THE RUSSIAN ASSOCIATION OF COLOPROCTOLOGY CLINICAL GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF HEMORRHOIDS

[Treatment of acute hemorrhoids according to the results of a multicenter observational study]

BACKGROUND

The issue of improving hemorrhoid treatment outcomes in outpatient practice is one of the most pressing in the daily work of coloproctologists today. Advances in the treatment of hemorrhoidal disease, the most common pathological condition in general proctology, in recent decades have been associated not only with the adoption of minimally invasive surgical techniques but also with the enhancement of pharmacological therapy. A key component of systemic pharmacotherapy for chronic and acute hemorrhoids is the use of venotonic drugs, including flavonoids which are included in the clinical guidelines. Therefore, a comprehensive and reliable evaluation of the clinical efficacy of diosmin is an important area of research, especially in cases of acute hemorrhoids.

OBJECTIVE

The study aimed to assess the effectiveness of using Phlebodia 600 and evaluate the dynamics of patients' quality of life with acute hemorrhoids of grades I-II in outpatient practice without employing minimally invasive surgical methods.

MATERIAL AND METHODS

A Russian multicenter prospective observational study was conducted involving an adult population of patients with grade I-II acute hemorrhoids in the city of Rostov-on-Don and the Rostov region. Outpatients (both men and women) aged 18 to 64 with a confirmed diagnosis of grade I-II acute hemorrhoids (thrombosis of external or internal hemorrhoidal nodes, including those with bleeding) established through standardized clinical examination were included. Therapy with Phlebodia 600 (diosmin) commenced no later than three days after the onset of clinical symptoms, which included a dominant set of symptoms such as enlarged hemorrhoidal nodes, pain, bleeding, anal itching, burning, or discomfort. The total sample size analyzed was 220 patients, and the medication was administered for at least 36 days.

RESULTS

The use of Phlebodia 600 for grade I-II acute hemorrhoids allowed for the resolution of complaints and stabilization of all key clinical parameters within the timeframes set by the study design. Following the proposed treatment regimen, early resolution and reduction of complaints such as pain, discomfort, itching, and blood streaks during defecation were observed by the control visit after seven days of therapy, compared to baseline. In 73% of cases, a reduction in the size of hemorrhoidal nodes was noted within this period. The proposed treatment regimen can be considered rational since, after 30 days, not only was there consistent resolution of complaints in the majority of patients, but there was also a significant improvement in quality of life (SF-36). No cases of intolerance to Phlebodia 600 or adverse reactions associated with its use were identified, indicating a high safety profile.

CONCLUSIONS

A 35-40 day course of Phlebodia 600 administered continuously according to the manufacturer's recommended regimen effectively reduces the severity and frequency of major complaints in patients with grade I-II acute hemorrhoids. This is achieved through improved microcirculation, venotonic, anti-inflammatory, and anti-edema effects. Diosmin (Phlebodia 600) favourable safety profile has been demonstrated. in acute hemorrhoids.

Rationale and effectiveness of combination therapy of chronic anal fissures and hemorrhoids

Hemorrhoids and anal fissures are a serious medical problem at the intersection of specialties. The disease has a progressive course, there are several stages. In the 3rd and 4th stages, surgical intervention is required, but in the 1st and 2nd stages, i.e. in more than 90% of all cases of the disease, it is enough to correct the lifestyle, physical activity, diet and nature of the diet, as well as conservative drug treatment. The complexity and multifactorial nature of the pathogenesis of hemorrhoidal disease dictate the need for the impact of therapy on the key mechanisms of the development of the disease. This can be achieved by combining agents with different effects and routes of administration to provide potentiation. Treatment of acute and chronic hemorrhoids includes general and local use of painkillers, antiinflammatory, phlebotonic, hemostatic and complex preparations. Among systemic drugs, the leading place belongs to phlebotonic agents of the flavonoid series of plant origin. Their effectiveness is associated with the effect both on the state of the vascular wall with a decrease in venous stasis and improvement of lymphatic outflow, and with an effect on the rheological properties of the blood. There is also a local anti-inflammatory effect of the combination “diosmin + hesperidin”, and in general, a palette of positive properties predetermines the use of these drugs for hemorrhoids. The combination of systemic flavonoids with local agents that provide repair of damaged tissues and have hemostatic effects contributes to an increase in the effectiveness of treatment. The combined use of systemic phlebotonic preparations and local reparative agents, which together provide a complex effect on various pathogenetic mechanisms and symptoms of hemorrhoids and anal fissures, accelerates the achievement of a positive result of treatment and the prevention of recurrence of the disease.

