Risk Factors for Readmission in Excisional Hemorrhoidectomy at a Tertiary Teaching Center

INTRODUCTION

Unplanned readmission is often seen after excisional hemorrhoidectomy. This study aims to explore associations between patient and operative factors, and readmission rates in excisional hemorrhoidectomy.

METHODS

We performed a retrospective analysis of all excisional hemorrhoidectomies performed in Capital and Coast District Health Board for an 8-year period from January 1, 2012, to December 31, 2020. The primary outcome measure was 30-day readmissions post hemorrhoidectomy. Univariate and multivariable logistic regression analyses were performed to identify risk factors to readmisson. A decision tree model was designed to further look at the interactions between risk factors.

RESULTS

There were a total 370 patients undergoing 389 excisional hemorrhoidectomies over the study period. There were 47 (12.1%) readmissions. The commonest reasons for readmission were pain (48.9%) and bleeding (38%). 17% of readmitted patients required operative intervention. Readmission was associated with the use of advanced energy devices (OR 2.21; P = 0.027). Trainees were more likely to use advance energy devices than consultants (51% versus 38%, P = 0.010). Consultants were involved in more procedures requiring a removal of 3 pedicles or more than trainees (43% versus 30%, P = 0.010). A decision tree model predicts readmission based on primary operator experience, age, advanced energy device use, and patient ethnicity.

CONCLUSIONS

Two risk models are presented showing the complex relationship between the factors associated with readmission after hemorrhoidectomy. Advanced energy device use was associated with an increased risk of readmission after hemorrhoidectomy in our population. Future work could involve targeted interventions to patients at increased risk of readmission such as preprocedural and postprocedural information, early interval follow-up and targeted analgesia regimes.

Transanal open haemorrhoidopexy: a well-tolerated, minimally invasive surgical method for haemorrhoids grade II to IV

BACKGROUND

To determine 1-year postoperative recurrence rates, postoperative pain and complication rates of transanal open haemorrhoidopexy applied also in grade IV haemorrhoids.

METHODS

Single-centre retrospective observational study without control group. The primary outcome was recurrence rate after 1 year postoperatively. Secondary outcomes were length of postoperative pain, use of opiates and postoperative complications. The recurrence rate was assessed with the Sodergren haemorrhoid symptom severity score questionnaire. For information on the early postoperative period, a retrospective chart review based on the routine 3-month clinical follow-up was done.

RESULTS

135 consecutive patients with haemorrhoids Goligher grades II-IV were operated with transanal open haemorrhoidopexy. 88 patients (65%) consented to participate in the study when approached later via mail. 23% of patients had haemorrhoids Goligher grade IV. 15 patients (17%) needed a second transanal open haemorrhoidopexy for residual haemorrhoidal prolapse. The recurrence rate of prolapsing haemorrhoids was 15% (13 patients) 1 year postoperatively. 21% of patients reported no postoperative pain, 54% described pain for a duration of up to 1 week and 22% for up to 2 weeks. Two patients reported a longer duration of pain of 3 and 4 weeks, respectively. No complications grade Clavien-Dindo III or higher were detected.

CONCLUSION

The results of our study indicate that transanal open haemorrhoidopexy has a recurrence rate comparable to traditional haemorrhoidectomy including grade IV haemorrhoids and is associated with less pain and tissue damage. A randomized controlled trial may provide further support for the routine application of this method, but may pose challenges.

Liposomal bupivacaine versus conventional anesthetic or placebo for hemorrhoidectomy: a systematic review and meta-analysis

BACKGROUND

Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia. Studies evaluating the efficacy of the LB against an active comparator (bupivacaine or placebo) on acute postoperative pain control in hemorrhoidectomy procedures are few and heterogeneous. Therefore, we performed a systematic review and meta-analysis comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients.

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials investigating the use of LB after haemorrhoidectomy. We searched the literature published from the time of inception of the datasets to August 19, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus.

RESULTS

A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included. The overall mean age was 45.84 years (SD ± 11.43), and there was a male predominance (53.55% male). In total 194 patients (52.2%) received LB and 144 (47.8%) received either bupivacaine or placebo. Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002). Compared to the bupivacaine/placebo group, the time to first use of opioids in the LB group was significantly longer at LB 199 mg (11 h vs. 9 h), LB 266 mg (19 h vs. 9 h), and LB 300 mg (19 h vs. 8 h) (p < 0.05). Moreover, compared to the bupivacaine/epinephrine group, it was significantly lower in the LB 266 mg group (3.7 vs. 10.2 mg) and at LB 300 mg (13 vs. 33 mg) (p < 0.05). Finally, regarding adverse effects, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16).

CONCLUSIONS

Comparing LB to conventional anesthetic/placebo anesthetic for hemorrhoidectomy, we found a statistically significant reduction in pain through 72 h, decreased opioid requirements, and delayed time to first opioid use. Moreover, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups.

Moxibustion for Managing Postoperative Urinary Retention After Hemorrhoidectomy and Anorectal Surgeries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Common surgical procedures for conditions affecting the anus and rectum such as hemorrhoidectomy are associated with high risks of postoperative urinary retention (POUR). Little is known about the efficacy of moxibustion in managing POUR after such surgical procedures. This systematic review and meta-analysis aimed to review the related literature and synthesize data on the effectiveness of moxibustion in managing POUR after common anorectal surgeries.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, EMBASE, CENTRAL, Chinese National Knowledge Infrastructure (CNKI), VIP information, and Wanfang databases were searched to October 1, 2021 using the keywords urinary retention, moxibustion, and moxa. Randomized controlled trials (RCTs) investigating patients who had developed POUR after hemorrhoidectomy or other anorectal surgeries were eligible for inclusion. Patients receiving moxibustion formed the intervention group and the control group received usual care alone. Primary outcomes were markedly effective rate, defined as spontaneous voiding with complete symptom relief within 30 to 60 minutes after treatment; and total effective rate (ie, markedly effective rate plus effective rate, defined as spontaneous voiding with partial relief of symptoms within 60 minutes to 4 hours after treatment). Secondary outcome was time to first urination after treatment.

FINDINGS

Thirty-four RCTs met the eligibility criteria. Pooled analysis revealed that the markedly effective rate was significantly higher in the moxibustion group than that in the control group (pooled RR = 2.53, 95% CI = 2.17-2.95), and the total effective rate in the moxibustion group was also higher than that in the control group (pooled RR = 5.02, 95% CI = 4.01-6.28). The intervention group had significantly shorter times to first urination than controls (pooled effect = -2.81, 95% CI = -2.06 to -3.56).

