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Suh JW, Lee MH, Oh HK, Kim HK, Kweon DK, Lee J, Ahn HM, Kim DW, Kang SB. Accelerated wound healing after topical application of hyaluronic acid cotton to hemorrhoidectomy wounds in a rat model. Ann Surg Treat Res 2024; 106:85-92. [PMID: 38318095 PMCID: PMC10838657 DOI: 10.4174/astr.2024.106.2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 02/07/2024] Open
Abstract
Purpose Anal wounds following hemorrhoidectomy can lead to severe pain and postoperative bleeding, impacting patient recovery and quality of life. Hyaluronic acid (HA) stimulates tissue regeneration and wound healing by accelerating cell migration and proliferation. This study aimed to investigate the differences in wound healing rate and completeness of recovery of perianal wounds topically treated with HA-soaked cotton in a murine model. Methods Forty-eight 8-week-old Sprague-Dawley rats with perianal wounds created using a biopsy punch were divided into 2 groups: simple dressing with gauze (control) and topical HA-soaked cotton. A single application of HA-soaked cotton was administered after surgery. Wound healing rate and completeness of recovery were evaluated by measuring the healed area and conducting histological analyses. Results The HA-cotton group exhibited a shorter complete wound healing duration compared to the control group (13.9 days vs. 16.4 days, P = 0.031). Differences in wound healing area between the 2 groups were greatest on postoperative day 2 (51.6% vs. 28.8%, P < 0.001). The HA-cotton group exhibited fewer cases of granulation tissue (2 vs. 5) or redness (0 vs. 3) upon complete wound healing. Histologically, the HA-cotton group showed accelerated reepithelialization, rapid shift to lymphocyte-dominant inflammation, enhanced fibroblast proliferation, and increased collagen deposition compared to the control group. Conclusion Herein, topical application of HA-soaked cotton on perianal wounds in rats resulted in accelerated wound healing, particularly in the initial stages, and improved completeness of recovery, underscoring the potential of the topical application of HA-soaked cotton on hemorrhoidectomy wounds in human patients to improve wound healing.
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Affiliation(s)
- Jung Wook Suh
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | | | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyung Kyung Kim
- Department of Pathology, Samsung Medical Center, Seoul, Korea
| | | | - Jeehye Lee
- Department of Surgery, Yongin Severance Hospital, Yongin, Korea
| | - Hong-min Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Dean KR, Pavuluri H, Fox S, Tan X, Watson B, Wallenborn JG, Blestel GA. The Impact of Antithrombotic Medications on Postoperative Bleeding Events Following Hemorrhoidectomy. Am Surg 2023; 89:4610-4615. [PMID: 36048039 DOI: 10.1177/00031348221124332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bleeding complications are a risk associated with hemorrhoid procedures. Despite the prevalence of anticoagulant and antiplatelet therapies, including newer direct oral anticoagulants (DOACs) in the aging patient population there is a paucity of data regarding the impact of the use of antithrombotic therapy (AT) especially DOACs, on bleeding complications of hemorrhoid procedures. METHODS We retrospectively reviewed charts of patients who had undergone a total of 1152 procedures, including hemorrhoid excision and ligation, at a single institution in the years 2016-2018. We noted whether they were prescribed AT, the indication for therapy, perioperative medication management, whether a PBE occurred, and how the PBE was managed. RESULTS PBE's were noted in 5.92% of patients on ATs, as opposed to 2.66% of patients not on ATs (P = .014.) The odds ratio of having a PBE when on ATs vs not on ATs is 2.3 (95% CI 1.21 to 4.38, P = .011). Seven out of 40 (17.5%) total PBE's required hospital admission or repeat procedure, and this was not associated with AT use. Surprisingly, although males represented most of the patients on ATs, females were statistically more likely to have a PBE following a hemorrhoidectomy if on ATs. DISCUSSION Patients on AT have an elevated risk of PBE compared to patients not on AT. No significant difference was found between the two groups when considering only those PBE's severe enough to require hospital admission or repeat procedure. Further research is required to establish clear guidelines regarding the perioperative management of AT for hemorrhoid procedures.
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Affiliation(s)
| | - Haritha Pavuluri
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Sarah Fox
- New Hanover Regional Medical Center/Colon and Rectal Surgery, Wilmington, NC, USA
| | - Xiyan Tan
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, SC, USA
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Kolbeinsson HM, Otto M, Kogelschatz B, Virk U, Luchtefeld MA, Ogilvie JW. Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications. Am Surg 2023; 89:4681-4688. [PMID: 36154315 DOI: 10.1177/00031348221129512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Post-hemorrhoidectomy bleeding is a serious complication after hemorrhoidectomy. In the setting of a new wave of anticoagulants, we aimed to investigate the relationship of post-operative anticoagulation timing and delayed bleeding. METHODS We performed a retrospective analysis of all patients undergoing hemorrhoidectomy at a single institution over a 10-year period. Fisher's exact and Wilcoxon Rank Sum tests were utilized to test for association between delayed bleeding and anticoagulation use. RESULTS Between January 2011 and October 2020, 1469 hemorrhoidectomies were performed. A total of 216 (14.7%) were taking platelet inhibitors and 56 (3.8%) other anticoagulants. Delayed bleeding occurred in 5.2% (n = 76) of which 47% (n = 36) required operative intervention. Mean time to bleeding was 8.7 days (SD ±5.9). Time to bleeding was longer in those taking antiplatelet inhibitors vs. non-platelet inhibitors vs. none (11 vs. 8 vs. 7 days, P = .05). Among anticoagulants (n = 56), novel oral anticoagulants were more common than warfarin (57% vs 43%) and had a nonsignificant increase in delayed bleeding (31% vs 16%, P = .21). Later restart (>3 days) of novel anticoagulants after surgery was associated with increased bleeding (10.5% vs 61.5%, P=.005). On multivariable analysis, only anticoagulation use (OR 4.5, 95% CI: 2.1-10.0), male sex (OR 1.8, 95% CI: 1.1-2.9), and operative oversewing (OR 3.5, 95% CI: 1.8-6.9) were associated with delayed bleeding. CONCLUSION Post-hemorrhoidectomy bleeding is more likely to occur with patients on anticoagulation. Later restart times within the first week after surgery was not associated with a decrease in bleeding.
