Approach to hemorrhoids

Inflammatory bowel disease and risk for hemorrhoids: a Mendelian randomization analysis

Observational studies have reported an association between inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), and hemorrhoids (HEM). However, the presence of a causal relationship within this observed association remains to be confirmed. Consequently, we utilized the Mendelian randomization (MR) method to assess the causal effects of IBD on hemorrhoids. We validated the association between IBD and hemorrhoids in humans based on genome-wide association studies (GWAS) data. To investigate the causal relationship between IBD and hemorrhoids, we performed a two-sample Mendelian randomization study using training and validation sets. The genetic variation data for IBD, CD, UC, and hemorrhoids were derived from published genome-wide association studies (GWAS) of individuals of European. Two-sample Mendelian randomization and Multivariable Mendelian randomization (MVMR) were employed to determine the causal relationship between IBD (CD or UC) and hemorrhoids. Genetically predicted overall IBD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.39 × 10-4) and 1.02 (95% CIs 1.01-1.03, P = 4.99 × 10-5) in the training and validation sets, respectively. Furthermore, we found that CD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.12 × 10-6) and 1.02 (95% CIs 1.01-1.02, P = 3.78 × 10-5) for CD in the training and validation sets, respectively. In addition, we found that UC in the training set was positively associated with hemorrhoids risk (ORs 1.02, 95% CIs 1.01-1.03, P = 4.65 × 10-3), while no significant causal relationship between UC and hemorrhoids was shown in the validation set (P > 0.05). However, after MVMR adjustment, UC in the training set was not associated with an increased risk of hemorrhoids. Our study showed that there is a causal relationship between CD and hemorrhoids, which may suggest that clinicians need to prevent the occurrence of hemorrhoids in CD patients.

Natural Products with Potential Effects on Hemorrhoids: A Review

Hemorrhoid disease is a common anorectal disorder affecting populations worldwide, with high prevalence, treatment difficulties, and considerable treatment costs. Compared to other treatment options, medical therapy for hemorrhoids offers minimal harm, more dignity to patients, and is more economical. Unfortunately, there are few chemical hemorrhoid medications available clinically, which makes the search for efficacious, cost-effective, and environmentally friendly new medication classes a focal point of research. In this context, searching for available natural products to improve hemorrhoids exhibits tremendous potential. These products are derived from nature, predominantly from plants, with a minor portion coming from animals, fungi, and algae. They have excellent coagulation pathway regulation, anti-inflammatory, antibacterial, and tissue regeneration activities. Therefore, we take the view that they are a class of potential hemorrhoid drugs, prevention products, and medication add-on ingredients. This article first reviews the factors contributing to the development of hemorrhoids, types, primary symptoms, and the mechanisms of natural products for hemorrhoids. Building on this foundation, we screened natural products with potential hemorrhoid improvement activity, including polyphenols and flavonoids, terpenes, polysaccharides, and other types.

The effectiveness of walking exercise on the bowel preparation before colonoscopy: a single blind randomized clinical trial study

BACKGROUND AND AIM

Bowel preparation is a crucial factor affecting the diagnostic accuracy of colonoscopy, and few randomized control trials evaluated enhancement in bowel preparation. In this study, we aimed to evaluate the effectiveness of walking exercises on bowel preparation before a colonoscopy procedure.

METHODS

The present study is a single-blind randomized controlled trial involving 262 patients scheduled for colonoscopy procedures. These patients were randomly assigned to two groups: an intervention group (n = 131) and a control group (n = 131). In the intervention group, participants followed a predetermined plan that included the consumption of specific liquids and foods, bisacodyl pills, polyethylene glycol powder, and a regimen of walking exercises in preparation for their colonoscopy. Conversely, individuals in the control group followed the same regimen but were not instructed to engage in walking exercises. On the day of the colonoscopy, both groups were assessed for their level of physical activity using a foot counter. Additionally, an experienced gastroenterologist evaluated and compared the bowel preparation between the two groups using the Boston Bowel Preparation Scale (BBPS).