Modern approach to the choice of laxative agent in surgical interventions in outpatient coloproctology

Introduction. Elimination of manifestations of functional constipation and normalization of the stool to date remain a complex and finally unresolved problem during typical surgical interventions in outpatient coloproctology.

Aim. To evaluate the clinical efficacy of the laxative agent sodium picosulfate in the surgical treatment of non-tumor diseases of the anal canal and rectum in outpatient settings.

Materials and methods. The results of surgical treatment of 566 patients with non-tumor diseases of the anal canal and rectum, which were divided into two groups, were analyzed. In 275 patients (group 1), laxative agents were not used during treatment or were used indiscriminately. In 291 patients (group 2), the laxative agent sodium picosulfate was used to normalize colon emptying and soften stools during treatment. Comparison criteria: level of pain syndrome after surgery, degree of inflammatory manifestations in the field of surgical intervention, shape, and nature of fecal masses (based on the Bristol scale), frequency of wound inflammatory complications and recovery time for patients.

Results. In the early stages after surgery, the stool had a softened consistency (type 5 and 6) in a much larger number of group 2 patients (89.7 ± 4.1 – 94.2 ± 5.1%) compared with group 1 patients (67.3 ± 4.8 – 76.7 ± 4.9%). At the same time, in group 2 patients, pain syndrome was less pronounced, inflammatory manifestations in the area of surgical intervention regressed faster, incidence of wound inflammatory complications decreased 2.8 times (from 16.4 to 5.8%) and work capacity was recovered earlier than in group 1 patients.

Conclusion. The use of the laxative agent sodium picosulfate in coloproctological patients when performing typical surgical interventions on the rectum and anal canal on an outpatient basis eliminates the manifestations of symptomatic constipation, ensures the formation of a softened stool in perioperative periods, reduces mechanical injury to the mucous membrane of the rectum by feces, reduces the level of pain syndrome, which improves the results of surgical treatment by reducing the number of wound inflammatory complications.

Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is common in adults. Treatment is largely conservative, although more invasive procedures may be required. Venoactive drugs such as micronized purified flavonoid fraction (MPFF) are widely used, but a recent and comprehensive review of supporting evidence is lacking. In acute HD, MPFF can reduce HD symptoms such as bleeding, pain, anal discomfort, anal discharge and pruritus. In patients undergoing surgery, postoperative adjunct MPFF consistently reduces pain, bleeding duration and use of analgesia. MPFF treatment is appropriate and effective both as a first-line conservative treatment and as a postoperative adjunct treatment. MPFF reduces the duration of hospital stay following surgery, facilitating a return to normal activity and improving quality of life. MPFF may also prevent HD recurrence.

[Interdisciplinary consensus on Russian-language terminology of anorectal sphincterometry and profilometry]

Aim to describe the results of a multidisciplinary discussion on the terminology of anorectal sphincterometry (AS) and profilometry (AP). We performed online survey with the use of public platform Google forms to harmonize Russian terms to be used to describe the results of AP and AS and their abbreviations. The invitation to participate in the survey was sent to the authors who use the results of AP and AS in clinical practice and perform the diagnostic procedures. The obtained answers were analyzed with the use of the aggregator and Statistica 10 (StatSoft Inc, USA) software. The level of consensus was analyzed with the use of modified Delphi criteria (C1 agreement of 90% of participants, C2 agreement of 75 to 90%, C3 less than 75%). Invitations sent 76, responses obtained 63 (response rate 82.9%). Consensus level 1 was reached for all the terms of AP and for 4out of 7 terms to describe the results of AS (3 out of 7 terms were of moderate agreement, C2). The need for the use of predefined abbreviations of terms for AS and AP was of a low rate of consensus (71.4%). The agreed terms of AS and AP should be used to prepare a conclusion for the diagnostic procedures and to publish scientific reports.