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Affiliation(s)
- Hordur M Kolbeinsson
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | - Maxwell Otto
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | | | - Usman Virk
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | - Martin A Luchtefeld
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
- Division of Colorectal surgery, Spectrum Health Medical Group, Grand Rapids, MI, USA
| | - James W Ogilvie
- Spectrum Health General Surgery Residency, Grand Rapids, MI, USA
- Department of Surgery, Michigan State University, Grand Rapids, MI, USA
- Division of Colorectal surgery, Spectrum Health Medical Group, Grand Rapids, MI, USA
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Yu J, Zhong J, Peng T, Jin L, Shen L, Yang M. Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study. BMC Surg 2022; 22:238. [PMID: 35725452 PMCID: PMC9210638 DOI: 10.1186/s12893-022-01688-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Massive, delayed bleeding (DB) is the most common major complication of Rubber Band Ligation (RBL) for internal hemorrhoids caused by premature band slippage. In this study we modified conventional RBL to prevent early rubber band slippage and evaluated its clinical efficacy and safety. Methods Study participants were consecutive patients with grade II or III internal hemorrhoids treated with RBL at Ningbo Medical Center of Lihuili Hospital from January 2019 to December 2020. Postoperative minor complications such as pain, swelling, anal edema, prolapse recurrence and major complications like DB were retrospectively reviewed. Results A total of 274 patients were enrolled, including 149 patients treated with modified RBL and 125 treated with conventional RBL. There was no statistically significant difference between the two groups at baseline. Five cases of postoperative DB have been observed in the conventional RBL group, compared to none in the modified ones, with a significant difference (P < 0.05). Within three months after surgery, 8 cases in the modified RBL group experienced a recurrence rate of 5.4%, whereas 17 patients in the conventional RBL group experienced a recurrence rate of 13.6%. The difference was statistically significant (P < 0.05). The VAS score, edema, and incidence of sensation of prolapse between the two groups were not significantly different at 3 and 7 days after surgery (P < 0.05). There were also no significant differences in HDSS and SHS scores between the two groups after surgery (P > 0.05). Conclusion Modified RBL may be associated with a lower rate of complications, especially with lower DB rate in comparison with standard RBL. Further studies in larger samples and different design are necessary to confirm these results.
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Affiliation(s)
- Jiazi Yu
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Jie Zhong
- Department of General Surgery, Qianhu Hospital, Ningbo, 315020, China
| | - Tao Peng
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Liangbin Jin
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Leibin Shen
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Mian Yang
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China. .,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China.
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Langenbach MR, Florescu RV, Köhler A, Barkus J, Ritz JP, Quemalli E, Siegel R, Zirngibl H, Lefering R, Bönicke L. OUP accepted manuscript. BJS Open 2022; 6:6594076. [PMID: 35639947 PMCID: PMC9154318 DOI: 10.1093/bjsopen/zrac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
Background Symptomatic haemorrhoids are a common anorectal disorder. The aim of the study was to investigate whether the omission of tamponade dressings after haemorrhoidectomy reduces postoperative pain without increasing the risk of severe bleeding. Method This was an open-label, randomized clinical trial conducted at 14 German hospitals. All patients with third- or fourth-degree haemorrhoids undergoing haemorrhoidectomy were considered eligible for selection in the intervention (no dressing) or control group (tamponade applied). Two co-primary outcomes were analysed by testing hierarchically ordered hypotheses. First, maximum pain intensity within 48 h after surgery was compared between the groups (superiority). This was followed by an analysis of severe bleeding complications, defined as any bleeding requiring surgical re-intervention within 7 days (non-inferiority). Secondary outcomes included health-related quality of life, patient satisfaction, haemoglobin levels, and adverse events. Results Out of 950 patients screened, 754 were randomized and 725 received intervention (366 patients in the intervention and 359 patients in the control group). In the group with tamponade dressings, median pain intensity on the 0 to 10 scale was 6 (interquartile range (i.q.r.) 4–7). Patients without tamponade dressings reported significantly less pain (median 5 (i.q.r. 3–7), P < 0.001). In each group, five patients (1.4 per cent) experienced severe bleeding. The absolute difference for the severe bleeding rate was −0.03 per cent with the 90 per cent confidence interval ranging from −1.47 per cent to +1.41 per cent, in line with the non-inferiority aim. No significant between-group difference was found for secondary outcomes. Conclusions The practice of inserting tamponade dressings after haemorrhoidectomy correlates with increased postoperative pain and does not provide benefits in terms of reduced postoperative bleeding. Registration number DRKS00011590
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Affiliation(s)
- Mike Ralf Langenbach
- Correspondence to: Mike Ralf Langenbach, Ev. Krankenhaus Lippstadt, Department of Surgery II, University of Witten-Herdecke, Wiedenbrücker Straße 33, 59555 Lippstadt, Germany (e-mail: )
| | - Razvan-Valentin Florescu
- Helios St. Elisabeth Klinik Oberhausen, Department of Surgery II, University of Witten/Herdecke, Oberhausen, Germany
| | | | - Jörg Barkus
- Helios Klinikum Niederberg, Velbert, Germany
| | | | | | | | - Hubert Zirngibl
- Helios Klinikum Wuppertal, Department of Surgery II, University of Witten/Herdecke, Wuppertal, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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Chen CW, Lu TJ, Hsiao KH. Surgical Outcomes of LigaSure Hemorrhoidectomy in the Elderly Population: A retrospective cohort study. BMC Gastroenterol 2021; 21:413. [PMID: 34715801 PMCID: PMC8555163 DOI: 10.1186/s12876-021-01969-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background This study aims to assess the association between age and outcomes in patients undergoing hemorrhoidectomy. Methods This is a population-based cohort study. A retrospectively collected database with consecutive patients whose symptomatic prolapsed hemorrhoids managed by the LigaSure hemorrhoidectomy between Jan. 2015 and May 2017 was reviewed. Among 1238 patients, 1075 were under 65 years old (group 1), and 163 were 65 years old or older (group 2). Both groups were compared regarding baseline characteristics and surgical outcomes. Results All patients tolerated the whole course of the operation in the prone jackknife position without anesthetic-associated complications. There was no significant difference between these two groups regarding sex, hemorrhoids grade, operation time, duration of hospital stays, postoperative pain score, analgesic consumption, total postoperative complications, re-admission rate, reoperation rate and follow-up times. The multivariate logistic regression analysis that may contribute to postoperative complications revealed no significant difference for all complications between both groups. Conclusion The LigaSure hemorrhoidectomy for elderly patients is safe and effective without significant difference in short-term operative outcomes and all complication rates, compared with younger patients.