CONCLUSIONS

Moxibustion appears superior to usual care in relieving POUR after common anorectal surgeries. Future studies are still warranted to confirm these findings.

Safety and Efficacy of Oral Nalbuphine on Postoperative Pain in Hemorrhoidectomy Patients: A Randomized, Double-blind, Placebo-controlled, Pivotal Trial

OBJECTIVES

Severe postoperative pain requiring opioid treatment has been reported in 20% to 40% of hemorrhoidectomy patients. Compared with morphine, nalbuphine offers better hemodynamic stability, a lower risk of respiratory depression, and a lower potential for addiction. Nalbuphine was developed from the intravenous form into an oral form (PHN131) to alleviate moderate-to-severe pain.

MATERIALS AND METHODS

A randomized, double-blind, placebo-controlled, multiple-dose, parallel-design trial was conducted to evaluate the safety and efficacy of PHN131 in patients undergoing hemorrhoidectomy. Eligible patients were randomly assigned to receive either PHN131 soft capsules containing nalbuphine hydrochloride 60 mg or placebo capsules. Intramuscular diclofenac was the rescue analgesic. Pain was measured by the area under the curve of mean Visual Analog Scale pain intensity scores.

RESULTS

Visual Analog Scale results in patients receiving PHN131 were significantly lower than placebo group scores through 48 hours postoperatively (149.2±75.52 vs. 179.6±65.97; P =0.0301). According to Brief Pain Inventory Short-Form scores, the impact of pain on quality of life was significantly smaller for the PHN131 group than for the placebo group. Time to the first use of diclofenac postoperatively was significantly longer in the PHN131 group than in the placebo group. The cumulative dosage of diclofenac in the PHN131 group was only around half of that in the placebo group ( P <0.0001). Drug-related adverse events were mild-to-moderate and resolved by the treatment end. No drug-related severe adverse events were observed.

DISCUSSION

Our findings demonstrate that PHN131 is effective and well-tolerated in the treatment of moderate-to-severe post hemorrhoidectomy pain and may provide another option for patients to control their pain.

Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study

BACKGROUND

Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids.

OBJECTIVE

This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease.

DESIGN

Multicenter retrospective study.

SETTINGS

Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study.

PATIENTS

Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period.

MAIN OUTCOME MEASURES

The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up.

RESULTS

Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device.

LIMITATIONS

The retrospective design and the self-reported nature of data from different centers.

CONCLUSIONS

Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).

Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial

PURPOSE

Pain and reduced quality of life (QoL) are major subjects of interest after surgery for hemorrhoids. The aim of this study was to find predictive parameters for postoperative pain and QoL after hemorrhoidectomy.

METHODS

This is a follow-up analysis of data derived from a multicenter randomized controlled trial including 770 patients, which examines the usefulness of tamponade after hemorrhoidectomy. Different pre-, intra-, and postoperative parameters were correlated with pain level assessed by NRS and QoL by the EuroQuol.

RESULTS

At univariate analysis, relevant (NRS > 5/10 pts.) early pain within 48 h after surgery was associated with young age (≤ 40 years, p = 0.0072), use of a tamponade (p < 0.0001), relevant preoperative pain (p = 0.0017), pudendal block (p < 0.0001), and duration of surgery (p = 0.0149). At multivariate analysis, not using a pudendal block (OR 2.64), younger age (OR 1.55), use of a tamponade (OR 1.70), and relevant preoperative pain (OR 1.56) were significantly associated with relevant early postoperative pain. Relevant pain on day 7 was significantly associated only with relevant early pain (OR 3.13, p < 0.001). QoL overall remained at the same level. However, n = 229 (33%) patients presented an improvement of QoL and n = 245 (36%) an aggravation. Improvement was associated with a reduction of pain levels after surgery (p < 0.0001) and analgesia with opioids (p < 0.0001).

CONCLUSION

Early relevant pain affects younger patients but can be prevented by avoiding tamponades and using a pudendal block. Relevant pain after 1 week is associated only with early pain. Relief in preexisting pain and opioids improve QoL.

TRIAL REGISTRATION

DRKS00011590 12 April 2017.

The Impact of Antithrombotic Medications on Postoperative Bleeding Events Following Hemorrhoidectomy

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.

Bleeding After Hemorrhoidectomy in Patients on Anticoagulation Medications

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.

Colonization of multidrug-resistant Gram-negative bacteria increases risk of surgical site infection after hemorrhoidectomy: a cross-sectional study of two centers in southern China

PURPOSE

The present study aims to determine the rectoanal colonization rate and risk factors for the colonization of present multidrug-resistant bacteria (MDRBs). In addition, the relationship between MDRB colonization and surgical site infection (SSI) following hemorrhoidectomy was explored.

METHODS

A cross-sectional study was conducted in the Department of Colorectal Surgery of two hospitals. Patients with hemorrhoid disease, who underwent hemorrhoidectomy, were included. The pre-surgical screening of multidrug-resistant Gram-negative bacteria (MDR-GNB) colonization was performed using rectal swabs on the day of admission. Then, the MDRB colonization rate was determined through the rectal swab. Logistic regression models were established to determine the risk factors for MDRB colonization and SSI after hemorrhoidectomy. A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 432 patients met the inclusion criteria, and the MDRB colonization prevalence was 21.06% (91/432). The independent risk factors for MDRB colonization were as follows: patients who received ≥ 2 categories of antibiotic treatment within 3 months (odds ratio (OR): 3.714, 95% confidence interval (CI): 1.436-9.605, p = 0.007), patients with inflammatory bowel disease (IBD; OR: 6.746, 95% CI: 2.361-19.608, p < 0.001), and patients with high serum uric acid (OR: 1.006, 95% CI: 1.001-1.010, p = 0.017). Furthermore, 41.57% (37/89) of MDRB carriers and 1.81% (6/332) of non-carriers developed SSIs, with a total incidence of 10.21% (43/421). Based on the multivariable model, the rectoanal colonization of MDRBs (OR: 32.087, 95% CI: 12.052-85.424, p < 0.001) and hemoglobin < 100 g/L (OR: 4.130, 95% CI: 1.556-10.960, p = 0.004) were independently associated with SSI after hemorrhoidectomy.

CONCLUSION

The rectoanal colonization rate of MDRBs in hemorrhoid patients is high, and this was identified as an independent risk factor for SSI after hemorrhoidectomy.

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.

Laser technology in proctological diseases: is it really the wave of the future?

