Comparison of surgical procedures implemented in recent years for patients with grade III and IV hemorrhoids: a network meta-analysis

Does the addition of perineal block enhance pain control after a haemorrhoidectomy? A prospective randomized, double-blind placebo-controlled study

BACKGROUND

Haemorrhoidectomy is associated with severe postoperative pain, a long rehabilitation, and QoL worsening for months. Most patients experience mild-to-moderate postoperative pain. We aimed to evaluate the intraoperative perineal block role for patients undergoing haemorrhoidectomy.

METHODS

In this prospective randomized, double-blind, placebo-controlled study, eligible patients with III-IV stage haemorrhoids were randomized to the experimental group (EG) with intraoperative perineal block and spinal anaesthesia and the control one (CG) only with spinal anaesthesia. During the postoperative period, the opioid consumption rate was evaluated as a primary endpoint, and the postoperative pain level according to VAS, systemic analgesics consumption, readmission, and complication rate, the timing of returning to work, patients' QoL, and overall satisfaction according to SF-36 were evaluated as secondary endpoints.

RESULTS

One hundred patients completed the study (48 in EG and 52 in CG). Patients of the EG had less postoperative pain intensity (P < 0.0001), required less opioid analgesia (P = 0.03), and had longer pain-free postoperative periods (P = 0.0002). 90% of patients in the CG required additional NSAID injections for adequate analgesia compared with only 58% in the EG. The average hospital stays, complication rate, and average operation duration didn't reach clinical significance. General health evaluation according to the SF-36 score and the median satisfaction rate was better in the EG (P < 0.001 and P = 0.012, respectively).

CONCLUSIONS

The administration of the perianal block is safe and effective and should be administered to appropriate patients undergoing anorectal surgery.

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

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

Efficacy of Micronized Purified Flavonoid Fraction in the Posthemorrhoidectomy Period Trial: Open-Label Randomized Controlled Trial

BACKGROUND

Frequent early postoperative complications of hemorrhoidectomy are thrombosis and edema of mucocutaneous "bridges."

OBJECTIVE

This study aimed to investigate the efficacy of micronized purified flavonoid fraction in preventing complications after elective hemorrhoidectomy.

DESIGN

Prospective unicentral open-label randomized controlled trial.

SETTINGS

2021-2022 at the Clinic of Colorectal and Minimally Invasive Surgery at Sechenov University (Moscow, Russia).

PATIENTS

Patients who underwent hemorrhoidectomy for grade III and IV hemorrhoids.

INTERVENTIONS

After hemorrhoidectomy, patients were randomly assigned either to standard treatment (peroral nonsteroid anti-inflammatory drugs and local anesthetics, topical steroids, psyllium, warm sitz baths, and nifedipine gel), referred to as the control group, or to standard treatment with micronized purified flavonoid fraction, referred to as the study group, and followed up for 60 days.

MAIN OUTCOME MEASURES

Thrombosis or edema of mucocutaneous bridges and pain intensity on a visual analog scale оn postoperative days 1-7, 14, 21, and 30; quality of life and patient-assessed treatment effect оn postoperative days 1, 3, 7, 21, and 30; and perianal skin tags оn postoperative day 60.

RESULTS

The data from 50 patients were analyzed (25 in each group). The visual analog scale demonstrated no differences between groups in each follow-up point. Compared to the control group, the patients in the study group had a significantly higher patient-assessed treatment effect оn postoperative days 1, 3, 7, 21, and 30 and a significantly lower rate of thrombosis or edema of mucocutaneous bridges оn postoperative days 1-7 and 14. Patients in the study group had significantly lower rates of perianal skin tags.

LIMITATIONS

Unicenter open-label design.

CONCLUSIONS

Micronized purified flavonoid fraction in the posthemorrhoidectomy period is an effective adjunct to standard treatment that helps reduce the rate of thrombosis and edema of mucocutaneous bridges, improves patient-assessed treatment effect, and prevents postoperative perianal skin tags formation. Micronized purified flavonoid fraction in the posthemorrhoidectomy period is not associated with additional pain relief in comparison with nonmicronized purified flavonoid fraction standard treatment. See Video Abstract .

