Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

Treatment of Hemorrhoidal Disease in Patients with Liver Cirrhosis: A Systematic Review

Introduction

The incidence of hemorrhoidal disease (HD) in cirrhotic patients is similar to that of general population, varying between 21% and 79%. Managing this clinical condition in these patients is challenging, due to the need to differentiate between bleeding originating from hemorrhoids or anorectal varices, and the unique hemostatic balance of each patient, which can lead to a decompensation of liver function and subsequently increase the anesthetic risk. To date, there are no systematic reviews specifically addressing this topic.

Methods

This was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were retrieved from three electronic databases. Efficacy (symptomatic improvement, patient satisfaction, quality of life improvement, disease recurrence/need for surgery and/or hemorrhoidal prolapse reduction in anoscopy) and safety (reported adverse events) outcomes were evaluated. Data from each study were initially described individually, followed by a comparative analysis for procedures applied in multiple studies.

Results

Six studies were included - 1 randomized clinical trial (RCT), 2 prospective cohort studies, 1 retrospective cohort study, and 2 case series. The considered techniques encompassed rubber band ligation (RBL), injection sclerotherapy (IS) using 3 agents - aluminum potassium sulfate and tannic acid (ALTA), ethanolamine oleate 5% (EAO), or N-butyl-cyanoacrylate, hemorrhoidopexy, and emborrhoid technique. RBL showed great symptomatic improvement and patient satisfaction in 63% and 73% of patients, respectively, and in 90% was associated with one-grade prolapse reduction after only one session. The most frequently reported adverse events included pain (16%) and ulceration/fissure (1-17%). Concerning IS, symptomatic improvement was observed in all patients. Recurrence rates varied with the agent used (EAO: 13% at 12 months; N-butyl-cyanoacrylate: 40% at 12 months; ALTA: 18% at 5 years), and 86.7% of patients exhibited more than one-grade reduction after the initial session. The most frequent adverse event was pain (EAO: 63%; N-butyl-cyanoacrylate: 60%). Stapled hemorrhoidopexy resulted in symptomatic improvement in all patients, although associated with a recurrence rate of 25% within 4 months. With an emborrhoid technique, 80% of the patients showed clinical improvement at a 3-month follow-up, without significant adverse events, at the cost of a 40% recurrence rate.

Conclusions

All the treatment methods assessed in the included studies appear to be effective and safe in cirrhotic patients. This assumption challenges previous concerns regarding significant bleeding after office-based procedures like RBL in this population. Future research should prioritize RCT to thoroughly assess the management of HD in these patients, particularly addressing polidocanol foam sclerotherapy, a minimally invasive technique that has previously been shown to be more effective than RBL in the general population and in patients with bleeding disorders.

Comparative analysis of Ferguson hemorrhoidectomy combined with doppler-guided hemorrhoidal artery ligation and Ferguson hemorrhoidectomy in hemorrhoidal disease treatment

BACKGROUND

In hemorrhoidal disease, despite the existence of numerous treatment options to alleviate symptoms, surgical intervention continues to be the gold standard. The advantages and disadvantages of many methods have been shown in numerous studies However, only a few studies have compared the effectiveness of combined methods.

AIM

To compare the results of a coloproctology clinic that switched to the Doppler-guided hemorrhoidal artery ligation (DG-HAL) + Ferguson hemorrhoidectomy (FH) technique from the FH in the treatment of hemorrhoidal disease.

METHODS

In this retrospective cohort, data from a total of 45 patients who underwent DG-HAL + FH (n = 24) and FH (n = 21) for grade III hemorrhoidal disease between 2020 and 2022 were analyzed. Demographic and clinical data, surgical duration, intraoperative blood loss, hospital stay, postoperative analgesic consumption, pain scores using the Visual Analog Scale (VAS), complications, time to return to normal activities, and the recurrence rate were compared in both groups.

RESULTS

The study included 45 patients, with 75.6% (n = 34) male and 24.4% (n = 11) female. The rate of intraoperative blood loss was higher in the FH group (P < 0.05). The VAS scores and postoperative complication rates were similar in both groups. The need for postoperative analgesics was lower in the DG-HAL + FH group (2 vs 4 days, P < 0.05), while the FH group showed a shorter time to return to normal activities (9.5 vs 6.0 days, P = 0.02). The recurrence rate (16.7% vs 0%) and Clavien-Dindo Score-1 complications (20.8% vs 9.5%, P = 0.29) were higher in the DG-HAL + FH group but were insignificant.