Different types of lasers have been applied for various proctological conditions. We discuss about published articles regarding the application of lasers, with concern about evidence-based use of these techniques and technologies. We performed a literature search about laser treatments for proctological conditions. 55 studies were included for the final revision. Meta-analysis of data was not performed because of heterogeneity of study designs and outcome measures. A scoping review was performed. Laser treatments for hemorrhoids require a shorter operative time and show less postoperative pain and bleeding compared to conventional hemorrhoidectomy, but are more expensive. Studies are heterogeneous in design, endpoints, postoperative assessment, length of follow-up and outcome measures. Only 3 RCTs are available and only three studies evaluate long-term outcomes. FiLaC (fistula laser closure) was initially described in 2011 for the treatment of anal fistula. In the published studies the reported healing rates vary between 20 and 82%, and the ideal indication is yet to be defined. Studies with long-term follow-up are lacking. SiLaT (sinus laser treatment) applied the technology used for FiLaC to the treatment of pilonidal sinus disease. This technique had less perioperative pain and shorter hospital stay, but a lower primary healing rate when compared to traditional techniques. Available data is very limited, and no randomized trials are published to date. Laser assisted techniques are a viable, minimally invasive, but expensive option for the treatment of several proctological conditions. Further researches are needed to assess if patients could benefit of their use, and for what indication.

French multicentre prospective evaluation of radiofrequency ablation in the management of haemorrhoidal disease

PURPOSE

The aim of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) in the management of haemorrhoidal disease with 1 year's follow-up.

METHOD

This prospective multicentre study assessed RFA (Rafaelo©) in outpatients with grade II-III haemorrhoids. RFA was performed in the operating room under locoregional or general anaesthesia. Primary endpoint was the evolution of a quality-of-life score adapted to the haemorrhoid pathology (HEMO-FISS-QoL) 3 months after surgery. Secondary endpoints were evolution of symptoms (prolapsus, bleeding, pain, itching, anal discomfort), complications, postoperative pain and medical leave.

RESULTS

A total of 129 patients (69% men, median age 49 years) were operated on in 16 French centres. Median HEMO-FISS-QoL score dropped significantly from 17.4/100 to 0/100 (p < 0.0001) at 3 months. At 3 months, the rate of patients reporting bleeding (21% vs. 84%, p < 0.001), prolapse (34% vs. 91.3%, p < 0.001) and anal discomfort (0/10 vs. 5/10, p < 0.0001) decreased significantly. Median medical leave was 4 days [1-14]. Postoperative pain was 4/10, 1/10, 0/10 and 0/10 at weeks 1, 2, 3 and 4. Seven patients (5.4%) were reoperated on by haemorrhoidectomy for relapse, and three for complications. Reported complications were haemorrhage (3), dysuria (3), abscess (2), anal fissure (1), external haemorrhoidal thrombosis (10), pain requiring morphine (11). Degree of satisfaction was high (+ 5 at 3 months on a - 5/+ 5 scale).

CONCLUSION

RFA is associated with an improvement in quality of life and symptoms with a good safety profile. As expected for minimally invasive surgery, postoperative pain is minor with short medical leave.

CLINICAL TRIAL REGISTRATION AND DATE

Clinical trial NCT04229784 (18/01/2020).

A rare presentation of large bowel obstruction post haemorrhoidectomy: a case report

BACKGROUND

Hemorrhoidal disease is a common anorectal pathology. Complications post hemorrhoidectomy are rare. Postoperative complications following hemorrhoidectomy include bleeding (2%), infection (0.4-8%), urinary retention (15%), and constipation (15-30%).

CASE PRESENTATION

A 40-year-old of Asian background female presented to a tertiary colorectal service with large bowel obstruction post hemorrhoidectomy. This is the first case in the surgical literature describing large bowel obstruction secondary to extrinsic compression from urinary retention following hemorrhoidectomy. The patient developed urinary retention and obstructed defecation in setting of inadequate analgesia post hemorrhoidectomy. The patient required indwelling catheter insertion and aggressive constipation management to resolve symptoms. Histopathology from the hemorrhoidectomy did not reveal a malignancy.

CONCLUSION

Anesthetic choice and postoperative analgesia are important factors to avoid the development of complications. A missed malignancy diagnosis must always be excluded with patients presenting post hemorroidectomy with bowel obstruction.

Effect of sacral erector spinae plane block on post-hemorrhoidectomy pain: A randomized controlled trial

BACKGROUND

Hemorrhoidectomy is a common surgical procedure associated with significant postoperative pain. The conventional analgesic methods used for hemorrhoidectomy often have adverse effects and may not provide adequate pain relief. The sacral erector spinae plane block (ESPB) is a newly introduced technique that has shown promise in various surgical procedures. This prospective, randomized, controlled trial aimed to evaluate the analgesic effects of sacral ESPB following hemorrhoidectomy.

METHODS

Seventy patients undergoing hemorrhoidectomy were divided into 2 groups: the control group and the sacral ESPB group. Bilateral sacral ESPB was performed in the sacral ESPB group, whereas no intervention was performed in the control group. The numeric rating scale at rest and during the active period (mobilizing) was used as the primary outcome measure. Secondary outcome measures were the cumulative doses of tramadol, the number of patients who required rescue analgesia postoperatively, and quality of recovery-15 Turkish version patient recovery quality.

RESULTS

The sacral ESPB group had significantly low numeric rating scale scores at various time points (P < .05). More patients in the control group needed rescue analgesia during the postoperative period (P < .001). The dosages of tramadol consumption after the first 24 hours postoperatively were significantly lower in the sacral ESPB group compared with the control group (P < .001). Furthermore, quality of recovery-15 Turkish version scores were high in the sacral ESPB group (P < .001).

CONCLUSION

The results suggest that sacral ESPB is an effective method for post-hemorrhoidectomy pain management, reducing the need for additional analgesics and improving patient recovery.

Milligan-Morgan hemorrhoidectomy combined with non-doppler hemorrhoidal artery ligation for the treatment of grade III/IV hemorrhoids: a single centre retrospective study

BACKGROUND

Milligan-Morgan hemorrhoidectomy (MMH) is the most widely used surgical procedure because of its precise curative effect, but it has the disadvantages such as obvious postoperative pain and bleeding. To retrospectively evaluate the efficacy and safety of MMH combined with non-Doppler hemorrhoidal artery ligation (MMH + ND-HAL) for the treatment of grade III/IV hemorrhoids.

METHODS

We conducted a retrospective analysis of 115 patients with grade III/IV hemorrhoids, 53 patients had received MMH + ND-HAL, and the remaining 62 patients received MMH. We collected and compared demographic and clinical characteristics of both groups, including intraoperative blood loss, postoperative visual analog scale (VAS) for pain, analgesic consumption, postoperative bleeding, perianal incision edema, urinary retention, anal stenosis, anal incontinence incidence, recurrence rate (prolapse or bleeding), and patient satisfaction.