EFICACIA DE LA FRACCIN DE FLAVONOIDES PURIFICADA MICRONIZADA EN EL PERODO POSTERIOR A LA HEMORROIDECTOMA ENSAYO MOST ENSAYO CONTROLADO, ALEATORIZADO, ABIERTO

ANTECEDENTES:Una complicación postoperatoria temprana frecuente de la hemorroidectomía es la trombosis y el edema de los "puentes" mucocutáneos.OBJETIVO:Investigamos la eficacia de la fracción de flavonoides purificada micronizada en la prevención de complicaciones después de una hemorroidectomía electiva.DISEÑO:Ensayo controlado aleatorio, prospectivo, unicentral, abierto.AJUSTES:2021-2022 Clínica de Cirugía Colorrectal y Mínimamente Invasiva Universidad Sechenov (Moscú, Rusia).PACIENTES:Pacientes después de hemorroidectomía, que se realizó para hemorroides de grado III-IV.INTERVENCIONES:Después de la hemorroidectomía, los pacientes fueron asignados aleatoriamente al tratamiento estándar (antiinflamatorios no esteroides perorales y anestésicos locales, esteroides tópicos, psyllium, baños de asiento tibios, gel de nifedipina) - grupo de control, o al tratamiento estándar con flavonoide purificado micronizado. fracción (grupo de estudio) y seguido durante 60 días.RESULTADOS DE MEDIDAS PRINCIPALES:Trombosis o edema de puentes mucocutáneos e intensidad del dolor en una escala analógica visual entre el 1.º, 7.º, 14.º, 21.º y 30.º día postoperatorio; calidad de vida y efecto del tratamiento evaluado por el paciente el día 1, 3, 7, 21 y 30 del postoperatorio; Marcas cutáneas perianales en el día 60 del postoperatorio.RESULTADOS:Se analizaron los datos de 50 pacientes (25 en cada grupo). La escala analógica visual no demostró diferencias entre grupos en cada punto de seguimiento. En comparación con el grupo de control, los pacientes en el grupo de estudio tuvieron un efecto del tratamiento evaluado por el paciente significativamente mayor en los días 1, 3, 7, 21 y 30 después de la operación, una tasa significativamente menor de trombosis o edema de los puentes mucocutáneos en los días 1, 7 y 14.. Los pacientes del grupo de estudio tuvieron tasas significativamente más bajas de marcas en la piel perianal.LIMITACIONES:Diseño Unicenter de etiqueta abierta.CONCLUSIONES:La fracción de flavonoides purificada micronizada en el período posterior a la hemorroidectomía es un complemento eficaz del tratamiento estándar que ayuda a reducir la tasa de trombosis y edema de los puentes mucocutáneos, mejora el efecto del tratamiento evaluado por el paciente y previene la formación de marcas cutáneas perianales posoperatorias. La fracción de flavonoides purificados micronizados en el período posterior a la hemorroidectomía no se asocia con un alivio adicional del dolor en comparación con el tratamiento estándar con la fracción de flavonoides purificados no micronizados. (Traducción-Yesenia Rojas-Khalil ).

Comparison between stapled hemorrhoidopexy and harmonic scalpel hemorrhoidectomy in the management of third- and fourth-degree piles: a randomized clinical trial

BACKGROUND

This study compared the results of stapled hemorrhoidopexy (SH) and harmonic scalpel hemorrhoidectomy (HSH) in the management of grade III and grade IV piles regarding the time of the procedure, postoperative pain, patient satisfaction, wound infection, bleeding, incontinence, and recurrence within 1 year.

PATIENTS AND METHODS

This was a single-blind, prospective, randomized, controlled, single-center trial conducted from January to December 2022 that included 50 (68.75%) male and 20 (31.25%) female patients with third- and fourth-degree piles.

RESULTS

The patients were divided into two groups of 35 patients each. Group I underwent SH and group II underwent HSH. The mean age of group I was 42.94 years and of group II, 42.20 years. The mean time of the procedure was 24.42 min ± 2.367 for SH and 31.48 min ± 2.21 for HSH. Postoperative pain in group I was lower than in group II during the first 2 weeks, but there was persistent mild pain in most patients in group I at the 2‑week follow-up. In group II there was significant improvement in pain after 2 weeks, with higher patient satisfaction. Wound infection was detected in 3 (5%) patients in group I and no patients in group II (p = 0.077). Postoperative bleeding occurred in 4 (11.4%) patients in group I in the form of spotting after defecation only during the first postoperative month; no bleeding was detected in group II (p = 0.039). There were 3 (15%) cases of flatus incontinence but after taking a detailed history these were found to be cases of urgency to defecate rather than incontinence. There were 7 (20%) cases of recurrence at the 1‑year follow-up in group I and 1 (2.9%) case in group II (p = 0.024).

CONCLUSION

Compared with SH, HSH was safer, easier, and associated with a lower incidence of recurrence after 1 year and with higher patient satisfaction.

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 ).

Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis

PURPOSE

This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids.

METHODS

PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January 15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis.