RESULTS

The number of footsteps recorded in the two groups exhibited a significant difference (P < 0.001). Although there was no statistically significant difference between the intervention and control groups in terms of mean BBPS scores (6.26 ± 1.9 vs. 6.29 ± 1.9, P = 0.416), individuals who took more than 6900 steps had significantly higher BBPS scores compared to those with fewer than 6900 footsteps (6.62 ± 1.8 vs. 5.92 ± 1.9, P = 0.003).In the univariate analysis, BBPS was found to be significantly associated with individuals under the age of 50 (OR: 2.45, 95% CI: 1.30-4.61, P = 0.006) and smoking status (OR: 0.41, 95% CI: 0.17-0.94, P = 0.043). In the multivariate analysis, the relationship between BBPS and age below 50 and smoking remained significant (OR: 2.50, 95% CI: 1.30-4.70, P = 0.005, and OR: 0.38, 95% CI: 0.16-0.93, P = 0.034, respectively).

CONCLUSION

A higher number of footsteps taken especially more than 6900 can significantly enhance bowel preparation; however, walking exercise as an intervention before colonoscopy is not significantly associated with BBPS. Also, older people and smokers seem to have fewer benefits from walking exercises for bowel preparation.

TRIAL REGISTRATION

ISRCTN32724024 (Registration date:22/08/2018).

Causal association between adiposity and hemorrhoids: a Mendelian randomization study

Background

Hemorrhoids are a very common anorectal disorder affecting a large number of individuals throughout the world. This study aimed to evaluate the causal effects of four adiposity traits including body mass index (BMI), body fat percentage, waist circumference, and waist-to-hip ratio on hemorrhoids by Mendelian randomization (MR).

Methods

We used summary statistics of BMI (N = 461,460), body fat percentage (N = 454,633), waist circumference (N = 462,166), waist-to-hip ratio (N = 212,244), and hemorrhoids (N = 337,199) from large-scale genome wide association studies of European ancestry. Univariable and multivariable MR were carried out to infer causality. The MR Steiger directionality test was used to test the causal direction.

Results

The primary MR analysis using the inverse variance weighted (IVW) method showed that there were positive effects of genetically determined BMI [odds ratio (OR) = 1.005, 95% confidence interval (CI): 1.003-1.008, per standard deviation (SD), p = 7.801 × 10-5], body fat percentage (OR = 1.005, 95% CI: 1.001-1.008, per SD, p = 0.008), waist circumference (OR = 1.008, 95% CI: 1.005-1.011, per SD, p = 1.051 × 10-6), and waist-to-hip ratio (OR = 1.010, 95% CI: 1.003-1.017, per SD, p = 0.003) on hemorrhoids. These findings were robust in multivariable MR adjusting for physical activity. The Steiger directionality test showed evidence against reverse causation.

Conclusion

Our MR study supports a causal role of adiposity in the development of hemorrhoids. Adiposity prevention may be an important strategy for reducing hemorrhoids risk.

Identification of the microRNA alterations in extracellular vesicles derived from human haemorrhoids

NEW FINDINGS

What is the central question of this study? What are the morphological features and microRNA (miRNA) expression features of extracellular vesicles (EVs) from haemorrhoids (Hae-EVs) and normal tissues? What are the potential functions of the differentially expressed (DE) miRNAs in Hae-EVs? What is the main finding and its importance? We present, for the first time, the morphological features and miRNA profile of human Hae-EVs. Four hundred and forty-seven significant DE-miRNAs were identified. Gene ontology and pathway analysis of the DE-miRNAs indicated diverse roles of the Hae-EVs through different pathways. Our findings provide EV-based pathological features and the underlying mechanism of haemorrhoids.

ABSTRACT

Extracellular vesicles (EVs) play important roles in many pathophysiologies as cell-to-cell communication vehicles. However, the features and potential functions of the EVs in haemorrhoids remain unclear. Therefore, we performed microRNA (miRNA) microarray analysis in EVs derived from haemorrhoid tissue to identify the profile of miRNAs in these EVs and predict their potential functions. We obtained typical EVs from both haemorrhoid and control tissues. Microarray analysis identified 447 miRNAs with significant differential expresssion (DE): 245 upregulated and 202 downregulated. The top three upregulated miRNAs in haemorrhoid EVs (Hae-EVs), namely miR-6741-3p, miR-6834-3p and miR-4254, were detected by RT-qPCR in both Hae-EVs and haemorrhoid tissues. Interestingly, we found a different expression pattern in the haemorrhoid tissues from that in Hae-EVs. The potential target genes of these DE-miRNAs were predicted by the miRWalk and miRDB databases. Gene ontology (GO) analysis of the target genes showed that the DE-miRNAs contributed mainly to protein kinase activity, transcriptional activity and ubiquitin-protein function. KEGG search found that the DE-miRNAs might regulate the MAPK and Ras signalling pathways. These findings revealed, for the first time, the miRNA profiles in Hae-EVs and provided potential targets and pathways involved in the pathological process.