CONCLUSION

Our study revealed that the addition of the DG-HAL to classical hemorrhoidectomy caused less intraoperative bleeding and a lower postoperative analgesia requirement.

Superselective superior rectal artery embolization in the treatment of hemorrhoidal disease

Hemorrhoids are a prevalent and benign anal disorder for which minimally invasive treatments are increasingly preferred. The UK National Institute for Health and Care Excellence clinical guideline (2010) recommends hemorrhoidal artery ligation as a treatment option for hemorrhoidal disease. Superior rectal artery embolization (SRAE) leverages this principle by using digital subtraction angiography to precisely identify and superselectively embolize the arteries supplying the hemorrhoidal region. This procedure has demonstrated favorable clinical outcomes. SRAE is minimally invasive, painless, preserves the anal sphincter and normal anal anatomy, and offers a quick recovery, establishing it as an effective minimally invasive surgical option. As a result, this technique has gained increasing clinical recognition and adoption. This article examines the efficacy and safety of superselective SRAE for hemorrhoidal disease.

Management of haemorrhoids through siddha formulation Kuppaimeni Samoola

Hemorrhoids are a very common anorectal condition characterized by symptomatic enlargement and distal dislodgment of anal cushions which mainly affects the quality of life. Siddha herbal medicine Kuppaimeni (Acalypha Indica) is indicated for haemorrhoids, was used in this pilot study to catalogue the feasibility of Kuppaimeni samoola choornam in the management of first, second, and third- degree internal Hemorrhoids, along with a dietary regimen, of including two fig fruits in the daily diet. Ten participants were selected for the study and they underwent medication with a drug administration calendar period of forty - eight days. Prognosis was assessed by using Hemorrhoids Symptoms Severity (HSS) Scoring. The study findings of KSC are: among the ten cases, eight subjects got complete relief from symptoms after 48 days of medication. HSS scoring reduced to zero for all (8) first and second degree hemorrhoid cases and these 8 cases never had repeated episodes in follow-up time (5 years of follow-up after withdrawing medication). This study suggests the feasibility of using KSC in treating first and second-degree internal hemorrhoids.

The efficacy of Aescin combined with MPFF for early control of bleeding from acute hemorrhoids, A randomized controlled trial

BACKGROUND

Hemorrhoidal disease, affecting over 20 % of the population, presents management challenges due to its multifaceted nature. While treatments like Micronized Purified Flavonoid Fraction (MPFF) show promise, Aescin's efficacy remains uncertain. This study assesses the combined effectiveness of Aescin with MPFF against MPFF alone in treating Grades 1 and 2 hemorrhoids, focusing on halting bleeding and reducing mass effect.

METHOD

This study recruited patients from the Division of Colorectal Surgery, Chiang Mai University. Patients were randomly assigned to receive MPFF alone or MPFF with Aescin. Outcomes included the duration until bleeding cessation and resolution of mass effect.

RESULTS

Of 120 patients randomized to each group, the combination therapy demonstrated superiority in halting bleeding (two days VS four days) and resolving mass effect (four days VS five days) compared to MPFF alone with statistically significant differences. Treatment failure rates were lower in the combination therapy group, with high patient satisfaction.

CONCLUSION

Combining Aescin with MPFF shows promise as a therapeutic approach for Grades 1 and 2 internal hemorrhoids, offering expedited relief from bleeding and mass effect. These findings suggest the need for further research to validate results in larger cohorts and optimize treatment strategies for hemorrhoidal disease.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

A Retrospective Study of Milligan-Morgan Versus LigaSure Hemorrhoidectomy in the Treatment of Symptomatic Hemorrhoids at an Institute in North India