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Affiliation(s)
- Chuang-Wei Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.).,School of Medicine, Tzu Chi University, Hualien, Taiwan (R.O.C.)
| | - Tzung-Ju Lu
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.)
| | - Koung-Hung Hsiao
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Sindian City, Taipei County, 231, Taiwan (R.O.C.).
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7
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Wlodarczyk JR, Yoon D, Lai R, Ault G, Ortega A, Lee SW, Cologne KG, Koller S. LigaSure™ haemorrhoidectomy and the risk of postoperative bleeding. Colorectal Dis 2021; 23:2699-2705. [PMID: 34252247 DOI: 10.1111/codi.15808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/07/2021] [Accepted: 07/06/2021] [Indexed: 02/08/2023]
Abstract
AIM LigaSure™ is an electro-surgical device that has increasingly been utilized in haemorrhoid surgery. However, recent literature has highlighted a possible increased risk of delayed postoperative bleeding following LigaSure haemorrhoidectomy (LH). We aim to evaluate the rates of postoperative bleeding following LigaSure compared to Ferguson (closed) haemorrhoidectomy (FH). METHODS A retrospective cohort study was undertaken at our single academic safety-net county hospital from August 2016 through July 2019 evaluating patients who received FH or LH. Patient demographics, surgical data, postoperative emergency department visit for pain or bleeding within 30 days and resulting transfusion requirement, and rates of readmission and interventions within 30 days were collected. RESULTS Sixty-one FH and 66 LH patients were identified. The groups had no difference in demographics. The LH group and FH group had similar rates of postoperative emergency department visits (29% vs. 23%, P = 0.454), as well as visits for bleeding (20% vs. 11%, P = 0.204). The average operating time was also significantly shorter with LH (14.5 min vs. 24.9 min, P ≤ 0.001). On multivariate analysis, male sex (OR 7.28, 95% CI 1.88-28.25) and haemorrhoid grade ≤2 (OR 4.64, 95% CI 1.31-16.49) were significantly associated with postoperative bleeding on multivariate analysis. Use of LH was not independently associated with postoperative bleeding risk (OR 1.89, 95% CI 0.70-5.11). CONCLUSIONS LH and FH have similar risks for postoperative bleeding and other complications. Male sex and haemorrhoid Grades 1 or 2 may be associated with increased postoperative bleeding risk. Excisional haemorrhoidectomy should be undertaken with caution for male patients with lower internal haemorrhoid grades.
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Affiliation(s)
- Jordan R Wlodarczyk
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dong Yoon
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rachel Lai
- School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Glenn Ault
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Adrian Ortega
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sang W Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sarah Koller
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Chen H, Tang Z, Wu Z, Shi R. Severe Postoperative Bleeding After Stapled Hemorrhoidopexy: Incidence and Causes. Indian J Surg 2021; 83:1223-1227. [DOI: 10.1007/s12262-020-02670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Maemoto R, Tsujinaka S, Miyakura Y, Machida E, Fukui T, Kakizawa N, Tamaki S, Ishikawa H, Rikiyama T. Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery. Cureus 2021; 13:e14983. [PMID: 33996339 PMCID: PMC8115195 DOI: 10.7759/cureus.14983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction Surgery for patients taking antithrombotic drugs for the prevention and treatment of cardiovascular disease, including anticoagulants and antiplatelet drugs, is increasing because of the aging society. In patients with moderate to high risk for cardiovascular events, receiving antiplatelet therapy, and requiring noncardiac surgery continuing antiplatelet drugs perioperatively is recommended. To date, there have been limited reports on the risk of secondary bleeding after proctological surgery in patients who are administered antithrombotic drugs. The purpose of this study was to identify the incidence and severity of secondary bleeding after proctological surgery for patients with or without antithrombotic therapy. Methods We retrospectively identified 113 patients who underwent proctological surgery in our hospital from March 2009 to February 2019. In general, antiplatelet drugs were continued and anticoagulant drugs were either substituted or withdrawn prior to surgery. The severity of secondary bleeding was classified as mild, moderate, or severe. Results Eighteen patients underwent antithrombotic therapy (A group) and 95 patients did not undergo antithrombotic therapy (N group). Secondary bleeding was observed in nine patients (8.0%) and patients in the A group exhibited a significantly higher rate of secondary bleeding than those in the N group (39% vs. 2.4%, P < 0.01). The median interval from surgery to the onset of secondary bleeding was five days (range: 0-11). The severity of bleeding was the highest in patients administered direct oral anticoagulants (DOAC) and was the lowest in those administered aspirin. There was no mortality or cardiovascular event. Conclusion Antithrombotic therapy carries a high risk of secondary bleeding after proctological surgery. Delaying the postoperative resumption of anticoagulants is considered while balancing the risk of postoperative thromboembolic complications against secondary bleeding.