RESULTS

The VAS pain score of the first postoperative defecation and at the postoperative 12 h, 1 day, 2 days, 3 days, and 7 days, as well as the total analgesic consumption within 7 days, for the MMH + ND-HAL group were lower than those for the MMH group (P < 0.05). The intraoperative blood loss, the incidence of postoperative bleeding, perianal incision edema, and urinary retention in the MMH + ND-HAL group was lower than that in the MMH group (P < 0.05). No anal stenosis or anal incontinence occurred in either group. At follow-up by telephone or outpatient 12 months after surgery, the recurrence rate (prolapse or bleeding) was lower in the MMH + ND-HAL group than in the MMH group (P < 0.05), and satisfaction was higher in the MMH + ND-HAL group than in the MMH group (P < 0.05).

CONCLUSIONS

MMH + ND-HAL was a satisfactory surgical modality for treating III/IV hemorrhoids.

Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend

PURPOSE

Hemorrhoidal disease (HD) is a common condition, and several surgical techniques have been proposed to date without being able to achieve definitive consensus on their use and indications. Laser hemorrhoidoplasty (LHP) is a minimally invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser limiting the postoperative discomfort and pain. The aim of the current study was to evaluate the postoperative outcomes of HD patients undergoing LHP vs conventional Milligan-Morgan hemorrhoidectomy (MM).

METHOD

Postoperative pain, wound care management, symptoms' resolution, patients' quality of life, and length of return to daily activity of grade III symptomatic HD patients undergoing LHP vs MM were retrospectively evaluated. The patients were followed-up for recurrence of prolapsed hemorrhoid or symptoms.

RESULT

From January 2018 to December 2019, 93 patients received conventional Milligan Morgan as control group and 81 patients received laser hemorrhoidoplasty treatment using a 1470-nm diode laser. No significant intraoperative complications occurred in both groups. Laser hemorrhoidoplasty patients experienced lower postoperative pain score (p < 0.0001) and smoother wound management. After 25 ± 8 months follow-up, the recurrence of symptoms occurred in 8.1% after Milligan-Morgan and 21.6% after laser hemorrhoidoplasty (p < 0.05) with a similar Rorvik score (7.8 ± 2.6 in LHP group vs 7.6 ± 1.9 in MM group, p = 0.12).

CONCLUSION

LHP demonstrated high efficacy in selected HD patients guaranteeing lower postoperative pain, easier wound care, higher rate of symptoms resolution, and greater patient appreciation compared to MM, even though it had a higher recurrence rate. Larger comparative studies are needed to address this issue.

The efficacy of topical sucralfate in improving pain and wound healing after haemorrhoidectomy procedure: A systematic review, meta-analysis, and meta-regression of randomised clinical trials

Pain and wound after haemorrhoidectomy constantly bothered the patient's convenience. Recurrently, topical sucralfate is used to treat excoriations and burns. It is considered to enhance epidermal growth and tissue granulation, thus, alleviating patients' problems. This study evaluated topical sucralfate's feasibility, safety, and superiority after haemorrhoidectomy. We searched randomised controlled trial (RCT) studies in PubMed, Google Scholar, Europe PMC, and ClinicalTrials.gov until March 29th, 2022. We investigated the influence of topical sucralfate on pain score postoperatively (24 hours, 7 days, and 14 days), pethidine usage, diclofenac usage, and wound healing rate compared to placebo. This study was conducted following the PRISMA guidelines. This study sorted the final six studies with 439 patients underwent haemorrhoidectomy. Topical sucralfate demonstrated significant outcomes on VAS 24 hours post-operative [Std. Mean Difference -1.00 (95% CI -1.70, -0.31), P = .005], VAS 7 days post-operative [Std. Mean Difference -2.29 (95% CI -3.34, -1.25), P < .0001], VAS 14 days post-operative [Std. Mean Difference -1.88 (95% CI -2.74, -1.01), P < .0001], pethidine usage within 24 hours post-operative [Std. Mean Difference -0.62 (95% CI -0.96, -0.27), P = .0004], diclofenac usage 7 days post-operative [Std. Mean Difference -1.76 (95% CI -2.61, -0.92), P < .0001], diclofenac usage 14 days post-operative [Std. Mean Difference -1.64 (95% CI -2.38, -0.91), P < .0001], and wound healing rate at 28-day post-operative [RR 1.45 (95% CI 1.25-1.68), P < .00001]. Topical sucralfate alleviated pain, improved wound healing, and minimised the usage of pethidine and diclofenac compared to placebo.

Comparing the efficacy and safety of different analgesic strategies after open hemorrhoidectomy: a systematic review and network meta-analysis

PURPOSE

To evaluate the clinical efficacy and safety of different analgesic interventions in the treatment of pain after open hemorrhoidectomy by systematic review and network meta-analysis.

METHODS

Randomized controlled trials that met the inclusion criteria in PubMed, Cochrane Library, Embase, Web of Science, Scopus, CNKI, WANFANG DATA, and VIP were searched from the date of database construction to June 28, 2022.

RESULTS

Among the 13 randomized controlled trials (RCTs), 731 patients were included in the network meta-analysis. Most interventions are more effective than placebo in relieving postoperative pain. 24 h postoperative Visual Analogue Scale (VAS): glyceryl trinitrate (GTN) (mean difference (MD) - 4.20, 95% CI - 5.35, - 3.05), diltiazem (MD - 1.97, 95% CI - 2.44, - 1.51), botulinum toxin (BT) (MD - 1.50, 95% CI - 2.25, - 0.75), sucralfate (MD - 1.01, 95% CI - 1.53, - 0.49), and electroacupuncture (EA) (MD - 0.45, 95% CI - 0.87, - 0.04). 48 h postoperative VAS: diltiazem (MD - 2.45, 95% CI - 2.74, - 2.15), BT (MD - 2.18, 95% CI - 2.52, - 1.84), and sucralfate (MD - 1.41, 95% CI - 1.85, - 0.97). 7 d postoperative VAS: diltiazem (MD - 2.49, 95% CI - 3.20, - 1.78) and sucralfate (MD - 1.42, 95% CI - 2.00, - 0.85). The first postoperative defecation VAS: EA (MD - 0.70, 95% CI - 0.95, - 0.46). There are few data on intervention safety, and additional high-quality RCTs are expected to study this topic in the future.