Objective The present study aimed to assess and compare the surgical outcomes of hemorrhoidectomies performed using two different techniques: conventional Milligan-Morgan and another popular vessel sealing approach of LigaSure hemorrhoidectomy. Methods This retrospective study was conducted at our tertiary care hospital and involved patients who underwent either of the surgical procedures from June 2016 to March 2022. The patient demographics and data on the duration of operation, hospital stay, and postoperative recovery were collected and evaluated. Results Of the 91 cases reviewed, a total of 44 patients underwent Milligan-Morgan open hemorrhoidectomy and 47 had LigaSure hemorrhoidectomy. The mean operative time was significantly shorter for LigaSure hemorrhoidectomy (33.84 ±9.18 vs. 23.15 ±3.36 minutes for Milligan-Morgan and LigaSure, respectively, p<0.0001). Additionally, in comparison to Milligan-Morgan open hemorrhoidectomy, the LigaSure hemorrhoidectomy group exhibited a significant reduction in hospital stay (2.20 ±0.79 vs. 1.47 ±0.50 days), lower pain score [6.55 ±1.19 vs. 5.30 ±1.10 on the visual analog scale (VAS) on day one and 2.25 ±1.26 vs. 1.47 ±0.78 VAS on day seven], and faster return to normal activities (18.18 ±4.30 vs. 14.85 ±3.15 days). Conclusions When pitted against the traditional Milligan-Morgan method, the LigaSure approach to performing a hemorrhoidectomy is superior, owing to the shorter duration of operation, shorter hospital stays, lesser pain, and earlier return to normal activities. In light of these findings, surgeons may consider choosing this procedure to improve surgical outcomes and efficiency.

Conventional Excisional Haemorrhoidectomy versus Transanal Haemorrhoidal Dearterialization for Haemorrhoids: A Systematic Review and Meta-Analysis

INTRODUCTION

Although effective, conventional excisional haemorrhoidectomy (CEH) is associated with significant postoperative pain. Novel techniques such as transanal haemorrhoidal dearterialization (THD) are suggested to reduce pain but may result in higher recurrence rates. We aimed to compare short- and long-term outcomes of CEH and THD in the present meta-analysis.

METHODS

A PRISMA-compliant meta-analysis was performed, searching PubMed, Embase, and CENTRAL databases for randomised controlled trials (RCTs) from 1995 to December 2022. The primary objective was recurrence. Secondary objectives included complication rates, length of stay (LOS), operative time, and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. Subgroup analysis was also performed.

RESULTS

A total of 6 RCTs encompassing 465 patients were captured. There were 142 (59%) males in the CEH group and 129 (54%) in the THD group. On random-effects analysis, THD had a higher recurrence rate (odds ratio = 2.76, 95% confidence interval [CI] = 1.03-7.38, p = 0.04) albeit a shorter return to baseline compared to CEH (mean difference = -14.05 days, 95% CI = -20.38 to -7.72, p < 0.0001). There were no differences in bleeding (p = 0.12), urinary retention (p = 0.97), incontinence (p = 0.41), anal stenosis (p = 0.19), thrombosed residual haemorrhoids (p = 0.16), operating time (p = 0.19), or LOS (p = 0.22). Results remained similar on subgroup analysis.

CONCLUSIONS

CEH is associated with lower recurrence but similar complication rates to THD, although patients take longer to return to baseline function postoperatively.

Comparison of the long-term efficacy and safety of multiple endoscopic rubber band ligations in a single session for varying grades of internal hemorrhoids

BACKGROUND

There is no consensus on the number of ligation bands for varying grades of internal hemorrhoids (IH) in a single session of endoscopic rubber band ligation (ERBL).

AIMS

The aims of this study were to investigate this issue.

METHODS

Patients with IH were treated with ERBL. The primary endpoint was no hemorrhoid symptoms 6 weeks after ERBL. The secondary endpoints were postoperative complications and recurrence.

RESULTS

One hundred twenty-three eligible patients met the inclusion criteria, and 3 patients were excluded. The average bands were 3.9 ± 1.1, and grade II hemorrhoids required significantly fewer bands than grade III hemorrhoids (3.45 ± 0.85 vs 4.35 ± 1.06, P = 0.000). 78.8% of patients achieved the primary endpoint. The efficacy of grade II hemorrhoids was higher than that of grade III hemorrhoids (87.8% vs 69.2%). The incidence of postoperative complications was not significantly correlated with the grade of hemorrhoids (P = 0.201) and the number of bands (P = 0.886). The median follow-up time was 14.3 ± 7.9 (1.3-30.9) months. The overall recurrence rate was 25.0%, with grade III significantly higher than grade I-II (32.8% vs 14.6%, P = 0.027). For grade III hemorrhoids, the recurrence rate was lower with more than 4 bands of ligation than with less than 4 bands (26.5% vs 53.3%).