RESULT

A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h.

CONCLUSION

Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24 h.

Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: Long-term Outcomes From the THDLIGA Randomized Controlled Trial

BACKGROUND

Both transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy are safe for grade III to IV hemorrhoid treatment. Whether one of them is superior regarding long-term results remains unclear.

OBJECTIVE

To compare long-term results after transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy.

DESIGN

Multicenter randomized controlled trial.

SETTINGS

This study was conducted at 6 centers.

PATIENTS

Patients ≥18 years of age with grade III to IV hemorrhoids were included in the study.

INTERVENTIONS

Patients were randomly assigned to transanal hemorrhoidal dearterialization (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41).

MAIN OUTCOME MEASURES

The primary outcome was hemorrhoid symptom recurrence assessed by a specific questionnaire 2 years postoperatively. Secondary outcomes included long-term complications, reoperations, fecal continence, and patient satisfaction and quality of life.

RESULTS

Five of the 80 patients included in the study were lost to follow-up. Thirty-six patients randomly assigned to transanal hemorrhoidal dearterialization and 39 patients randomly assigned to vessel-sealing device hemorrhoidectomy were included in the long-term analysis. The differences between mean baseline and mean 2-year score in the 2 groups were similar (-11.0, SD 3.8 vs -12.5, SD 3.6; p = 0.080). Three patients in the transanal hemorrhoidal dearterialization group underwent supplementary procedures for hemorrhoid symptoms, compared with none in the vessel-sealing device hemorrhoidectomy group ( p = 0.106). Four patients in the vessel-sealing hemorrhoidectomy group and none in the transanal hemorrhoidal dearterialization group experienced chronic opened wound ( p = 0.116).

LIMITATIONS

Lack of stratification for hemorrhoid grade and power calculation based on the main outcome trial but not on the end point of this long-term study.

CONCLUSIONS

Transanal hemorrhoidal dearterialization with mucopexy is associated with hemorrhoid symptom recurrence similar to vessel-sealing device hemorrhoidectomy at 2 years. See Video Abstract at http://links.lww.com/DCR/B933 .

REGISTRATION

Clinicaltrials.gov ; ID: NCT02654249.

DESARTERIALIZACIN HEMORROIDAL TRANSANAL CON MUCOPEXIA VERSUS HEMORROIDECTOMA CON DISPOSITIVO DE SELLADO DE VASOS PARA HEMORROIDES DE GRADO IIIIV RESULTADOS A LARGO PLAZO DEL ENSAYO CLNICO ALEATORIZADO THDLIGARCT

ANTECEDENTES:Tanto la desarterialización hemorroidal transanal como la hemorroidectomía con dispositivo de sellado de vasos son seguras y bien toleradas para el tratamiento de las hemorroides de grado III-IV. La primera se asocia con una necesidad más breve de analgesia posoperatoria que la hemorroidectomía con dispositivo de sellado de vasos. No está claro si uno de ellos es superior con respecto a los resultados a largo plazo.OBJETIVO:El objetivo fue comparar los resultados a largo plazo después de la desarterialización hemorroidal transanal y la hemorroidectomía con dispositivo de sellado de vasos.DISEÑO:Se realizó un ensayo clínico aleatorizado multicéntrico.AJUSTE:Este estudio se realizó en 6 centros.PACIENTES:Se incluyeron en el estudio pacientes de ≥18 años con hemorroides de grado III-IV.INTERVENCIONES:Los pacientes fueron asignados al azar a desarterialización hemorroidal transanal (n = 39) o hemorroidectomía con dispositivo de sellado de vasos (n = 41).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia de los síntomas de hemorroides evaluada mediante un cuestionario específico 2 años después de la operación. Los resultados secundarios incluyeron complicaciones a largo plazo, reoperaciones, continencia fecal, satisfacción del paciente y calidad de vida.RESULTADOS:Cinco de los 80 pacientes incluidos en el estudio se perdieron durante el seguimiento. En el análisis a largo plazo se incluyeron 36 pacientes aleatorizados a desarterialización hemorroidal transanal y 39 aleatorizados a hemorroidectomía con dispositivo de sellado de vasos. Las diferencias entre la puntuación inicial media y la puntuación media a los 2 años en los dos grupos fueron similares (-11,0, DE 3,8 frente a -12,5, DE 3,6; p = 0,080). Tres pacientes en el grupo de desarterialización hemorroidal transanal se sometieron a procedimientos complementarios por síntomas de hemorroides, en comparación con ninguno en el grupo de hemorroidectomía con dispositivo de sellado de vasos (p = 0,106). Cuatro pacientes en el grupo de hemorroidectomía con sellado de vasos y ninguno en el grupo de desarterialización hemorroidal transanal experimentaron herida abierta crónica (p = 0,116). No se encontraron diferencias en cuanto a continencia fecal (p = 0,657), satisfacción del paciente (p = 0,483) y calidad de vida.LIMITACIONES:No hay estratificación para el grado de hemorroides ni el cálculo del poder basado en el resultado principal del ensayo, pero no en el criterio de valoración de este estudio a largo plazo.CONCLUSIONES:La desarterialización hemorroidal transanal con mucopexia se asocia con una recurrencia de síntomas de hemorroides similar a la hemorroidectomía con dispositivo de sellado de vasos a los dos años. See Video Abstract at http://links.lww.com/DCR/B933 . (Traducción- Dr. Francisco M. Abarca-Rendon )REGISTRO DE PRUEBA:Clinicaltrials.gov (NCT02654249).