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

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

Prevalence of Obstructed Defecation among Patients Who Underwent Hemorrhoidectomy and Correlation between Preoperative Constipation Score and Postoperative Patients' Satisfaction: A Prospective Study in Two Centers

BACKGROUND AND OBJECTIVES

obstructed defecation syndrome (ODS) is a common but underestimated condition that may affect the outcomes after hemorrhoidectomy. Therefore, the aim of this study was to determine the prevalence of obstructed defecation syndrome (ODS) among patients who underwent hemorrhoidectomy and to assess the correlation between preoperative constipation score and postoperative patients' satisfaction.

MATERIALS AND METHODS

This prospective study included adult patients who underwent hemorrhoidectomy for 3rd and 4th-grade hemorrhoidal diseases. All participant patients underwent an assessment of functional OD severity by the Agachan-Wexner Constipation Scoring System. All patients were subjected to conventional hemorrhoidectomy. At 6 months postoperatively, patients were assessed again for their constipation score and postoperative patients' satisfaction.

RESULTS

The study included 120 patients (62 males and 58 females) with a mean age of 38.7 ± 12.1 years. About one-quarter of patients (24.2%) had obstructed defecation (constipation score ≥12). ODS (constipation score ≥12) was found to be significantly more among older patients, female patients, especially those with multiple pregnancies and multiple labors, and those with perineal descent. The postoperative constipation score (5.6 ± 3.3 mean ± SD) showed significant improvement (p = 0.001) compared to (9.3 ± 3.9 mean ± SD) preoperatively. Postoperative patients' satisfaction (mean 12.3 ± 3.0) at 6 months had a negative correlation with preoperative total constipation score (r = -0.035, p = 0.702).

CONCLUSIONS

The prevalence of obstructed defecation among patients with hemorrhoids was higher than reported among the general population. High preoperative constipation scores had a negative correlation with postoperative patients' satisfaction. Routine preoperative measurement of ODS can allow the detection of this particular group of patients who require a more physical and psychological evaluation, in addition to special preoperative counseling.

Comparision of Ligasure hemorrhoidectomy and conservative treatment for thrombosed external hemorrhoids (TEH) in pregnancy

BACKGROUND

Ligasure hemorrhoidectomy for thrombosed external hemorrhoids in pregnancy has been rarely studied.

OBJECTIVE

The purpose of this article is to study the efficacy and safety of Ligasure hemorrhoidectomy comparing with conservative treatment for thrombosed external hemorrhoids in pregnancy.

DESIGN

This was a retrospective cohort study.

SETTING

The patients were treated at a tertiary referral center in China.

PATIENTS

94 pregnant patients hospitalized for thrombosed external hemorrhoids from September 2020 to December 2021.

INTERVENTIONS

Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes.

MAIN OUTCOME MEASURES

Symptom relief, recurrence and satisfaction of thrombosed external hemorrhoids in pregnancy with different interventions.

RESULTS

There were no differences between groups in maternal age, gestational age, body mass index, parity, constipation and a prior history of thrombosed external hemorrhoids. The pain scores were less in surgical group than in conservative group in post-treatment days 1 and 7. Time to return to normal activities was shorter in surgical group than in conservative group (6.51 vs. 13.52 days, P < 0.001). Post-treatment complications were mild in surgical group and there were no significant differences concerning the rate of abortion, preterm birth, cesarean delivery and weight of fetus. Recurrence rate was significantly lower in surgical group (8.57% vs. 30.43%, P = 0.017). The patient satisfaction scores were significantly higher in surgical group than in conservative group (Z = - 2.979, P = 0.003).

LIMITATIONS

This was a retrospective study with a limited number of patients, the data was obtained from only one center.

CONCLUSIONS

Comparing with conservative treatment, Ligasure hemorrhoidectomy for TEH in pregnancy results in more rapid pain relief, shorter time to return to normal activities, lower incidence of recurrence, and better patient satisfaction. This type of surgery has low and mild postoperative complications, is not attended by any risk to the mother or her fetus.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review

BACKGROUND

Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.

AIM

To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.

METHODS

We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.

RESULTS

Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.