CONCLUSIONS

The average ERBL treatment of IH requires nearly four bands, and grade II hemorrhoids require less banding than grade III hemorrhoids, while the efficacy was better. Increasing the number of bands improves the treatment efficacy for grade III IH, which could be a strategy to reduce the recurrence rate without increasing postoperative complications.

Comparison of ointment-based agents after excisional procedures for hemorrhoidal disease: a network meta-analysis of randomized controlled trials

INTRODUCTION

Efficient postoperative pain control is important after hemorrhoidal surgery. Although several locally applied medications have been used, current evidence regarding the optimal strategy is still conflicting. This network meta-analysis assessed analgesic efficacy and safety of the various topical medications in patients submitted to excisional procedures for hemorrhoids.

METHODS

The present study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The last systematic literature screening was performed at 15 June 2023. Comparisons were based on a random effects multivariate network meta-analysis under a Bayesian framework.

RESULTS

Overall, 26 RCTs and 2132 patients were included. Regarding postoperative pain, EMLA cream (surface under the cumulative ranking curve (SUCRA) 80.3%) had the highest ranking at 12-h endpoint, while aloe vera cream (SUCRA 82.36%) scored first at 24 h. Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation. Lidocaine (SUCRA 87.9%) displayed the best performance regarding overall morbidity rates.

CONCLUSIONS

Due to the inconclusive results and several study limitations, further RCTs are required.

A retrospective comparative study of hemorrhoidal artery ligation versus ligasure hemorrhoidectomy for the third degree hemorrhoidal disease

BACKGROUND

Hemorrhoidal disease (HD) is the most common disease of the anorectal region. Excision of pathological hemorrhoidal structures by providing bipolar energy transfer with Ligasure, which is basically an electrosurgical device, is one of the treatment methods Ligasure hemorrhoidectomy (LH). In another method applied for the first time by Morinaga, the vascular plexus is provided by Doppler-guided ligation of the hemorrhoidal arteries (ADHL). In our study, we aimed to compare and evaluate the results of these two minimally invasive treatment methods.

MATERIALS AND METHODS

Patients treated with ADHL and LH for HD in our Surgery Clinic were included in the study. Demographic data, complaints, number of hemorrhoidal structures, location, complications, operation time, bleeding during and after the operation, length of hospital stay, postoperative pain scoring, and postoperative results were evaluated from the patient files.

RESULTS

The number of patients included in the study was 91. While 54 patients were treated with ADHL (group 1), 37 patients (group 2) were treated with LH. Although the gender distribution between the groups was similar, there was male predominance in both groups. The mean operative time was shorter in group 1. The number of packages was 2.7 in group 1 and 2.4 in group 2. The mean hospital stay was 1.5 days in the ADHL-treated group, compared to. 3.05 days in the LH group. In the postoperative period, bleeding was not observed after an average of 1.4 days in group 1, while this period was 4.9 days in group 2. While recurrence occurred in 4 patients in the ADHL group, recurrence developed in 3 patients who underwent LH.

CONCLUSION

ADHL and LH techniques have advantages and disadvantages over each other. Although the ADHL technique seems to be superior to LH in terms of post-defecation pain and shorter hospital stay, prospective randomized controlled studies are needed to determine which method should be chosen in which patient.

Evaluation of Clinical Manifestations of Hemorrhoidal Disease, Carried Out Surgeries and Prolapsed Anorectal Tissues: Associations with ABO Blood Groups of Patients

Hemorrhoidal disease (HD) is a chronic multifactorial disease. Increased abdominal pressure, along with hyperperfusion, neovascularization, overexpression of inflammatory mediators, and dysbiosis, contributes to the development of HD. The deterioration of the anchoring connective tissue with reduced collagen content and altered collagen ratios, dilatation of blood vessels and thrombosis, muscle injury, and inflammation gradually lead to clinically manifesting prolapse and bleeding from hemorrhoids. The associations of the ABO blood types with a disease have been investigated for the upper gastrointestinal tract only. This study aimed to evaluate HD clinical manifestations, surgeries carried out, and the status of prolapsed anorectal tissues by exploring the associations with the patients' ABO blood groups. Clinical and various morphological methods, combined with extensive bioinformatics, were used. The blood type 0, grade III and IV HD individuals constituted the largest group in a moderately-sized cohort of equally represented males and females studied and submitted to surgical treatment of hemorrhoids. There were significantly more complaints reported by HD females compared to males (p = 0.0094). The Longo technique appeared mostly used, and there were proportionally more surgeries performed below the dentate line for HD individuals with blood type 0 compared to other blood type patients (24% vs. 11%). HD males were found to present with significantly more often inflamed rectal mucosa (p < 0.05). Loosening and weakening of collagenous components of the rectal wall combined with vascular dilation and hemorrhage was found to differ in 0 blood type HD individuals compared to other types. HD males were demonstrated to develop the ruptures of vascular beds significantly more often when compared to HD females (p = 0.0165). Furthermore, 0 blood type HD males were significantly more often affected by a disease manifested with tissue hemorrhage compared to the 0 blood type HD females (p = 0.0081). Collectively, the local status of chronically injured anorectal tissue should be considered when applying surgical techniques. Future studies could include patients with HD grades I and II to gain a comprehensive understanding of the disease progression, allowing for a comparison of tissue changes at different disease stages.