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Affiliation(s)
- Ryo Maemoto
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Shingo Tsujinaka
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Yasuyuki Miyakura
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Erika Machida
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Taro Fukui
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Nao Kakizawa
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Sawako Tamaki
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Hideki Ishikawa
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
| | - Toshiki Rikiyama
- Surgery, Saitama Medical Center, Jichi Medical University, Saitama, JPN
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Abstract
PURPOSE The aim of this study was to determine the incidence of delayed post-hemorrhoidectomy bleeding (DPHB) after hemorrhoidectomy using a semi-closed procedure. We also investigated risk factors associated with DPHB. METHODS This retrospective study enrolled a total of 1645 consecutive patients with symptomatic grade II to IV hemorrhoids who underwent a semi-closed procedure at the Seoul Songdo Hospital between September 2018 and May 2019. All patients underwent a semi-closed procedure with submucosal feeding vessel ligation, a method commonly performed at our institution. RESULTS A total of 1645 patients (mean age: 48.67 (±14.38) years, 823 (50.0%) male/822 (50.0%) female) underwent semi-closed hemorrhoidectomy. Critically, 24 (1.5%) patients experienced DPHB. Of these patients, 13 (0.8%) experienced stump bleeding, whereas 11 (0.7%) experienced marginal bleeding. The mean bleeding period was 8.21±4.45 days. Multivariate analysis showed that male sex, drinking history, more than four hemorrhoid piles, and laxative agents were independent risk factors for DPHB. The risk of stump bleeding was significantly associated with male sex (OR=5.55, 95% CI 1.23-25.14, p=0.026), more than four hemorrhoid piles (OR=5.90, 95% CI 1.62-21.53, p=0.007), and laxative usage (OR=3.92, 95% CI 1.31-11.74, p=0.015). Conversely, the risk of marginal bleeding were significantly associated with drinking history (OR=10.48, 95% CI 1.34-82.03, p=0.025) and more than four hemorrhoid piles (OR=4.71, 95% CI 1.24-17.81, p=0.023). CONCLUSION Male sex, drinking history, more than four hemorrhoid piles, and laxative usage were independent risk factors for DPHB in patients undergoing semi-closed hemorrhoidectomy. The risk factors for stump bleeding included male sex, more than four hemorrhoid piles, and laxative usage. In contrast, the risk factors for marginal bleeding were drinking history and more than four hemorrhoid piles.
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Affiliation(s)
- Hong Yoon Jeong
- Department of Surgery, Seoul Songdo Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Republic of Korea
| | - Do-Yeon Hwang
- Department of Surgery, Seoul Songdo Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Republic of Korea.
| | - Dong Ho Cho
- Department of Surgery, Seoul Songdo Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Republic of Korea
| | - Jong Kyun Lee
- Department of Surgery, Seoul Songdo Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Republic of Korea
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11
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Martin G, Chatellier G, Beaussier H, de Parades V. Secondary bleeding following proctological surgery: Rare but potentially severe. J Visc Surg 2020; 158:462-468. [PMID: 33277204 DOI: 10.1016/j.jviscsurg.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Haemorrhage following proctological surgery is one of the complications with the greatest potential for severity. The aim of this work was to assess the frequency and risk factors of haemorrhage requiring hospitalization during 30-days postoperatively. METHODS A retrospective cohort review of all surgeries performed in a Parisian department of medico-surgical proctology between January 2016 and June 2018 was performed. Demographic and surgical data were collected for patients who were hospitalized for postoperative haemorrhage. Their analysis was conducted as a single analysis followed by multivariate analysis. RESULTS A total of 7533 surgeries were performed on 6727 patients. The mean patient age was 42.6 (±14.3) years and 67.2% were males. Postoperative haemorrhage occurred in 111 patients (1.5%) with a total of 123 haemorrhagic episodes (12 relapses) within a mean of 6 (±5.5) days. In therapeutic terms, 28.5% of haemorrhages required transfusion, 37.4% required haemostasis in the operating theatre and 14.6% required haemostasis under local anaesthesia. Using multivariate analysis, haemorrhage was more frequent after haemorrhoid surgery and in the case of anticoagulant treatment, particularly direct oral anticoagulants, and if the ASA score was equal to 3. Active smoking was associated with a decreased risk of haemorrhage. CONCLUSION Haemorrhage requiring hospitalization occurred in 1.5% of cases following proctological surgery, 52.8% were severe and recurred in 10.8% of cases. The study also specified certain risk factors for haemorrhage and demonstrated the protective effect of active smoking.
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Affiliation(s)
- G Martin
- Medical-Surgical Proctology Department, Paris Saint-Joseph Hospital Center, 75014 Paris, France
| | - G Chatellier
- Clinical Investigation Center (CIC1418), hôpital européen Georges-Pompidou, 75015 Paris, France
| | - H Beaussier
- Clinical Research Center, groupe hospitalier Paris Saint-Joseph, 75015 Paris, France
| | - V de Parades
- Medical-Surgical Proctology Department, Paris Saint-Joseph Hospital Center, 75014 Paris, France.