Can patients with low-risk prostate cancer really benefit from radical treatment?: A systematic review and network meta-analysis

Radical prostatectomy, radiotherapy and active surveillance are three widely used treatment options for patients with low-risk prostate cancer, but the relative effects are controversial. We searched PubMed, Embase and Web of Science until June 2020, focusing on the studies comparing the effect of radical prostatectomy, radiotherapy and active surveillance in patients with low-risk prostate cancer. Through the random-effects model, dichotomous data were extracted and summarised by odds ratio with a 95% confidence interval. Twenty-two studies containing 185,363 participants were pooled for the comprehensive comparison. The Bayesian mixed network estimate demonstrated the cancer-specific mortality of radical prostatectomy was significantly lower than active surveillance (OR, 0.46; 95% CI 0.34-0.64) and external beam radiation therapy (OR, 0.66; 95% CI 0.46-0.96), but not brachytherapy (OR, 0.63; 95% CI 0.41-1.03). The brachytherapy demonstrated the best treatment ranking probability results in terms of all-cause mortality, while no significant difference was observed when compared with other three treatment modalities. Brachytherapy and radical prostatectomy were associated with a similar risk of cancer-specific mortality, and both of them were significantly superior to active surveillance and external beam radiation therapy; nevertheless, there was no significant difference among the aforementioned treatment methods in all-cause mortality.

Linear Pinched Hemorrhoidectomy: A Retrospective Observational Study (An Innovative, Simplified Hemorrhoidectomy)

OBJECTIVES

There was an urgent need to create a simple, reliable hemorrhoidectomy procedure for high-risk cases in our university hospital. We performed linear pinched hemorrhoidectomy (LPH) and evaluated its effectiveness compared to conventional hemorrhoidectomy (CH).

METHODS

We included 215 Goligher grade 3 and 4 hemorrhoid cases in this study. Of these cases, 167 were in the CH group, and 48 patients were in the LPH group. We retrospectively compared the lengths of hospital stay, operative times, blood loss, and complications.

RESULTS

The age tended to be higher in the LPH group (mean: CH 60 years, LPH 68 years). In the univariate analysis, LPH had more resections, shorter operative times, and less blood loss. LPH had shorter operative times in the multivariate analysis, less blood loss, and more anticoagulant use. There were no significant differences between the two groups in terms of complications. Five and two patients in the CH and LPH groups, respectively, had postoperative hemorrhage requiring hemostasis. Only the CH group had three and four cases of anal stenosis and wound edema, respectively.

CONCLUSIONS

We studied simplified hemorrhoidectomy using an ultrasonic scalpel and cylindrical proctoscope in a university hospital. We found that it a useful procedure with few complications and was easy for residents to learn. We believe that advances in surgical devices will make it possible to perform safer and simpler hemorrhoidectomy in the future.

Non-Doppler hemorrhoidal artery ligation and hemorrhoidopexy combined with pudendal nerve block for the treatment of hemorrhoidal disease: a non-inferiority randomized controlled trial

BACKGROUND

In this study, we proposed a combined outpatient treatment modality for hemorrhoidal disease.

METHODS

This study was a prospective non-inferiority randomized controlled trial (RCT). The experimental group included the dearterialization and hemorrhoidopexy under pudendal nerve block, whereas the comparator consisted of the standard Doppler guided hemorrhoidal artery ligation and hemorrhoidopexy, under spinal anesthesia. As primary hypothesis, we considered the non-inferiority of the proposed modality in terms of the presenting symptom remission rate (non-inferiority margin: 10%). Randomization was based on a 1:1 ratio. Blinding was confined to the patient and the investigator.