Results of sclerotherapy and mucopexy with haemorrhoidal dearterialization in II and III degree haemorrhoids. A 4 years' single centre experience

Introduction

Haemorrhoidal disease (HD) affects a considerable portion of the adult population. The aim of this study is to confirm the safety and efficacy of the treatments and to report the long-term outcomes of Sclerotherapy (ST) and Mucopexy and Haemorrhoidal Dearterialization (MHD) performed over the last 4 years in a single tertiary centre. The secondary outcome is to evaluate the usefulness of both techniques and to demonstrate how those can be associated as a bridge to surgery.

Materials and methods

Patients affected by second-third-degree haemorrhoids and undergoing ST or non-Doppler guided MHD between 2018 and 2021 were enrolled. Safety and efficacy, recurrence rate, Haemorrhoid Severity Score (HSS) and pain resulting from both techniques were evaluated.

Results

Out of 259 patients, 150 underwent ST. Further, 122 (81.3%) patients were male and 28 (18.7%) were female. The mean age was 50.8 (range 34-68) years. Most of the patients (103, 68.6%) were affected by second-degree HD, while 47 (31.4%) were affected by third-degree HD. The overall success rate was 83.3%. The median pre-operative HSS score was 3 (IQR 0-4, p = 0.04) and at 2 year the median HSS was 0 (IQR 0-1, p = 0.03). No intraoperative complications and no drug-related side effects occurred. The mean follow-up for ST was 2 years (range 1-4; SD ±0.88). MHD was performed on 109 patients. In detail, 80 patients (73.4%) were male while 29 patients (26.6%) were female. The mean age in this group was 51.3 (range 31-69). Further, 72 patients (66.1%) were affected by third-degree HD and 37 (33.9%) by second-degree HD. The median HSS score was 9 (IQR 8-10, p = 0.001) preoperatively two years after treatment was 0 (IQR 0-1, p = 0.004). Major complications occurred in three patients (2.75%). The overall success rate was 93.5% (second degree 89.2% vs. third degree 95.8%). The mean follow-up for MHD was 2 years (range 1-4; SD ±0.68).

Conclusions

The results confirm the usefulness of those techniques, which can be considered safe and easily repeatable procedures, with a low recurrence rate after 2 years of median follow-up.

Altered Gut Microbic Flora and Haemorrhoids: Could They Have a Possible Relationship?

To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.

Utility of botulinum toxin injection for post-operative pain management after conventional hemorrhoidectomy: a systematic review and meta-analysis of clinical trials

BACKGROUND

Botulinum Toxin (BTX) has been found to have anti-spasm and analgesic effects. The utility of BTX after conventional hemorrhoidectomy remains unclear. Thus, a systematic review and meta-analysis are required to find out its utility after conventional hemorrhoidectomy.

METHODS

Using specific keywords, we comprehensively go through the potential articles on PubMed, ClinicalTrials.gov, and Europe PMC sources until March 27th, 2022. All published studies on botulinum toxin anal sphincter injection after conventional hemorrhoidectomy were collected. We were using Review Manager 5.4 software to conduct statistical analysis.

RESULTS

Five clinical trial studies with a total of 260 patients undergoing hemorrhoidectomy were included in the analysis Our pooled analysis revealed that BTX injection after hemorrhoidectomy was associated with lower VAS at 24 h post-operative [Mean Difference -1.35 (95% CI -1.90, -0.80), p < 0.00001, I2 = 0%] and shorter time to return work [Mean Difference -8.94 days (95% CI -12.57, -5.30), p < 0.00001, I2 = 0%]. However, BTX injection did not differ significantly from placebo in terms of time to first defecation (p = 0.22), fecal incontinence (p = 0.91) and urinary retention incidence (p = 0.18).