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12
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Sirikurnpiboon S, Jivapaisarnpong P. Botulinum Toxin Injection for Analgesic Effect after Hemorrhoidectomy: A Randomized Control Trial. J Anus Rectum Colon 2020; 4:186-192. [PMID: 33134600 PMCID: PMC7595677 DOI: 10.23922/jarc.2020-027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022]
Abstract
Objectives: Hemorrhoid is a common disease in surgical practice, but only a few numbers of patients need surgical treatment. The most common concern of patients is postoperative pain. This study aimed to evaluate the efficacy and safety of an intersphincteric injection of botulinum toxin for post-hemorrhoidectomy pain relief. Methods: Overall, 90 patients were enrolled, and 44 were randomized into a botulinum toxin injection group. Preoperative gradings were grade III 37 patients and grade II 2 patients. Patients received an intersphincteric injection of 0.5 ml of a solution containing 30 units of botulinum toxin (BTX). The postoperative data were collected pain score in a visual analog score (VAS), an analgesic used, hospital stay, and complication. Results: The VAS was lower in the BTX group at 12 hours and 24 hours postoperative phase. VAS at 12 hours 4.435 ± 2.149 vs 6.232 ± 2.307 (p < 0.001), VAS at 24 hours 2.205 ± 2.079 vs 3.744 ± 2.361(p = 0.003). The BTX group has a shorter time in defection without pain than the control group (3 vs. two days, p = 0.007). There was no difference in immediate and delay complications between the two groups. Conclusions: Postoperative hemorrhoidectomy needs multimodalities for pain reduction. Botulinum toxin has some benefit in postoperative pain reduction.
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Affiliation(s)
- Siripong Sirikurnpiboon
- Division of Colorectal Surgery, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Paiboon Jivapaisarnpong
- Division of Colorectal Surgery, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
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Gallo G, Di Saverio S, Clerico G, Sturiale A, Manigrasso M, Luc AR, Trompetto M, Sammarco G. Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR). BMC Surg 2020; 20:251. [PMID: 33092570 PMCID: PMC7583301 DOI: 10.1186/s12893-020-00914-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022] Open
Abstract
Background Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). Methods This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. Results In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). Conclusions The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698—Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1
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Affiliation(s)
- G Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy. .,Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy.
| | - S Di Saverio
- Department of General Surgery, University of Insubria, Varese, Italy
| | - G Clerico
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - A Sturiale
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - M Manigrasso
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - A Realis Luc
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - M Trompetto
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - G Sammarco
- Department of Health Sciences, University of Catanzaro, Catanzaro, Italy
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Xia W, MacFater WS, Barazanchi AWH, Sammour T, Hill AG. Risk factors associated with unplanned readmission following excisional haemorrhoidectomy. Colorectal Dis 2020; 22:187-194. [PMID: 31491051 DOI: 10.1111/codi.14852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
AIM Excisional haemorrhoidectomy is the gold standard for management of advanced symptomatic haemorrhoids. Although an effective treatment, it is associated with significant postoperative morbidity with pain, bleeding and a high readmission rate. This study seeks to investigate potential risk factors that may predict unplanned 30-day readmissions following excisional haemorrhoidectomy. METHOD A retrospective cohort review of all haemorrhoidectomies performed at Counties Manukau District Health Board, Auckland, New Zealand, between January 2012 and December 2017 was performed. Baseline demographic data, readmission data and potential variables for readmission were recorded. Univariate and multivariate logistic regression analyses were performed to determine significant variables for readmission within 30 days. RESULTS In total, 485 cases of excisional haemorrhoidectomy were included in the final analysis with 62 (12.8%) unplanned readmissions. The demographics between the no readmission and unplanned readmission groups were similar. Multivariate logistic regression analysis demonstrated that male gender (P = 0.018) and the use of non-diathermy devices (P = 0.017) were significant risk factors for readmission. Initial dispensing of opioid analgesia did not decrease the risk of readmission. CONCLUSION This study suggests that male gender and surgical technique are associated with increased risk of readmission.
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Affiliation(s)
- W Xia
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - W S MacFater
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - A W H Barazanchi
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - T Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - A G Hill
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
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Langenbach MR, Seidel D. Tamponade dressings versus no tamponade after hemorrhoidectomy: study protocol for a randomized controlled trial. Trials 2019; 20:188. [PMID: 30940201 PMCID: PMC6444871 DOI: 10.1186/s13063-019-3280-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Symptomatic hemorrhoids are one of the most common anorectal disorders. Many surgeons use tamponades after open hemorrhoidectomy to manage postoperative bleeding. The question of whether a tamponade is necessary and beneficial after hemorrhoidectomy has not yet been conclusively answered. A previously conducted single-center pilot trial included 100 patients after Milligan–Morgan hemorrhoidectomy. The data indicated that insertion of an anal tamponade after hemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. The findings of this pilot trial are now to be verified by means of a multicenter randomized clinical study called NoTamp. Methods We plan to include 953 patients after Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study. The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to postoperative bleeding, and that the patients report less pain. Primary endpoints of the trial are the maximum postoperative pain within 48 h and the incidence of severe postoperative bleeding that requires surgical revision within 7 days after the surgical procedure. Secondary endpoints of the study are the use of analgesics in the postoperative course, the lowest hemoglobin documented within 7 days, quality of life and patient satisfaction. Safety analysis includes all adverse and serious adverse events in relation to the study treatment. Further information can be found in the registration at the German Registry of Clinical Studies (DRKS00011590) and on the study webpage (https://notamp.de/en-GB/trial/main/setLocale/en_GB/). The study is financed by the HELIOS research funding. Discussion The study received full ethics committee approval. The first patient was enrolled on 3 May 2017. This trial will finally answer the question whether the insertion of a tamponade after open hemorrhoidectomy is necessary and beneficial. Trial registration German Clinical Trials Register (Deutsches Register Klinischer Studien (DRKS), DRKS00011590. Registered on 12 April 2017.
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Affiliation(s)
- Mike Ralf Langenbach
- Klinik für Allgemein-/Viszeralchirurgie und Koloproktologie, Helios St. Elisabeth Klinik, Josefstr. 3, 46045, Oberhausen, Germany
| | - Dörthe Seidel
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimerstraße 200 Haus 38, 51109, Köln, Germany.