CONCLUSION

Diltiazem ointment may be the most effective medication for pain relief following open hemorrhoidectomy, and it can dramatically reduce pain within one week of surgery. The second and third recommended medications are BT and sucralfate ointment. GTN has a significant advantage in alleviating pain 24 h after open hemorrhoidectomy, but whether it causes headache is debatable; thus, it should be used with caution. EA's analgesic efficacy is still unknown. There was limited evidence on the safety of the intervention in this study, and it was simply presented statistically.

Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis

Laser hemorrhoidoplasty (LHP) is known as a new minimally invasive and painless procedure for symptomatic hemorrhoids. However, Milligan-Morgan (MM) may offer the best result of long-term cure rates. In this study, we aim to compare the efficacy between LHP and MM for hemorrhoidal disease treatment. Using specific keywords, we comprehensively go through the potential articles on PubMed, Europe PMC, and Google Scholar sources until April 19, 2022. All published studies on LHP and MM hemorrhoidectomy were collected. Statistical analysis was done by using Review Manager 5.4 software. Twelve studies with a total of 1756 patients with hemorrhoid grades II-IV were included for the analysis. Our pooled analysis revealed that LHP was associated with shorter operative time (p < 0.00001), shorter length of hospital stay (p = 0.0005), lower risk of urinary retention (p = 0.005) and anal stenosis (p = 0.0004), and lower VAS 24-h post-operative (p < 0.00001) when compared with MM. However, LHP and MM did not differ in terms of recurrence rate (p = 0.70). LHP was superior to MM procedure in terms of shortening the recovery time and minimizing post-operative complications for patients with hemorrhoidal disease.

Comparison of the outcomes of hemorrhoidectomy and PPH in the treatment of grades III and IV hemorrhoids

ABSTRACT

To investigate the clinical effect and outcome of traditional hemorrhoidectomy and procedures for prolapse and hemorrhoid (PPH) for the treatment of grades III and IV hemorrhoids.We retrospectively reviewed 1003 grades III and IV hemorrhoid patients who presented to our hospital. A total of 585 patients underwent PPH, and 418 patients underwent hemorrhoidectomy. The outcomes were 1-year recurrence, postoperative complications, surgery-related complications, and indicators.No significant difference between the 2 treatment groups regarding patient demographics. All patients underwent more than 12months of postoperative follow-up. No significant difference between the 2 treatment groups in 1-year recurrence. PPH can markedly improve anal pain, postoperative bleeding, difficult urination, and postoperative resting anal pressure. The operative blood loss, operative time, wound healing time, and wound infection rates were decreased significantly in the PPH group compared with the traditional hemorrhoidectomy group.Our data suggest that PPH is useful and safe for grades III and IV hemorrhoids. It can reduce postoperative and surgery-related complications. However, this was a single-hospital retrospective study. Therefore, well-designed, multicenter, randomized controlled trials are needed to evaluate the value of PPH for grades III and IV hemorrhoids.

OUP accepted manuscript

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

OUP accepted manuscript

Background

The aim of this study was to compare a modified ligation procedure versus stapled haemorrhoidectomy (SH) in patients with symptomatic haemorrhoids.

Methods

This randomized trial included patients with symptomatic haemorrhoids treated in Shanghai from May 2018 to September 2021. Eligible patients were randomly 1:1 assigned the modified ligation procedure for prolapsed haemorrhoids (MLPPH) and SH groups. The primary outcome was the assessment of efficacy at 6 months after the intervention. The operating time, incidence of complications, clinical effectiveness (pain, Wexner incontinence, haemorrhoid symptom severity (HSS) scores, and 6-month cure rate) were collected, and quality-adjusted life years (QALYs) were adopted as indicator for the cost-effectiveness analysis (CEA).

Results

Out of 187 patients screened, 133 patients were randomized (67 for MLPPH and 66 for SH). One patient in the MLPPH group was excluded, and two patients were lost to follow-up. The mean operating time was longer in MLPPH than in SH (57.42 min versus 30.68 min; P < 0.001). The median pain score was higher in SH than in MLPPH at postoperative day 3 (P = 0.018), day 7(P = 0.013), and day 14 (P = 0.003). The median Wexner incontinence score was higher in SH than in MLPPH at postoperative month 1 (P = 0.036) and month 3 (P = 0.035), but was similar in the two groups at month 6. In addition, the median HSS score was lower in MLPPH than in SH 6 months after surgery (P = 0.003). The 6-month cure rate was higher in MLPPH than in SH (P = 0.003). CEA showed lower mean costs in MLPPH than in SH (EUR 1080.24 versus EUR 1657.97; P < 0.001) but there was no significant difference in effectiveness (P = 0.181). However, MLPPH was cost-effective (incremental cost-effectiveness ratio, −120 656.19 EUR/QALYs).

Conclusion

MLPPH was documented as a longer but cost-effective procedure, it provided lower short-term pain, and Wexner and HSS scores.

Registration number: Chinese Clinical Trial Registry ChiCTR1800015928 (http://www.chictr.org.cn/searchproj.aspx).

Pressure dressings versus nonpressure dressings after hemorrhoidectomy: study protocol for a randomized controlled trial

BACKGROUND

Pressure dressings have been used after open hemorrhoidectomy to protect surgical wounds and manage postoperative bleeding for many years. However, pressure dressings may increase the incidence of postoperative complications, such as urinary retention, medical adhesive-related skin injury, and pain. A previous controlled trial included 67 patients who underwent Milligan-Morgan hemorrhoidectomy. The data indicated that the use of a nonpressure dressing after hemorrhoidectomy reduces the incidence of urinary retention and catheterization. However, the incidence of severe postoperative bleeding and other postoperative complications was not assessed. There is no consensus on whether it is necessary and beneficial to use a nonpressure dressing after hemorrhoidectomy. The results of this randomized clinical study will help answer this question.

METHODS

In this study, we plan to include 186 patients who have undergone modified Milligan-Morgan hemorrhoidectomy, which only sutured external hemorrhoids to reduce the risk of bleeding. The purpose is to determine whether the use of nonpressure dressings after open hemorrhoidectomy is inferior to the use of pressure dressings in terms of severe postoperative bleeding and postoperative complications. The primary endpoints of the trial are the incidence of urinary retention within 24 h after surgery and the incidence of severe postoperative bleeding 1 h after dressing removal, which requires revision surgery within 24 h after the surgery. The secondary endpoints of the study are the pain score, anal distension score, postoperative use of analgesics, and incidence of medical adhesive-related skin injury, all of which will be assessed before removing the dressings. The length of hospitalization in days and hospitalization expenses will be recorded. Safety will be assessed with consideration of all adverse and severe adverse events related to the study treatment.