RESULTS

Overall, 60 patients were enrolled. The primary hypothesis of this RCT (96.7% vs 73.3%) was validated. The experimental group was associated with a lower operation duration and an expedited onset of mobilization and feeding. Moreover, a favorable profile regarding short-term morbidity and analgesia was identified. The control group displayed a higher pile recurrence rate and a suboptimal patient satisfaction. A significant effect of the treatment modality in most of the SF-36 components was confirmed.

CONCLUSIONS

The proposed treatment modality was associated with favorable short and long-term outcomes. Due to specific limitations, further RCTs, with a larger sample size, are required. Trial Registration ClinicalTrials.gov : NCT03298997.

Acupuncture therapy on postoperative nausea and vomiting in abdominal operation: A Bayesian network meta analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after surgery. However, drugs cannot prevent it completely, and acupuncture therapy shows the potential in preventing PONV, yet the best choice hasn't been demonstrated.

OBJECTIVE

This network meta analysis aimed to evaluate the effectiveness of different acupuncture therapies used for preventing PONV in abdominal operation.

METHODS

Authors searched articles from PubMed/Medline, Cochrane library, Web of Science, Ebsco and Ovid/Embase, and established database from setup time to June 2019. Quality evaluation of included studies was performed with Cochrane risk-of-bias tool (ROB 2.0). Pairwise and network meta analysis were conducted by RevMan and Addis respectively.

RESULTS

Twenty studies with 2862 patients were included in this research. Pairwise meta analysis shows that compared with placebo, transcutaneous electric nerve stimulation had lower risk of postoperative nausea (PON) (odds ratio (OR) = 0.42, 95%confidence interval (CI): 0.30-0.60), postoperative vomiting (POV) (OR = 0.53, 95%CI: 0.36-0.78), PONVs (OR = 0.46, 95%CI: 0.31-0.68), and postoperative rescue (POR) (OR = 0.61, 95%CI: 0.41-0.90), Capsicum had lower risk of PON (OR = 0.16, 95%CI: 0.09-0.28), PONVs (OR = 0.23, 95%CI: 0.12-0.45), Acupressure had lower risk of POV (OR = 0.42, 95%CI: 0.25-0.70), POR (OR = 0.42, 95%CI: 0.27-0.64). In network meta analysis, compared with usual care, the probability rank suggested that Acupoint Injection showed lowest risk of PON (OR = 0.02, 95%CI: 0.00-0.11), POV (OR = 0.06, 95%CI: 0.01-0.49), Usual care for PONVs (OR = 0.31, 95%CI: 0.13-0.75), and Capsicum for POR (OR = 0.39, 95%CI: 0.07-2.33). Further study should be carried out to verify this result.

CONCLUSION

Both pairwise and network meta analysis showed acupuncture therapy was superior to placebo and usual care. Different acupuncture therapy regimens may have advantages in different aspects. And compared with POV, PON seems easier to control. Research results may provide guidance for the prevention of PONV.Systematic review registration: PROSPERO CRD42019147556.

Network meta-analysis of randomized controlled trials comparing the procedure for prolapse and hemorrhoids, Milligan-Morgan hemorrhoidectomy and tissue-selecting therapy stapler in the treatment of grade III and IV internal hemorrhoids(Meta-analysis)

BACKGROUND

Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to update and expand our previous work to compare the safety and efficacy of the procedure for prolapse and hemorrhoids (PPH), Milligan-Morgan hemorrhoidectomy (MMH) and tissue-selecting therapy stapler (TST) in the treatment of grade III and IV internal hemorrhoids.

METHODS

We performed a network meta-analysis. We searched the Cochrane library, Embase, PubMed, Medline, Web of Science, CNKI, Wangfang, and VIP databases up to May 20, 2019. All randomized controlled trials (RCTs) comparing PPH, MMH and TST in the treatment of grade III and IV internal hemorrhoids were included. We performed a Bayesian network meta-analysis to integrate the adverse events of all treatments. This work is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. This study was registered with PROSPERO, number CRD42019137270.

RESULT

Twenty-two RCTs that recruited 3511 patients were identified. Among these patients, 1379 patients underwent PPH, 805 patients underwent TST, and 1327 patients underwent MMH. In terms of adverse events, TST presented the lowest urinary retention rates and fecal incontinence rates. TST exhibited fewer incidences of anal stenosis than PPH and MMH. Importantly, PPH showed the weakest effects on reducing recurrence rates in hemorrhoid patients.

CONCLUSIONS

The current study indicated that TST showed optimal potential superior clinical effects for grade III and IV hemorrhoids compared to PPH and MMH. However, high-quality large sample RCTs are still expected.