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Abstract
PURPOSE Delayed post-hemorrhoidectomy bleeding (DPHB) is a rare but serious complication. We investigated the incidence and risk factors of DPHB in patients undergoing hemorrhoidectomy using the LigaSure device or the Ferguson procedure. METHODS This retrospective study included 382 consecutive patients with symptomatic grades II to IV hemorrhoids who received either LigaSure (184 patients) or Ferguson (198 patients) hemorrhoidectomy procedures. Thirty-two patients who experienced DPHB after discharge were followed up. RESULTS Significantly fewer Ferguson group patients had DPHB compared to the LigaSure group (5.1% vs. 11.9%; P = 0.015). In the overall population, the risk of DPHB was higher in (1) males compared to that of females (OR = 3.39; 95% CI 1.50-7.69, P = 0.003); (2) in the LigaSure group compared to the Ferguson group (OR = 2.77; 95% CI 1.23-6.24, P = 0.01); and (3) in patients with constipation (OR = 6.59; 95% CI 2.73-15.89, P < 0.0001). Males in the LigaSure group had a significantly higher rate of delayed bleeding than those in the Ferguson group (20% vs. 5.8%, P = 0.004); no significant differences were found in females (4.9% vs. 4.5%, P = 0.878). Subgroup analysis showed that in males, risk of DPHB increased significantly with postoperative constipation (OR = 4.73, 95% CI 1.45-15.43, P = 0.010) and the LigaSure procedure (OR = 3.99, 95% CI 1.37-11.62, P = 0.011). In females, the risk of DPHB was significantly associated with postoperative constipation (OR = 8.80, 95% CI 2.24-34.54, P = 0.002). CONCLUSIONS The LigaSure procedure and constipation are independent risk factors for DPHB in patients undergoing hemorrhoidectomy and can be used as predictors of outcome.
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Affiliation(s)
- Ko-Chao Lee
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301 Taiwan
| | - Chia-Cheng Liu
- Department of Surgery, Pingtung Christian Hospital, Pingtung, Taiwan
| | - Wan-Hsiang Hu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301 Taiwan
| | - Chien-Chang Lu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301 Taiwan
| | - Shung-Eing Lin
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301 Taiwan
| | - Hong-Hwa Chen
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, DAPI Rd. Niaosng Dist, Kaohsiung City, 83301 Taiwan
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Abstract
BACKGROUND Hemorrhoid operations are performed frequently in Germany. After the operation severe complications can occur that require appropriate management. OBJECTIVE Presentation of current complications and suitable therapeutic options. MATERIAL AND METHODS Data including operative procedures and complications that have been collected in an electronic online-based survey of all resident, affiliated and private practice German surgeons during the period from 1 December 2009 to 31 January 2010 are presented. A review of the current literature in a PubMed search is given. RESULTS Stapled hemorrhoidopexy has several benefits during the early postoperative phase in comparison to conventional hemorrhoidectomy; however, patients should be informed about the possibility of postoperative defecation disorders, elevated recurrence and reoperation rates and rare life-threatening complications. CONCLUSION The aim should be to keep risks at a low level by means of prevention, patient selection, careful analysis of indications and relevant expertise. In cases of complications early recognition and direct initiation of adequate treatment are crucial.
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Atallah S, Maharaja GK, Martin-Perez B, Burke JP, Albert MR, Larach SW. Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient? Tech Coloproctol 2016; 20:461-6. [PMID: 27170327 DOI: 10.1007/s10151-016-1481-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/28/2016] [Indexed: 01/01/2023]
Abstract
Background Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation. Methods During a 53-month period (February 2009–July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery. Results During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455–3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study’s 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049). Conclusions These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.
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Li SL, Jing FY, Ma LL, Guo LL, Na F, An SL, Ye Y, Yang JM, Bao M, Kang D, Sun XL, Deng YJ. Myofibrotic malformation vessels: unique angiodysplasia toward the progression of hemorrhoidal disease. Drug Des Devel Ther 2015; 9:4649-56. [PMID: 26316703 PMCID: PMC4541538 DOI: 10.2147/dddt.s90209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45–65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids. Materials and methods A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson’s trichrome, CD34, and smooth muscle actin. Results The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease. Conclusion MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.
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Affiliation(s)
- Sheng-Long Li
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Fang-Yan Jing
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Ma
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Guo
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Feng Na
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Sheng-Li An
- Department of Biostatistics, Southern Medical University, Zengcheng, Guangzhou, People's Republic of China
| | - Yan Ye
- Department of General Surgery, Xintang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Jun-Ming Yang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Ming Bao
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Dong Kang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Xiao-Lan Sun
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Yong-Jian Deng
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
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Picchio M, Greco E, Di Filippo A, Marino G, Stipa F, Spaziani E. Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review. Indian J Surg 2014; 77:1301-7. [PMID: 27011555 DOI: 10.1007/s12262-014-1087-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/23/2014] [Indexed: 12/26/2022] Open
Abstract
Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.
