Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff

Nutritional and lifestyle predictors of rectal bleeding in functional constipation: A machine learning approach

BACKGROUND

Rectal bleeding among young adults is an increasingly common clinical concern often linked with chronic constipation and unhealthy lifestyle habits. Early identification of at-risk individuals through machine learning models-based approach may help in prevention and targeted intervention.

OBJECTIVES

We aim to identify dietary and lifestyle risk factors for rectal bleeding and to develop machine learning-based models for risk prediction.

METHODS

A descriptive observational study was conducted on 875 Indian college going participants. A structured questionnaire assessed fiber intake, physical activity, constipation symptoms, and body mass index (BMI). Multiple machine learning algorithms were evaluated, and their performance was assessed using accuracy and area under the receiver operating characteristic curve (ROC-AUC).

RESULTS

Low intake of boiled vegetables or oatmeal (<50 g/day) was associated with a 43.92 % bleeding rate (p < 0.001). Participants consuming inadequate whole grains (>25 g/day) showed a 44.81 % bleeding rate. Overweight or obese individuals exhibited a significantly higher bleeding incidence (12.26 %) than those with normal BMI (5.55 %; p = 0.008). The KNeighbors Classifier showed the highest accuracy (98.86 %) and ROC-AUC (0.994). Variables related to symptoms had greater predictive importance than those related to lifestyle.

CONCLUSIONS

The findings support the role of dietary fiber and BMI in the development of rectal bleeding in constipated individuals. The predictive models demonstrate strong potential for identifying at-risk individuals and is considered a simple and useful tool for predicting rectal bleeding in functional constipation, suggesting preventive health strategies and dietary modifications. This novel algorithm might enable clinicians to perform personalized dietary strategies with improved clinical outcomes. Further validation across larger and more diverse populations is recommended.

Latest Research Trends on the Management of Hemorrhoids

Hemorrhoids manifest with a range of symptoms and severities, prompting the development of various conservative, interventional, and surgical treatments. Selecting the most suitable treatment for each case is challenging, especially with the continuous evolution of new methods. This review aims to advance hemorrhoid treatment and research by exploring recent developments over the last five years. Conservative approaches have focused on isolating active ingredients from traditional herbal remedies to create new products and understand their mechanisms. In office-based treatments, advanced devices such as modified rubber band ligation and polymer clips with stronger binding forces have been introduced. Polidocanol in foam form has shown promise in sclerotherapy, while infrared coagulation is being replaced by alternative energy-based methods. Additionally, endoscopic office treatments and embolization of hemorrhoidal vessels via angiography are increasingly used as safer options for patients with high surgical risks or bleeding issues. Stapled hemorrhoidopexy has shifted to partial resection instead of complete circular resection, and hemorrhoidal artery ligation techniques have been reported to be effective when combined with stapled hemorrhoidopexy or excisional hemorrhoidectomy in severe cases. Evidence is growing that hemorrhoidal artery ligation remains effective even without Doppler guidance. With ongoing research into various methods, there is a need for scientific comparison and evaluation of their advantages and disadvantages, standardization of indicators and treatment protocols, and cost-effectiveness considerations. Surgeons should offer well-informed options and explanations to patients, based on a comprehensive understanding of available treatments.

Global treatment of haemorrhoids-A worldwide snapshot audit conducted by the International Society of University Colon and Rectal Surgeons

AIM

There is no universally accepted treatment consensus for haemorrhoids, and thus, management has been individualized all over the world. This study was conducted to assess a global view of how surgeons manage haemorrhoids.

METHODS

The research panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) developed a voluntary, anonymous questionnaire evaluating surgeons' experience, volume and treatment approaches to haemorrhoids. The 44 multiple-choice questionnaire was available for one month via the ISUCRS email database and the social media platforms Viber and WhatsApp.

RESULTS

The survey was completed by 1005 surgeons from 103 countries; 931 (92.6%) were in active practice, 819 (81.5%) were between 30 and 60 years of age, and 822 (81.8%) were male. Detailed patient history (92.9%), perineal inspection (91.2%), and digital rectal examination (91.1%) were the most common assessment methods. For internal haemorrhoids, 924 (91.9%) of participants graded them I-IV, with the degree of haemorrhoids being the most important factor considered to determine the treatment approach (76.3%). The most common nonprocedural/conservative treatment consisted of increased daily fibre intake (86.9%), increased water intake (82.7%), and normalization of bowel habits/toilet training (74.4%). Conservative treatment was the first-line treatment for symptomatic first (92.5%), second (72.4%) and third (47.3%) degree haemorrhoids; however, surgery was the first-line treatment for symptomatic fourth degree haemorrhoids (77.6%). Rubber band ligation was the second-line treatment in first (50.7%) and second (47.2%) degree haemorrhoids, whereas surgery was the second-line treatment in third (82.9%) and fourth (16.7%) degree symptomatic haemorrhoids. Rubber band ligation was performed in the office by 645(64.2%) of the participants. The most common surgical procedure performed for haemorrhoids was an excisional haemorrhoidectomy for both internal (87.1%) and external (89.7%) haemorrhoids - with 716 (71.2%) of participants removing 1, 2 or 3 sectors as necessary.

CONCLUSION

Although there is no global haemorrhoidal treatment consensus, there are many practice similarities among the different cultures, resources, volume and experience of surgeons around the world. With additional studies, a consensus statement could potentially be developed.

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.