DISCUSSION

The study received full ethics committee approval. The first patient was enrolled on 27 November 2020. The results of this trial will finally answer the question of whether a nonpressure dressing after open hemorrhoidectomy is necessary and beneficial.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000040283 . Registered on 28 November 2020.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis

Background

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

Methods

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

Results

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

Conclusion

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

An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments.

METHODS

A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS.

RESULTS

A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser.

CONCLUSION

There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Topical Diltiazem Ointment For Post- Hemorrhoidectomy Pain

BACKGROUND

Hemorrhoids are one of the most common anal pathology affecting millions of people around the world. Milligan-Morgan open hemorrhoidectomy is the most effective hemorrhoidectomy method used as gold standard procedure. Post-operative pain is recognized as a distressing complication of hemorrhoidectomy leading to increase hospital stay and psychological stress to both patient and surgeon. This study is designed to determine the efficacy of diltiazem gel in relieving pain after hemorrhoidectomy caused by anal muscle spasm. This will lead to decreased hospital stay and save both patient and surgeon from stress in postoperative period.

OBJECTIVE

To compare mean post-operative pain in patients undergoing hemorrhoidectomy with vs. without topical application of diltiazem gel.

METHODS

Total 80 patients who were diagnosed with third- and fourth-degree hemorrhoids and undergo hemorrhoidectomy were included in the study. Patients were randomly allocated to two groups using opaque sealed envelope method. Group A and B both have 40 patients in each group. Pain score was measured on visual analogue scale (VAS) by asking the patients to fill a questionnaire or by the help of the doctor.

RESULTS

The patient's average age was 39.98±7.98 years. At 24 hours, mean pain score was significantly high in group B than group A [7.23±0.95 vs. 5.38±1.06; p=0.0005]. At 3rd post-operative day, mean pain score was significantly high in group B than group A [5±0.78 vs. 3.08±0.99; p=0.0005]. Seventy percent cases were observed in group B which required rescue analgesia.

CONCLUSIONS

It is concluded that application of diltiazem ointment at perianal area with standard treatment considerably decreases pain after haemorrhoidectomy.

Ligasure Hemorrhoidectomy: Updates on Complications After an 18-Year Experience

BACKGROUND

Hemorrhoidal disease represents one of the most common anorectal disorders in the general population. Energy devices, such as LigaSure^TM scalpel, have reshaped the concept of hemorrhoid surgery and in turn, have improved patient outcomes and simplified the work of surgeon.

OBJECTIVE

The study aims to evaluate the outcomes of LigaSure^TM hemorrhoidectomy (LH) analyzing main post-operative complications rate, length of stay, operating time, and time to return to work.

METHODS

In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed. Complications were classified in early, late, and long-term if they occurred within 1 month, between 1 and 2 months or after 2 months, respectively.

RESULTS

90.2% of patients were treated in day surgery regimen and the mean operating time was 14.3 minutes. The post-operative pain decreased from 3.7 mean VAS on the 1st postoperative day to 0.1 mean VAS on 30th post-operative day. Early complications rate was 2.1%: urinary retention accounted for 1.8% of patients. 0.3%-of patients experienced postoperative bleeding and only one required reoperation. Late complications rate was 5.8%: anal stenosis, incomplete healing, and anal fissure were detected in 3.6%, 1.2%, and 1% of patients, respectively. The long term complications rate was 5.3%: anal fistula, soiling, perianal abscess, and recurrence were identified in 0.2%, 0.1%, 0.3%, and 4.8% of patients, respectively.

CONCLUSION

LH is a safe and fast procedure with a proven minimal complication rate.

[Analysis on clinical efficacy, safety and economy of Shaobei injection and elastic band ligation in the treatment of grade II or III hemorrhoids]

Objective: Currently, various treatments such as hemorrhoidectomy, ligation and sclerotherapy injection can be applied in grade II or III hemorrhoids. This study aims to compare the clinical efficacy, safety and economy between Shaobei injection and elastic band ligation in treating patients with grade II or grade III hemorrhoids. Methods: A retrospective cohort study was used. Clinical data of 60 patients with grade II or grade III hemorrhoids at Department of Anorectal Surgery of the Sixth Affiliated Hospital, Sun Yat-sen University between January 2019 and October 2019 were collected. Patients were divided into two groups according to surgical methods. Patients in the Shaobei group received Shaobei injection (n=28), and those in the ligation group received elastic band ligation (n=32). Inclusion criteria: (1) diagnosis of grade II or III hemorrhoid; (2) application of Shaobei injection or elastic band ligation; (3) age between 18-75 years old. Exclusion criteria: (1) comorbidity with anal fissure, anal fistula, anal sinusitis or other perianal diseases; (2) patients with mental disorder or poor compliance; (3) incomplete clinical or follow-up data. Recurrent rate, postoperative pain, anal edema, anal distension, total cost of hospitalization, length of hospitalization, and postoperative life quality EQ-5D-3L score were compared between the two groups at postoperative 6-month. Results: No significant difference was observed in the baseline data (including Nystrom hemorrhoid symptom score) between the two groups (all P>0.05), except gender ratio [male proportion: Shaobei 75% (21/28) vs. ligation 37.5%(12/32), χ(2)=8.485, P=0.004]. No significant difference in recurrent rate was found between the two groups [14.3% (4/28) vs. 9.4% (3/32), χ(2)=0.035, P=0.851]. Compared to the ligation group, Shaobei group showed less pain at postoperative day 1 [VAS median (range): 2 (1-6) vs. 3 (1-7), Z=2.814, P=0.005] and postoperative day 7 [VAS median (range): 0 (0-2) vs. 1 (0-4), Z=3.149, P=0.002]; lower anal edema ratio at postoperative day 1 [10.7% (3/28) vs. 34.4% (11/32), Z=4.673, P=0.037]; lower anal distension ratio at postoperative day 1 [7.1% (2/28) vs. 28.1% (9/32), Z=4.391, P=0.048]; less hospitalization cost [(6343.5±1444.1) yuan vs. (10 587.1± 1719.0) yuan, t=12.515, P<0.001] and shorter postoperative hospital stay [median (range): 1 (1-5) days vs. 3 (1-6) days, Z=5.879, P<0.001]. The EQ-5D-3L scores of two groups were significantly improved six months after treatment [Shaobei group: (0.90±0.16) vs. (0.73±0.14); ligation group: (0.91±0.13) vs. (0.74±0.10); both P<0.001], while there was no statistically significant difference between the two groups (t=0.130, P=0.897). No complications such as massive hemorrhage, infection, iatrogenic anal fistula, rectal stricture and local induration occurred after the injection. Conclusions: Shaobei injection is effective and safe in treating grade II or III hemorrhoids. Compared with elastic band ligation, it can reduce morbidity of complications and hospitalization expenses.