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Affiliation(s)
- Marcello Picchio
- Department of Surgery, Civil Hospital "P. Colombo", Via Orti Ginnetti 7, 00049 Velletri Rome, Italy ; Via Giulio Cesare, n. 58, 04100 Latina, Italy
| | - Ettore Greco
- Department of Surgery, Civil Hospital "P. Colombo", Via Orti Ginnetti 7, 00049 Velletri Rome, Italy
| | - Annalisa Di Filippo
- Department of Surgery, Sapienza University of Rome, Polo Pontino Via Firenze, s.n.c., 04019 Terracina Latina, Italy
| | - Giuseppe Marino
- Department of Surgery, Civil Hospital "P. Colombo", Via Orti Ginnetti 7, 00049 Velletri Rome, Italy
| | - Francesco Stipa
- Department of Surgery, Hospital "S. Giovanni-Addolorata", Via dell'Amba Aradam 9, 00184 Rome, Italy
| | - Erasmo Spaziani
- Department of Surgery, Sapienza University of Rome, Polo Pontino Via Firenze, s.n.c., 04019 Terracina Latina, Italy
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Langenbach MR, Chondros S, Sauerland S. Tamponade dressings may be unnecessary after haemorrhoidectomy: a randomised controlled clinical trial. Int J Colorectal Dis 2014; 29:395-400. [PMID: 24292489 DOI: 10.1007/s00384-013-1800-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Bleeding after haemorrhoidectomy is common. Many surgical textbooks recommend insertion of an anal tampon in order to reduce postoperative bleeding. This practice, however, is bothersome and probably painful for patients. The effect of using a tamponade has not been validated in randomised controlled trials. METHODS The study included 100 patients who were scheduled for Milligan-Morgan haemorrhoidectomy. During surgery, patients were randomly assigned to receive or not to receive an anal tampon at the end of the procedure. Data on pain, complications and wound care were collected. The trial was registered (DRKS00003116) and all analyses were by intention-to-treat. RESULTS There were 48 patients in the group with tamponade, and 52 patients were left without tamponade. The trial's primary outcome and maximum pain intensity, averaged 6.1 and 4.2 in the two groups (P = 0.001). In the group with tamponade, a complication was recorded in seven patients (15 %), which was similar to the group without tamponade (21 %). Severe anal bleeding occurred in two and five patients, respectively. Bandage changes were less necessary often in the group treated without tamponade (P = 0.013). Hospital stay was 4 days in both groups. CONCLUSIONS Data indicate that insertion of an anal tampon after haemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. After haemorrhoidectomy, anal tampons should not be used routinely but may be considered when specific indications justify its use.
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Shaikh AR, Dalwani AG, Soomro N. An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad, Pakistan. Pak J Med Sci 2013; 29:122-7. [PMID: 24353522 PMCID: PMC3809167 DOI: 10.12669/pjms.291.2858] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/19/2012] [Accepted: 10/25/2012] [Indexed: 01/16/2023] Open
Abstract
Objective: o compare the outcome of Milligan-Morgan (MMH) and Ferguson (FH) techniques for haemorrhoidectomy with regard to postoperative pain, control of bleeding, early mobilization of patients and wound healing. Methodology: In this prospective, randomized clinical study conducted between January 2005 to December 2008, 213 patients with late 2nd degree; third or fourth degree hemorrhoids were assigned to two groups. One hundred ten patients in group A were operated by an open method and 103 patients in group B were operated by closed method. Results: Age ranged from 22-70 years with mean age of 45.5 years. Peak incidence was between 41-50 years. Out of 213 patients, 170 (79.81%) were male and 43 (20.18%) were females. The mean ± SD operating time was significantly more in group B (31.3±4.8 min) than group A (25.2±5.6). The duration of hospitalization and duration off from work was more in group A than the group B. Wound healing was quicker in group B than the group A. Post operative pain scores were significantly low in the Group A than Group B during first 24 hours and at first bowel movements. Reactionary hemorrhage occurred in 4 (3.63%) patients of group A, no patient in group B developed this complication. Retention of urine was seen in 13 (11.81%) patients in group A and 4 (3.88%) in group B. No patient in group A developed anal stenosis, while 3 (2.91%) patients in group B developed anal stenosis. Wound infection was one (0.9%) in group A and two (1.9%) in group B. Two (3.63%) patients in group A came with recurrent hemorrhoids and in group B, only one (0.97%) patient reported recurrence. Conclusions: The closed technique is more beneficial with respect to postoperative pain, control of bleeding, early mobilization of patients and wound healing.
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Affiliation(s)
- Abdul Razaque Shaikh
- Dr. Abdul Razaque Shaikh, Department of General Surgery, Liaquat University of Medical Health & Sciences Jamshoro, Sindh, Pakistan
| | - Abdul Ghafoor Dalwani
- Dr. Abdul Ghafoor Dalwani, MS, Department of General Surgery, Liaquat University of Medical Health & Sciences Jamshoro, Sindh, Pakistan
| | - Nasarullah Soomro
- Dr. Nasuarullah Soomro, MBBS, Department of General Surgery, Liaquat University of Medical Health & Sciences Jamshoro, Sindh, Pakistan
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Abstract
Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.
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Abstract
AIM This prospective observation study evaluated the incidence of secondary bleeding after proctological surgery without interruption of oral anticoagulant or platelet-inhibitor treatments. METHOD The number of episodes of postoperative bleeding was identified prospectively from the day of surgery to the last follow-up visit in consecutive patients operated on during 2010 in two units dedicated to proctology. RESULTS A total of 2513 procedures were performed in 2314 patients (1379 men), 46 ± 16 years of age. Secondary bleeding occurred after 115 (4.6%) procedures, no later than day 24 after surgery, requiring rehospitalization in 86% of cases and further surgery and/or transfusion in 36%. The highest frequency was noted after surgery for haemorrhoids (haemorrhoidopexy, 7.9%; haemorrhoidectomy, 6.2%) (P = NS and transanal excision of rectal tumours (6.5%). On multivariate analysis, the frequency was significantly increased by clopidogrel (15%) [relative risk (RR) = 10). In patients on oral anticoagulants, bleeding occurred in 23% (RR = 5.8) if the anticoagulants were not interrupted and in 57% (RR = 42) if the anticoagulants were discontinued and replaced with heparin. CONCLUSION During proctological surgery the overall risk of postoperative bleeding is low, but it can occur up to 3 weeks after surgery and is often severe. Maintenance treatment with oral anticoagulants is the most important risk factor, aggravated by a change to heparin. Clopidogrel also significantly increases the bleeding risk.
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Affiliation(s)
- F Pigot
- Hôpital Bagatelle, Service de Proctologie, Talence, France.
