haemorrhoidal disease: a systematic review

AIM

Haemorrhoidal disease can severely affect a patient's quality of life. Its classification is commonly based on morphology of the degree of prolapse; however, this does not take into account the symptoms and impact on the quality of life. The aim of this systematic review was to determine the most appropriate instruments that classify the severity of disease according to symptoms.

METHOD

A PRISMA-compliant search was conducted in December 2019 to identify studies that described the validation of a haemorrhoidal symptom score. The measurement properties of the scoring systems were assessed based on the consensus-based standards for the selection of health status measurement instruments (COSMIN) methodology for systematic reviews for patient-reported outcome measures.

RESULTS

A total of 5288 articles were identified, with five articles included. Three studies developed a scoring system based on a set of core symptoms for a cohort of patients and validated the score against treatment outcomes. One study developed a disease-specific quality of life questionnaire based on symptoms to evaluate disease burden. One study combined both quality of life and symptom measures and tested measurement properties on two cohorts of patients. Only one study demonstrated satisfactory valid, reliable and responsive measurement criteria.

CONCLUSION

A single study demonstrated sufficient quality in measurement properties to be recommended for clinical use. Further studies in this area should utilize consensus-based standards for designing and reporting validation research to ensure that the appropriate evidence base is acquired if any further patient-reported outcome measures are to be recommended.

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.

European Society of ColoProctology: guideline for haemorrhoidal disease

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Scoring systems as outcomes assessment of the treatments for haemorrhoidal disease: a systematic review of the literature

PURPOSE

The comparison between haemorrhoidal treatments is still unclear. Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials. We aimed to systematically review the available outcome scores of haemorrhoidal treatment.

METHODS

MEDLINE/Pubmed, Web of science, Embase and Cochrane were searched from database implementation until the December 6th 2019. All studies describing or referencing a score to assess haemorrhoidal disease treatment were included. Likert scale alone, incontinence score alone, general assessment of quality of life or scores developed for other proctologic disorders were excluded. The main outcome measures were validation of the scores and correlation of the score items to the core outcome set for haemorrhoidal disease developed by the European Society of Coloproctology.

RESULTS

From the 633 records initially screened, 22 studies were included: 8 original articles describing a scoring system and 14 referencing a previously described scoring system. Only 1 score was validated by an external prospective cohort. All the scores evaluated the symptoms of haemorrhoidal disease. No score integrated the disease recurrences or patient's satisfaction. Scores values tended to decrease postoperatively.

CONCLUSIONS

The scores described by Gerjy et al. and by Shanmugan et al. are available questionnaires, which have been validated and used in various studies. These scores might help researchers for comparative studies between treatment modalities and optimize haemorrhoids treatment.

Cap-assisted endoscopic sclerotherapy for internal hemorrhoids: technique protocol and study design for a multi-center randomized controlled trial

BACKGROUND

Cap-assisted endoscopic sclerotherapy is a new interventional therapy for internal hemorrhoids and rectal prolapse under colonoscopy. The proper length of the endoscopic injection needle is the core for performing cap-assisted endoscopic sclerotherapy well with more benefits and less complications. However, no data are currently available to guide endoscopists to consider the length of injection needle before cap-assisted endoscopic sclerotherapy. This study is designed to evaluate the efficacy and safety of cap-assisted endoscopic sclerotherapy with long or short injection needle in the treatment of internal hemorrhoids.

METHODS

This is a nationwide multi-center, prospective, single-blind and randomized controlled trial. Patients with grade I-II internal hemorrhoids who have failed to conservative treatments and grade III internal hemorrhoids who are not suitable for surgery or refuse surgery will be included. Participants will be randomized 1:1 into either long or short injection needle group. The primary outcome is the recurrence rate of internal hemorrhoids 24 weeks after cap-assisted endoscopic sclerotherapy. The secondary outcomes are as follows: (1) symptom severity score, (2) three-level EuroQoL five dimensions health scale scores, (3) occurrence of adverse events and severe adverse events, and (4) patients' attitudes toward cap-assisted endoscopic sclerotherapy. Data collection will be conducted before and during operation, the 1st day, 1st week, 2nd week, and 24th week after cap-assisted endoscopic sclerotherapy.

DISCUSSION

The outcome of this study is expected to provide a practical clinical protocol of cap-assisted endoscopic sclerotherapy for patients with internal hemorrhoids and promote the use of this new endoscopic technique.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03917056. Registered on 12 April 2019.

Benign anorectal disease: hemorrhoids, fissures, and fistulas

Hemorrhoids, anal fissures, and fistulas are common benign anorectal diseases that have a significant impact on patients’ lives. They are primarily encountered by primary care providers, including internists, gastroenterologists, pediatricians, gynecologists, and emergency care providers. Most complex anorectal disease cases are referred to colorectal surgeons. Knowledge of these disease processes is essential for proper treatment and follow up. Hemorrhoids and fissures frequently benefit from non-operative treatment; they may, however, require surgical procedures. The treatment of anorectal abscess and fistulas is mainly surgical. The aim of this review is to examine the etiology, diagnosis, medical, and surgical treatment for these benign anorectal diseases.