CONCLUSION

Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

Sclerotherapy for III- and IV-degree hemorrhoids: Results of a prospective study

Background

In the last 2 years, anorectal surgery has been strongly affected and even surgery for urgent cases cannot be scheduled; also, patients with III- and IV-degree bleeding hemorrhoids should be treated conservatively. The aim was to evaluate the effectiveness of sclerotherapy in patients who had to postpone surgery.

Methods

We included all patients with III- and IV-degree bleeding hemorrhoids who underwent outpatient sclerotherapy. The visual analog scale and the hemorrhoid severity score were used at the baseline and at 4 weeks after the procedure with a telephone interview, and all patients were outpatient-evaluated 1 week, 1 month, and 1 year after the treatment. All pre- and postoperative data were recorded.

Results

From October 2020 to November 2021, 19 patients with III- (12 patients; 63%) and IV-degree (7 patients; 37%) bleeding hemorrhoids were enrolled. The mean operative time was 4.5 min, and no intraoperative complications occurred. One case of tenesmus and three failures were detected. Six months after the procedure, the overall success rate was 84%, although all of the patients enrolled reported persistent bleeding at the end of the study period. Of these, 5 patients (26%) were scheduled for surgery and 11 patients (58%) refused surgery and asked to undergo a re-do sclerotherapy.

Conclusion

Sclerotherapy with 3% polidocanol foam is a safe and effective procedure also in III- and IV-degree bleeding hemorrhoids. The long-term data on the length of the foam remain to be evaluated in additional studies.

Polidocanol Foam Sclerotherapy Versus Rubber Band Ligation in Hemorrhoidal Disease Grades I/II/III: Randomized Trial

BACKGROUND

Rubber band ligation and sclerotherapy are considered the office-based procedures of choice in hemorrhoidal disease. However, there are no studies comparing rubber band ligation and polidocanol foam sclerotherapy.

OBJECTIVE

We aimed to evaluate the efficacy and safety of polidocanol foam sclerotherapy compared with rubber band ligation.

DESIGN

This study was a randomized open-label study with 1-year follow-up.

SETTINGS

The study was conducted in the colorectal unit of a tertiary hospital.

PATIENTS

One hundred twenty patients with hemorrhoidal disease grades I to III were included.

INTERVENTIONS

Patients were stratified by hemorrhoidal disease grade and randomly assigned (1:1) to treatment with either rubber band ligation (n = 60) or polidocanol foam sclerotherapy (n = 60).

MAIN OUTCOME MEASURES

Efficacy outcomes included therapeutic success and recurrence. Safety outcomes included the occurrence of complications related to the procedures.

RESULTS

Therapeutic success was not significantly different between the groups (polidocanol foam sclerotherapy 93.3% vs rubber band ligation 85.0%, p = 0.14). However, complete success rate was higher in the polidocanol foam sclerotherapy group (88.3% vs 66.7%, p = 0.009) with fewer office-based sessions (mean ± SD: 1.32 ± 0.60 vs 1.62 ± 0.76, p = 0.02). Recurrence rates were lower in the polidocanol foam sclerotherapy group (16.1% vs 41.2%, p = 0.004). Most recurrences were mild (83.3%). Complications were more frequent in the rubber band ligation group (30.0% vs 10.0%, p = 0.01) and were mostly minor (91.7%). No severe complications were observed in either group.

LIMITATIONS

This study was performed in a single center, and both patients and investigators were not blinded to the treatment group.

CONCLUSIONS

Both procedures are effective in the treatment of hemorrhoidal disease grades I to III. Polidocanol foam sclerotherapy was more effective than rubber band ligation when considering complete success. Patients in the polidocanol foam sclerotherapy group needed fewer treatment sessions, had lower recurrence rates, and were less likely to have complications. See Video Abstract at http://links.lww.com/DCR/B816.

REGISTRATION

https//www.clinicaltrials.gov; Identifier: NCT04091763.