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Abstract
Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or office-based procedures. The authors review the anatomy, pathophysiology, presentation, and management of hemorrhoids.
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Affiliation(s)
- Caroline Sanchez
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry–Robert Wood Johnson Medical School, Edison, New Jersey
| | - Bertram T. Chinn
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry–Robert Wood Johnson Medical School, Edison, New Jersey
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Abstract
Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm. Symptomatic hemorrhoidal tissues located above the dentate line are referred to as internal hemorrhoids and produce bleeding and prolapse. Thrombosis in external hemorrhoids results in painful swelling. Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation. Internal hemorrhoids that fail to respond to these measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy, either open or closed. A stapled hemorrhoidopexy treats symptomatic internal hemorrhoids and should be employed with care and only after thorough training of the surgeon because of the risk of rare, severe complications. The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon.
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Affiliation(s)
- Amy Halverson
- Division of Surgical Oncology, Northwestern Medical Faculty Foundation, Chicago, Illinois 60611, USA.
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Yano T, Matsuda Y, Asano M, Kawakami K, Nakai K, Nonaka M, Kimura K, Yoshihara K. The outcome of postoperative hemorrhaging following a hemorrhoidectomy. Surg Today 2009; 39:866-9. [PMID: 19784725 DOI: 10.1007/s00595-009-3971-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 01/16/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative hemorrhage (PH) is rare, but it is widely recognized as a postoperative complication of a hemorrhoidectomy. The assessment of this complication may provide information which can be used to improve the clinical outcome of a patient who has undergone a hemorrhoidectomy. METHODS Between January 2006 and December 2007, a total of 1294 patients with symptomatic hemorrhoids underwent a hemorrhoidectomy at our hospital. The patient records were retrospectively analyzed. RESULTS In this study, 23 patients had suffered from PH and had undergone a second operation (1.7%). The bleeding points were located as follows: 14 anterior,7 right laterally, 8 left laterally, and 2 posteriorly. Of these patients with early hemorrhage, 1 case was at the anterior, 1 was left lateral, and 2 were posterior. A significant correlation was observed between the period and the location of postoperative hemorrhage (P = 0.0023). From one to four piles were excised (1 in 264 patients, 2 in 240 patients, 3 in 702 patients, 4 in 88 patients). A significant correlation was also observed between the number of piles and the occurrence of PH (P = 0.032). CONCLUSIONS At the posterior wall, a late period hemorrhage is less likely to be found than an early period hemorrhage. It was found that the more piles that were excised, the greater the occurrence of PH.
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Affiliation(s)
- Takaaki Yano
- Matsuda Hospital Colo-Proctological Institute, 753 Irino-cho, Nishi-ku, Hamamatsu, Shizuoka 432-8061, Japan
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Ceci F, Picchio M, Palimento D, Calì B, Corelli S, Spaziani E. Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids. Dis Colon Rectum 2008; 51:1107-12. [PMID: 18484135 DOI: 10.1007/s10350-008-9333-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 11/06/2007] [Accepted: 11/17/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years. METHODS Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy. RESULTS A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent. CONCLUSIONS Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.
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Affiliation(s)
- Francesco Ceci
- Department of Surgery, Civil Hospital A. Fiorini, Terracina, Latina, Italy
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Hourigan J, Luchtefeld M. Excisional Hemorrhoidectomy. Seminars in Colon and Rectal Surgery 2007. [DOI: 10.1053/j.scrs.2007.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Huang WS, Chin CC, Yeh CH, Lin PY, Wang JY. Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study. Int J Colorectal Dis 2007; 22:955-61. [PMID: 17171354 DOI: 10.1007/s00384-006-0244-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2006] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-term and mid-term outcomes of stapled hemorrhoidopexy (SH) were compared with those for Ferguson hemorrhoidectomy (FH) for treating hemorrhoids. MATERIALS AND METHODS Patients with prolapsed hemorrhoids were randomized into two groups treated with SH (N = 300) and FH (N = 296) at Chang Gung Memorial Hospital at Chiayi in Taiwan between January 2002 and December 2004. The outcomes of the procedures were evaluated postoperatively (short-term, i.e., intra-/postoperative conditions, hospital stay, pain intensity scoring, time off work, and procedure-related morbidity) and over a follow-up period of minimum 18 months (mid-term, i.e., relapse of prolapse and/or bleeding, anal stricture, anal sepsis, and the acceptability of the procedures to the patients). RESULTS SH was superior to FH in operative time, intraoperative blood loss, postoperative pain intensity, and return to work. Based on telephone interviews over the follow-up period, most patients who received SH appreciated the procedure better than those with FH. CONCLUSIONS This study confirms that SH generates less postoperative suffering, less time off work, and more complete resolution of primary symptoms associated with hemorrhoids in the mid-term follow-up than FH.
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Affiliation(s)
- Wen-Shih Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Road, Putz, Chiayi, Taiwan.
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Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal Disease: A Comprehensive Review. J Am Coll Surg 2007; 204:102-17. [PMID: 17189119 DOI: 10.1016/j.jamcollsurg.2006.08.022] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 08/24/2006] [Accepted: 08/25/2006] [Indexed: 12/11/2022]
Affiliation(s)
- Orit Kaidar-Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Guenin MO, Rosenthal R, Kern B, Peterli R, von Flüe M, Ackermann C. Ferguson hemorrhoidectomy: long-term results and patient satisfaction after Ferguson's hemorrhoidectomy. Dis Colon Rectum 2005; 48:1523-7. [PMID: 15937612 DOI: 10.1007/s10350-005-0084-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Perioperative morbidity and long-term results after hemorrhoidectomy (Ferguson's technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy. METHODS All records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients. RESULTS Five-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22-96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1-7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases. CONCLUSION Ferguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.
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