CONCLUSION

BTX sphincter injection may offer some benefit after conventional hemorrhoidectomy in reducing pain from the first day after the procedure and promoting wound healing without complication. Further randomized clinical trials are still needed to confirm the results of our study.

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.

Evaluation of the clinical efficacy and safety of TST33 mega hemorrhoidectomy for severe prolapsed hemorrhoids

BACKGROUND

The pathogenesis of hemorrhoids is mainly anal cushion prolapse. Although the traditional treatment has a certain curative effect, it is not ideal. The remission rate of postoperative symptoms is low. Even if temporary remission is achieved, patients with hemorrhoids easily relapse after 1-2 years. The new technique of using staplers to treat prolapsed hemorrhoids has good therapeutic effects in clinical practice.

AIM

To explore the effect of TST33 mega stapler prolapse and hemorrhoid mucosal resection in the treatment of patients with severe prolapsed hemorrhoids.

METHODS

A total of 204 patients with severe prolapse hemorrhoids who were admitted to the department of anorectal in our hospital from April 2018 to June 2020 were selected, and the patients were randomly divided into group A and group B with 102 cases in each group using a randomized controlled clinical research program. Patients in Group A were treated with a TST33 mega stapler and hemorrhoid mucosal resection to treat prolapse, and patients in Group B were treated according to the Procedure for Prolapse and Hemorrhoids; the operation time, intraoperative blood loss, hospital stay, the difference in operation time, intraoperative blood loss, hospitalization time, pain degree before and after operation, degree of anal edema, anal Wexner score, and surgical complications were compared between the two groups of patients.

RESULTS

The operation time, intraoperative blood loss and hospitalization time in Group A were significantly lower than those in Group B (P < 0.05). The cure rate of Group A was 98.04%, compared with 95.10% cure rate of Group B, and the difference was not statistically significant (P > 0.05). The visual analogue scale (VAS) at 12 h and 24 h postoperatively in Group A were significantly lower than those in Group B (P < 0.05). The comparison of the VAS scores between Group A and Group B at 48 h, 72 h and 96 h postoperatively revealed that the difference was not statistically significant (P > 0.05). One day postoperatively, the degree of perianal edema in Group A was compared with that in Group B, and the difference was not statistically significant (P > 0.05). Seven days postoperatively, the degree of perianal edema in Group A was significantly lower than that in Group B (P < 0.05). The comparison of anal Wexner scores between the two groups preoperatively and at 1 mo, 3 mo and 6 mo postoperatively showed that the difference was not statistically significant (P > 0.05). The Wexner scores of the two groups at 1 mo, 3 mo and 6 mo postoperatively were significantly lower than the scores preoperatively (P < 0.05). The postoperative complication rate of Group A was 2.94% lower than that of Group B (11.76%), which was statistically significant (P < 0.05).

CONCLUSION

TST33 mega anastomotic hemorrhoidectomy treatment for patients with severe prolapse hemorrhoids, leads to less postoperative pain, the rapid recovery of perianal edema and has fewer complications.

Comparison of post-operative bleeding incidence in laser hemorrhoidoplasty with and without hemorrhoidal artery ligation: a double-blinded randomized controlled trial

Introduction

The effectiveness of hemorrhoidal artery ligation supplementation in reducing the incidence of post laser hemorrhoidoplasty bleeding has not been investigated.

Methods

This was a double-blind, randomized controlled trial comparing post-operative bleeding incidence in patients undergoing laser hemorrhoidoplasty (LHP) only versus LHP with hemorrhoidal artery ligation (HAL). Outcome measures included post-operative bleeding and its severity (i.e. verbal rating scale and Clavien-Dindo classification), presence of perianal swelling and pain score (visual analog score) at 1-day, 1-week and 6-weeks post-operatively. Statistical tests were performed and a value of P < 0.05 was considered significant.

Results

Seventy-six patients were randomized. There was no difference in median operating time. The bleeding incidence was highest at 1-week post-operatively (17.1%), and decreased to 1.3% at 6-weeks. There was no significant difference in bleeding incidence between both groups at any of the measured timepoints (P > 0.05). Severity of bleeding and incidence of post-operative perianal swelling were similar in both groups (P > 0.05). There was no difference in median pain scores.