ESCLEROTERAPIA CON ESPUMA DE POLIDOCANOL VERSUS LIGADURA CON BANDA DE GOMA EN LOS GRADOS I / II / III DE ENFERMEDAD HEMORROIDAL ENSAYO ALEATORIZADO

ANTECEDENTES:La ligadura con banda elástica y la escleroterapia se consideran los procedimientos de elección en el consultorio para la enfermedad hemorroidal. Sin embargo, no hay estudios que comparen la ligadura con bandas elastica y la escleroterapia con espuma de polidocanol.OBJETIVO:Nuestro objetivo fue evaluar la eficacia y seguridad de la escleroterapia con espuma de polidocanol en comparación con la ligadura con bandas elastica.DISEÑO:Estudio aleatorizado randomizado, abierto, con seguimiento de 1 año.AJUSTES:El estudio se realizó en una unidad colorrectal de un hospital terciario.PACIENTES:Se incluyeron 120 pacientes con enfermedad hemorroidal grados I a III.INTERVENCIONES:Los pacientes fueron estratificados por grado de enfermedad hemorroidal y asignados al azar (1: 1) al tratamiento con ligadura con banda elastica (n = 60) o escleroterapia con espuma de polidocanol (n = 60).PRINCIPALES MEDIDAS DE RESULTADO:Los resultados de eficacia incluyeron el éxito terapéutico y la recurrencia. Los resultados de seguridad incluyeron la aparición de complicaciones relacionadas con los procedimientos.RESULTADOS:El éxito terapéutico no fue significativamente diferente entre los grupos (escleroterapia con espuma de polidocanol 93,3% vs ligadura con banda de goma 85,0%, p = 0,14). Sin embargo, la tasa de éxito completo fue mayor en el grupo de escleroterapia con espuma de polidocanol (88,3% vs 66,7%, p = 0,009), con menos sesiones en el consultorio (media ± desviación estándar: 1,32 ± 0,60 vs 1,62 ± 0,76, p = 0,02). Las tasas de recurrencia fueron más bajas en el grupo de escleroterapia con espuma de polidocanol (16,1% vs 41,2%, p = 0,004). La mayoría de las recurrencias fueron leves (83,3%). Las complicaciones fueron más frecuentes en el grupo de ligadura con bandas elastica (30,0% vs 10,0%, p = 0,01) y fueron en su mayoría menores (91,7%). No se observaron complicaciones graves en ninguno de los grupos.LIMITACIONES:Este estudio se realizó en un solo centro y ni los pacientes ni los investigadores estaban cegados al grupo de tratamiento.CONCLUSIONES:Ambos procedimientos son efectivos en el tratamiento de la enfermedad hemorroidal grados I a III. La escleroterapia con espuma de polidocanol fue más eficaz que la ligadura con banda de goma cuando se consideró el éxito completo. Los pacientes del grupo de escleroterapia con espuma de polidocanol necesitaron menos sesiones de tratamiento, tuvieron tasas de recurrencia más bajas y menos probabilidades de tener complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/B816. (Traducción-Dr Yolanda Colorado)ClinicalTrials.gov, número NCT04091763.

Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review

Background and Objectives: Excisional hemorrhoidectomy is considered as a mainstay operation for high-grade hemorrhoids and complicated hemorrhoids. However, postoperative pain remains a challenging problem after hemorrhoidectomy. This systematic review aims to identify pharmacological and non-pharmacological interventions for reducing post-hemorrhoidectomy pain. Materials and Methods: The databases of Ovid MEDLINE, PubMed and EMBASE were systematically searched for randomized controlled trails (published in English language with full-text from 1981 to 30 September 2021) to include comparative studies examining post-hemorrhoidectomy pain as their primary outcomes between an intervention and another intervention (or a sham or placebo). Results: Some 157 studies were included in this review with additional information from 15 meta-analyses. Fundamentally, strategies to reduce post-hemorrhoidectomy pain were categorized into four groups: anesthetic methods, surgical techniques, intraoperative adjuncts, and postoperative interventions. In brief, local anesthesia-alone or combined with intravenous sedation was the most effective anesthetic method for excisional hemorrhoidectomy. Regarding surgical techniques, closed (Ferguson) hemorrhoidectomy performed with a vascular sealing device or an ultrasonic scalpel was recommended. Lateral internal anal sphincterotomy may be performed as a surgical adjunct to reduce post-hemorrhoidectomy pain, although it increased risks of anal incontinence. Chemical sphincterotomy (botulinum toxin, topical calcium channel blockers, and topical glyceryl trinitrate) was also efficacious in reducing postoperative pain. So were other topical agents such as anesthetic cream, 10% metronidazole ointment, and 10% sucralfate ointment. Postoperative administration of oral metronidazole, flavonoids, and laxatives was associated with a significant reduction in post-hemorrhoidectomy pain. Conclusions: This systematic review comprehensively covers evidence-based strategies to reduce pain after excisional hemorrhoidectomy. Areas for future research on this topic are also addressed at the end of this article.