A systematic review of the literature assessing the outcomes of stapled haemorrhoidopexy versus open haemorrhoidectomy

Background

Symptomatic haemorrhoids affect a large number of patients throughout the world. The aim of this systematic review was to compare the surgical outcomes of stapled haemorrhoidopexy (SH) versus open haemorrhoidectomy (OH) over a 20-year period.

Methods

Randomized controlled trials published between January 1998 and January 2019 were extracted from Pubmed using defined search criteria. Study characteristics and outcomes in the form of short-term and long-term complications of the two techniques were analyzed. Any changes in trend of outcomes over time were assessed by comparing article groups 1998–2008 and 2009–2019.

Results

Twenty-nine and 9 relevant articles were extracted for the 1998–2008 (period 1) and 2009–2019 (period 2) cohorts, respectively. Over the two time periods, SH was found to be a safe procedure, associated with statistically reduced operative time (in 13/21 studies during period 1 and in 3/8 studies during period 2), statistically less intraoperative bleeding (3/7 studies in period 1 and 1/1 study in period 2) and consistently less early postoperative pain on the visual analogue scale (12/15 studies in period 1 and 4/5 studies in period 2) resulting in shorter hospital stay (12/20 studies in period 1 and 2/2 studies in period 2) at the expense of a higher cost. In the longer term, although chronic pain in SH and OH patents is comparable, patient satisfaction with SH may decline with time and at 2-year follow-up OH appeared to be associated with greater patient satisfaction.

Conclusions

SH appears to be safe with potential advantages, at least in the short term, but the evidence is lacking at the moment to suggest its routine use in clinical practice.

Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial

BACKGROUND

Hemorrhoids are one of the most common conditions that lead to surgery, and until now surgical hemorrhoidectomy has been the major effective treatment. Post-operative pain from hemorrhoidectomy has been experienced by thousands of patients and remains a major inconvenience of the operation.

OBJECTIVE

This study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This was a single-center, patient-assessor-blinded and randomized controlled trial with 154 patients receiving Milligan hemorrhoidectomy surgery. Eligible patients were randomly assigned to either a treatment group or a control group at a ratio of 1:1. The treatment group received the pestle needle therapy, with manual stimulation at Yaoshu (DU2), Mingmen (DU4), Changqiang (DU1), Chengshan (BL57), Erbai (EX-UE2) and the perianal points (1, 3, 5, 7, 9, and 11o'clock around the lesion); while the control group received a sham treatment with very light pressure. Three sessions of treatment were performed at 30 min, 4 h and 12 h after the surgery, and each lasted for 15 min.

MAIN OUTCOME MEASURES

The primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery. The secondary outcomes included the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery, the analgesic dose, the time and the VAS score of the patients' first defecation after surgery, as well as the Hamilton Rating Scale for Anxiety (HAMA) evaluated before discharge.

RESULTS

The mean pain score of the treatment group was significantly lower than that of the control group (3.10 ± 1.27 vs 4.82 ± 1.29; P < 0.001) at 12 h after surgery. Compared with the control group, patients in the treatment group needed a smaller dose of analgesic within the first 24 hours after surgery (P = 0.002); and their HAMA scores before discharge were lower (4.07 ± 2.40 vs 5.10 ± 2.45, P = 0.009). Compared to the treatment group, patients in the control group had a greater time to the first defecation after surgery ([52.34 ± 15.72] h vs [27.08 ± 13.68] h; P < 0.001), but there was no difference in their VAS scores at the first defecation (P = 0.092).

CONCLUSION

The pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR-A Proposal for a Decision-Making Algorithm

Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases - transabdominal surgery (3 colostomies, 1 Hartmann' procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars -hemodynamic stability and the finding of contrast CT.

Effect of lateral internal sphincterotomy in patients undergoing excisional hemorrhoidectomy

BACKGROUND

Excisional hemorrhoidectomy (EH) is the major surgical option for high-grade symptomatic hemorrhoids, but it has some shortcomings, especially postoperative pain. This study was performed to assess the effect of lateral internal sphincterotomy (LIS) in patients undergoing excisional hemorrhoidectomy.

METHODS

A systematic literature search (Medline, Embase, Cochrane Library, Science Citation Index, Science Direct, Springer Link, Ovid Journals, and EBSCO) was performed to identify all eligible articles. Randomized controlled trials (RCTs) published until July 7, 2017 comparing EH combined with LIS (experimental group) with EH only (control group) were eligible for inclusion. The primary outcome of interest was postoperative pain.

RESULTS

Ten RCTs involving 1560 patients were identified for inclusion. The pooled analysis revealed that patients undergoing EH and LIS were associated with lower pain score [standardized mean difference (SMD), -0.75; 95% confidence interval (CI), -1.14 to -0.36; z = 3.76; P = .0002] and resting anal pressure [odds ratio (OR), -17.19; 95% CI, -25.66 to -8.72; z = 3.98; P < .0001], and lower incidence of anal stricture (OR, 0.12; 95% CI, 0.03-0.53; z = 2.85; P = .004). However, the differences of urinary retention, bleeding and length of hospital stay were similar between the 2 methods.

CONCLUSION

Our meta-analysis suggests that LIS effectively relieves postoperative pain and reduces patient's postoperative analgesic requirements. LIS also reduces the incidence of anal stenosis but increases the incidence of fecal incontinence.

Transanal hemorrhoidal dearterialization versus stapled hemorrhoidectomy in the treatment of hemorrhoids: A PRISMA-compliant updated meta-analysis of randomized control trials

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the outcomes of transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidectomy (SH) in the treatment of hemorrhoids by a meta-analysis.

METHODS

Randomized control trials (RCTs) comparing SH with THD were searched for in databases, including MEDLINE, PubMed, Web of science, Embase, and the Cochrane Library database. Data were independently extracted from each study, and a meta-analysis was performed using RevMan5.2 software.

RESULTS

Eight RCTs, including 977 patients, were included in this meta-analysis. No statistically significant differences were noted between THD and SH in terms of total complications (OR, 0.93; 95% CI, 0.69, 1.25), but a significant differences were noted in terms of bleeding (OR, 1.85; 95% CI, 1.10, 3.10). The total recurrence rate was higher in THD than in SH on short-term follow-up; however, the recurrence rate was equal in both the THD and SH groups on long-term follow-up. The present study showed that no significant difference between SH and THD in terms of postoperative pain (OR, 0.43; 95% CI, -0.43, 1.29), operative time (OR, -3.12; 95% CI, -7.01, 0.77), hospital time (OR, -0.00; 95% CI, -0.21, 0.20), time before returning to work (OR,-0.50; 95%CI, -4.42,3.43), and reoperation rate (OR, 1.81; 95% CI, 0.93, 3.54).