Conclusion

Supplementation of HAL to LHP does not reduce the post-operative bleeding incidence. LHP is sufficient as a stand-alone procedure for treating haemorrhoids.

Trial registration: National Registration Number is NMRR-15-1112-24065 (IIR). The trial start date was 1st January 2015 with the ClinicalTrials.gov identifier and registration number as NCT04667169.

Therapeutics in Radiation-induced Proctopathy: A Systematic Review

Malignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm.

The Laser Therapy for Hemorrhoidal Disease: A Prospective Study

Aim: This prospective study aimed to determine the outcomes and postoperative complications of hemorrhoid disease (HD) treated by hemorrhoidal laser procedure (HeLP).

Background: We, herein report the results of 18 months of methodical use of mini-invasive laser procedures in 100 patients with grades 2 and 3 hemorrhoids and minimum to a mild degree of rectal prolapse. The surgical technique is called HeLP.

Methods: Data were collected on the duration of the procedure, intraoperative complications, postoperative pain, the declivity of hemorrhoids, persistency or complete resolution, and recurrence of hemorrhoids were collected prospectively.

Results: No evidence of intraoperative complications occurred. The median follow-up was nine months. Postoperative pain was not significant or null in most patients. There was no rectal tenesmus or alteration of defecation habits. Plateau of hemorrhoid symptoms and downgrading of hemorrhoid size reached approximately three to seven months post-procedure. The frequency of pain, bleeding, pruritus ani, and acute hemorrhoidal syndrome decreased by 75-80%. There was a significant reduction in hemorrhoids with the rate of recurrence being 7% over 12 months of follow-up.

Conclusion: Our study evaluated and demonstrated that HeLP is an effective, safe, and non-painful procedure for the management of patients with the symptomatic second or third degree of hemorrhoid with mild to the minimum degree of rectal mucosal prolapse. It is a suitable ambulatory treatment.

Lifestyle and Risk Factors in Hemorrhoidal Disease

Constipation, a low fiber diet, a high Body Mass Index, pregnancy, and a sedentary lifestyle are often assumed to increase the risk of hemorrhoidal disease (HD). However, evidence regarding these factors is controversial. This mini-review aims to examine and critically analyze the association between main risk factors and the prevalence of HD, focusing both on the patient's clinical history and on a tailored treatment. Moreover, some practical suggestions about lifestyle and conservative approaches are given to help clinicians in the management of patients with HD and to obtain the best results from therapy.

Rubber band ligation of symptomatic hemorrhoids: an old solution to an everyday problem

PURPOSE

The aim of this prospective study is to present the results of rubber band ligation (RBL) in 2635 consecutive patients with 2^nd, 3^rd, and 4^th degree symptomatic hemorrhoids, the pain risk factors, and the applicability of the method in patients with liver cirrhosis and portal hypertension.

METHODS

A total of 1256 patients with 2^nd, 1159 with 3^rd, and 220 with 4^th degree hemorrhoids were included in the study. Fifty-seven patients with hemorrhoids had liver cirrhosis and portal hypertension. RBL was performed using St Marks', McGinvey, and suction ligators. Single ligation was done in 178 patients, while 2457 patients had synchronous multiple ligations, in one (272), two (1289), and three (896 patients) sessions.

RESULTS

After the end of treatment, 86.8% of our patients were asymptomatic and 84.5% remained asymptomatic 2 years later. A total of 593 patients had complications. Thirty required hospitalization, while pain was the most frequent complication (16.16 %). Multiple banding, young age, male sex, and external hemorrhoids were pain risk factors. RBL proved to be safe in 57 patients with coagulation disorders due to cirrhosis. Symptomatic recurrence was detected in 327 out of 2110 patients (15.49%), with repeat RBL in 219 cases and surgery in 108 cases.

CONCLUSION

RBL is a safe, effective method for treating symptomatic 2^nd and 3^rd degree hemorrhoids. It can also be applied in selected cases of 4^th degree hemorrhoids and patients with cirrhosis and portal hypertension.

Pudendal Nerve Block in Hemorrhoid Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, especially in a surgical day care setting.