Office-Based Procedures in the Management of Hemorrhoidal Disease: Rubber Band Ligation versus Sclerotherapy - Systematic Review and Meta-Analysis

Introduction

The most frequently used office-based procedures in hemorrhoidal disease (HD) are rubber band ligation (RBL) and sclerotherapy. Few studies have been published comparing the various types of instrumental therapy. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of sclerotherapy and RBL.

Methods

Three online databases were searched. Efficacy (control of symptoms, prolapse, bleeding and pain, patients' satisfaction, and disease recurrence) and safety (complications, such as pain and bleeding) were the assessed outcomes. Pooled relative risks (RR) were computed for each outcome using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I².

Results

Six RCTs and three cohort studies were included. Control of prolapse and bleeding was significantly higher with RBL (93.1% RBL vs. 66.4% sclerotherapy, RR 1.34, 95% CI 1.12-1.60 and 89.1% RBL vs. 78.7% SCL, RR 1.17, 95% CI 1.02-1.34, respectively). Both techniques had similar results in terms of pain relief, overall control of symptoms, and risk of recurrence at 3 months. Although patient satisfaction was significantly higher with RBL (77.8% RBL vs. 46.7% sclerotherapy, RR 1.59, 95% CI 1.01-2.50), post-procedural pain was significantly higher with this technique (24% RBL vs. 14% sclerotherapy, RR 1.74, 95% CI 1.32-2.28). There was no significant difference regarding post-procedure bleeding (11.1% RBL vs. 8.7% sclerotherapy, RR 1.29, 95% CI 0.86-1.94). In the subgroup analysis, according to the HD grade, post-procedure pain was higher with RBL only in HD grade II (vs. HD grade I-III).

Conclusions

RBL performs better than sclerotherapy in controlling HD symptoms, specifically prolapse and bleeding, although post-procedural pain is a frequent complication. Recurrence is similar with both procedures. While waiting for the publication of results with sclerotherapy with new sclerosants, RBL remains the office-based treatment of choice in HD.

Outcome of a modified Park's submucosal hemorrhoidectomy versus Milligan-Morgan for grade III-IV circumferential prolapsed hemorrhoids

BACKGROUND

This prospective randomized controlled study compared the short- and long-term efficacy and advantages of modified Park's submucosal over Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of grade III and IV circumferential prolapsed hemorrhoids (CPH).

METHODS

A total of 186 consecutive patients with grade III or IV CPH were enrolled. The patients were randomized to MPSH (n = 93) or MMH (n = 93) treatment groups. Patient data included demographics, clinical characteristics, surgical parameters, underlying or arising complications, and CPH recurrence. The patients were closely followed up for at least 24 months.

RESULTS

The patient demographic data and clinical parameters were comparable in the two groups (P > 0.05). MPSH took significantly longer operative time (P < 0.05). Although there was no significant difference in mean postoperative pain between the two groups at days 3 and 14, pain at day 7 was significantly more frequent and severe in the MMH group (P < 0.05). There were no significant group differences in postoperative bleeding, intraoperative blood loss, or development of anal stenosis (P > 0.05). However, the cumulative relapse-free rate was substantially higher in the MPSH group (P < 0.05).

CONCLUSION

MPSH and MMH are both practical and safe techniques for treating grade III and IV CPH disease. However, MPSH is safer, easier, and faster to perform and is associated with fewer recurrences within 24 months of surgery. Additional clinical studies are needed to validate these conclusions.

Insights into the management of anorectal disease in the coronavirus 2019 disease era

Coronavirus 2019 disease (COVID-19) has created major impacts on public health. The virus has plagued a large population requiring hospitalization and resource utilization. Knowledge about the COVID-19 virus continues to grow. It can commonly present with gastrointestinal symptoms; initially, this was considered an atypical presentation, which led to delays in care. The pandemic has posed serious threats to the care of anorectal diseases. Urgent surgeries have been delayed, and the care of cancer patients and cancer screenings disrupted. This had added to patient discomfort and the adverse outcomes on healthcare will continue into the future. The better availability of personal protective equipment to providers and standard checklist protocols in operating rooms can help minimize healthcare-related spread of the virus. Telehealth, outpatient procedures, and biochemical tumor marker tests can help with mitigation of anorectal-disease-related problems. There is limited literature about the clinical management of anorectal diseases during the pandemic. We performed a detailed literature review to guide clinicians around management options for anorectal disease patients. We also highlighted the health challenges seen during the pandemic.