CONCLUSION

Our meta-analysis indicated that THD and SH are equally effective techniques for the treatment of hemorrhoids. However, future studies addressing cost-effectiveness, satisfaction rate, and recurrence rate over a long follow-up period are needed to validate these results.

Evidence Corner: Taking Itch Seriously

Dear Readers, Itching (pruritus) of a wound, scar, or dermatologic disorder can negatively impact a patient's quality of life, resulting in injurious scratching1 or impeded rehabilitation.2 Like pain, itch can cause the su erer to lose sleep and appetite or even consider suicide.3,4 Clinical measures of pruritus have proved reliable and valid in individuals with burn wounds, dermatologic conditions, or urticaria5-7 or resulting scars,2 allowing studies to clarify its impact on human experience and compare the e ects of interventions to reduce itching. This Evidence Corner explores the e ects on pruritus of interventions applied at 2 very different stages of wound healing: the rst during early healing stages after hemorrhoidectomy8 and the other in postburn hypertrophic scarring with contracture.9 Each condition generates distressing levels of pruritus from which patients eagerly seek relief.

Effects of Topical Atorvastatin (2 %) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial

BACKGROUND

Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2 %) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated.

METHODS

A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing.

RESULTS

There was no significant difference in the average postoperative pain scores in the first 48 h (P _12h = 1, P _24h = 0.128 and P _48h = 0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P = 0.004), which also was the same at the week 2 (P = 0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12 h and 24 h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P = 0.04).

CONCLUSIONS

Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy.

TRIAL REGISTRATION NUMBER

IRCT201404013014N8.

Implementation of a New High-Volume Circular Stapler in Stapled Anopexy for Hemorrhoidal Disease: Is Patient's Short-Term Outcome Affected by a Higher Volume of Resected Tissue?

BACKGROUND

Stapled anopexy is a safe technique for the treatment of hemorrhoids but carries a higher risk of recurrence, which might be caused due to the limited volume of resected tissue. In this study, we investigated the introduction of a high-volume circular stapling device; in particular whether an increased amount of resected tissue could affect patients' short-term postoperative outcome.

METHODS

Between 2011 and 2015, stapled anopexy was performed for hemorrhoids and/or anal prolapse in 141 patients (n = 25 conventional PPH-3©-stapler versus n = 116 high-volume CHEX©-stapler). In this prospectively collected dataset, operation details and short-term postoperative outcome were compared.

RESULTS

With the high-volume stapler, a significantly higher amount of tissue was resected: 9.8 g (range 6.2-11.4) vs. 6.4 g (range 4.9-8.8) with the conventional stapler, p < 0.01. Postoperative short-term outcome did not differ in terms of readmission and complication rates. In all 5 patients who underwent a redo operation for residual hemorrhoids or prolapse, the high-volume stapler was used in the primary operation.

CONCLUSION

A high-volume stapling device for stapled anopexy was introduced safely with a significantly higher amount of resected tissue without a worse short-term outcome. However, it remains unclear whether higher stapling volumes may lead to improved long-term outcome with less reinterventions.

Randomized clinical study on the analgesic effect of local infiltration versus spinal block for hemorrhoidectomy

BACKGROUND AND OBJECTIVES:

Postoperative analgesia and early recovery are important for hospital discharge. The primary objective of this study was to compare the analgesic effectiveness of perianal infiltration and subarachnoid anesthesia for hemorrhoidectomy. The secondary objective was to compare time to discharge, adverse effects and complications.

DESIGN AND SETTING:

Randomized, prospective and comparative study at Dr. Mário Gatti Hospital.

METHODS:

Forty patients aged 18-60, in American Society of Anesthesiologists physical status category 1 or 2, were included. The local group (LG) received local infiltration (0.75% ropivacaine) under general anesthesia; the spinal group (SG) received subarachnoid block (2 ml of 0.5% bupivacaine). Analgesic supplementation consisted of fentanyl for LG and lidocaine for SG. Postoperative pain intensity, sphincter relaxation, lower-limb strength, time to discharge, analgesic dose over one week and adverse effects were assessed.

RESULTS:

Eleven LG patients (52.4%) required supplementation, but no SG patients. Pain intensity was higher for LG up to 120 min, but there were no differences at 150 or 180 min. There were no differences in the need for paracetamol or tramadol. Times to first analgesic supplementation and hospital discharge were longer for SG. The adverse effects were nausea, dizziness and urinary retention.

CONCLUSIONS:

Pain intensity was higher in LG than in SG over the first 2 h, but without differences after 150 and 180 min. Time to first supplementation was shorter in LG. There were no differences in doses of paracetamol and tramadol, or in adverse effects.

REGISTRATION:

ClinicalTrials.gov NCT02839538.

Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Two commonly performed surgical interventions are available for severe (grade II-IV) haemorrhoids; traditional excisional surgery and stapled haemorrhoidopexy. Uncertainty exists as to which is most effective. The eTHoS trial was designed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery.

METHODS

The eTHoS trial was a large, open-label, multicentre, parallel-group, pragmatic randomised controlled trial done in adult participants (aged 18 years or older) referred to hospital for surgical treatment for grade II-IV haemorrhoids. Participants were randomly assigned (1:1) to receive either traditional excisional surgery or stapled haemorrhoidopexy. Randomisation was minimised according to baseline EuroQol 5 dimensions 3 level score (EQ-5D-3L), haemorrhoid grade, sex, and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery. The primary outcome was area under the quality of life curve (AUC) measured with the EQ-5D-3L descriptive system over 24 months, assessed according to the randomised groups. The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables. This trial is registered with the ISRCTN registry, number ISRCTN80061723.

FINDINGS

Between Jan 13, 2011, and Aug 1, 2014, 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery). Stapled haemorrhoidopexy was less painful than traditional excisional surgery in the short term and surgical complication rates were similar between groups. The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months; mean difference -0·073 (95% CI -0·140 to -0·006; p=0·0342). EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery, the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group. 24 (7%) of 338 participants who received stapled haemorrhoidopexy and 33 (9%) of 352 participants who received traditional excisional surgery had serious adverse events.

INTERPRETATION

As part of a tailored management plan for haemorrhoids, traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice.

FUNDING

National Institute for Health Research Health Technology Assessment programme.