OBJECTIVE

The aim of this study was to investigate the use of pudendal nerve block in patients undergoing hemorrhoidectomy.

DATA SOURCES

PubMed, Google Scholar, Cochrane Library, and Web of Science databases were searched up to December 2020.

STUDY SELECTION

Randomized trials evaluating the pudendal nerve block effect in patients undergoing hemorrhoidectomy were selected.

INTERVENTIONS

Hemorrhoidectomy under general or spinal anesthesia with or without pudendal nerve block was performed.

MAIN OUTCOME MEASURES

Opioid consumption, pain on the visual analogue scale, length of hospital stay, and readmission rate were the main outcomes of interest and were plotted by using a random-effects model.

RESULTS

The literature search revealed 749 articles, of which 14 were deemed eligible. A total of 1214 patients were included, of whom 565 received the pudendal nerve block. After hemorrhoidectomy, patients in the pudendal nerve block group received opioids less frequently (relative risk, 0.364; 95% CI, 0.292-0.454, p < 0.001) and in a lower cumulative dose (standardized mean difference, -0.935; 95% CI, -1.280 to -0.591, p < 0.001). Moreover, these patients experienced less pain at 24 hours (standardized mean difference, -1.862; 95% CI, -2.495 to -1.228, p < 0.001), had a shorter length of hospital stay (standardized mean difference, -0.742; 95% CI, -1.145 to -0.338, p < 0.001), and had a lower readmission rate (relative risk, 0.239; 95% CI, 0.062-0.916, p = 0.037). Sensitivity analysis excluded the occurrence of publication bias on the primary end point, and the overall evidence quality was judged "high."

LIMITATIONS

Occurrence of publication bias among some secondary end points and heterogeneity are the main limitations of this study.

CONCLUSIONS

This systematic review and meta-analysis show significant advantages of pudendal nerve block use. A reduction in opioid consumption, postoperative pain, complications, and length of stay can be demonstrated. Despite the limitations, pudendal nerve block in patients undergoing hemorrhoidectomy should be considered.

Superior Rectal Artery Embolization with Tris-Acryl Gelatin Microspheres: A Randomized Comparison of Particle Size

PURPOSE

To evaluate the safety and efficacy of superior rectal artery embolization (SRAE) with different-sized tris-acryl gelatin microspheres in symptomatic hemorrhoidal disease (HD).

MATERIALS AND METHODS

Forty-two patients (male, 30; female, 12; median age, 45 years) with symptomatic HD (2 grade I, 8 grade II, 17 grade III, and 15 grade IV) were divided into 3 experimental arms (500-700 μm, 700-900 μm, and 900-1,200 μm groups; each had 14 patients) in a prospective randomized style to perform SRAE. Follow-up was performed by rectoscopy, clinical examination, and questionnaires. The primary outcome measure was the clinical success rate at 12 months. Secondary outcome measures were technical success rate, recurrence rate, procedure-related mortality, procedure-related complications, and any outcome changes between particle sizes.

RESULTS

No procedure-related deaths or major morbidities were observed. There was a 54% minor complication rate (n = 23/42) in the treated zone: 45% sustained small superficial ulcerations (n = 19/42), 7% small rectosigmoid junction ulcerations (n = 3/42), and 2% small fibrotic scar tissue (n = 1/42). The clinical success rate was 93%. Of the groups, the best French bleeding score decrease was obtained in the 900-1,200 μm group. There were improvements in the quality of life score and visual analogue scale score after the SRAE procedure, although not in the Goligher score. No recurrent disease was observed.

CONCLUSIONS

SRAE with tris-acryl gelatin microspheres for symptomatic HD is a safe and efficient treatment, with results favoring the use of larger microspheres.

Emergency treatment of bleeding hemorrhoids in a patient taking aspirin and clopidogrel using a 1470 nm diode laser and the ELITE minimal invasive technique

A 74-year-old male patient, receiving anticoagulation treatment after previous angioplasty stenting for severe coronary artery disease, was admitted to the clinic with a 2-day rectal bleeding. Clinical examination followed by an urgent colonoscopy to exclude other potential reasons for his symptoms both confirmed the diagnosis of Grade III thrombosed hemorrhoids. Due to the acute presentation of the case along with the existing medication of the patient, the decision was made to treat the problem using the expert laser intrahemorrhoidal therapy technique, which is a diode laser minimally invasive operation without the need to stop any of the patient’s medication.