Clinical study of herbal mixture "Diding Oral Medicine" as an alternative to preventative antibiotics in perioperative hemorrhoids: A CARE-compliant article

To study the clinical effects of Diding Oral Medicine as an alternative to preventative antibiotics in perioperative hemorrhoids.From August 2017 to February 2018, a total of 214 patients who were treated with external exfoliation and internal ligation of mixed hemorrhoids in our hospital were divided into the control group and experimental group by way of stratified random (107 cases in each group). Patients in the control group were given antibiotics preventatively before operation, while patients in the experimental group took Diding Oral Medicine before operation, and the white blood cell count, neutrophil count, wound recovery, pain score, anal bulge score, and pathogen culture of wound secretions were compared between the 2 groups.There was no significant difference in white blood cell count and neutrophil count between both groups before and after operation (P > .05). The wound seepage score, wound edema score, and wound area score in the experimental group were lower than those in the control group, and the wound healing in the experimental group was shorter than that in the control group (all P < .05). The pain score and anal bulge score of the experimental group were decreased significantly compared to the control group (P < .05). In addition, the detection rate of pathogenic bacteria in the experimental group was downregulated significantly compared to the control group (P < .05).The Diding Oral Medicine has prominent bacteriostatic and antibacterial effects on patients with hemorrhoids during perioperative period, and promotes wound healing, reduces pain stress, and anal bulge.

Evaluation of clinical efficacy of suture-fixation mucopexy in the treatment of prolapsed hemorrhoid

BACKGROUND

The aim of this study was to evaluate the clinical efficacy of suture-fixation mucopexy in the treatment of prolapsed hemorrhoids.

METHODS

A total of 123 patients with grade II, III, and IV hemorrhoids were admitted to The TCM Hospital of Pu Dong New District between 2018 and 2019. They were randomly divided into the suture-fixation group (SF, N.=60) and the Milligan-Morgan hemorrhoidectomy group (MM, N.=63). Clinical efficacy, postoperative pain, average operation time, hospital stay, complications, and patient satisfaction were prospectively evaluated.

RESULTS

No significant differences were identified in clinical efficacy; operation time and hospital stay between the two groups (P>0.05). However, VAS Score in the SF group was lower than that in the MM group. And the SF group was also more advantageous in anal function protection (P<0.05). In addition, the results of the follow-up survey revealed no significant difference in postoperative recurrence rate and patient satisfaction (P>0.05).

CONCLUSIONS

Compared with Milligan-Morgan hemorrhoidectomy, suture-fixation mucopexy is as effective in the treatment of prolapsed hemorrhoid, but it has more advantages in reducing postoperative pain and protecting the anal function.

Trends Associated with Hemorrhoids in Japan: Data Mining of Medical Information Datasets and the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan

Hemorrhoids are a common anorectal disease. Epidemiological studies on medication trends and risk factors using information from real-world databases are rare. Our objective was to analyze the relationship between hemorrhoid treatment prescription trends and several risk factors using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan and related medical information datasets. We calculated the standardized prescription ratio (SPR) based on the 2nd NDB Open Data Japan from 2015. The correlation coefficients between the SPR of antihemorrhoidals and those of "antispasmodics," "antiarrhythmic agents," "antidiarrheals, intestinal regulators," "purgatives and clysters," "hypnotics and sedatives, antianxietics," "psychotropic agents," and "opium alkaloids preparations" were 0.7474, 0.7366, 0.7184, 0.6501, 0.6320, 0.4571, and 0.4542, respectively. The correlation coefficient between the SPR of antihemorrhoidals and those of "average annual temperature," "percentage of people who were smokers," and "percentage of people who drank regularly" were -0.7204, 0.6002, and 0.3537, respectively. The results of cluster analysis revealed that Hokkaido and Tohoku regions tended to have low average annual temperature values and high percentage of people who were smokers and had comparatively high SPRs of "antispasmodics," "antiarrhythmic agents," "antidiarrheals, intestinal regulators," "purgatives and clysters," "hypnotics and sedatives, antianxietics," "psychotropic agents," and "opium alkaloids preparations." Antihemorrhoidals are frequently used in Hokkaido and Tohoku, Japan; thus, it is important for these prefectural governments to focus on these factors when taking measures regarding health promotion.

Amelioration of muscular spasm-induced pain of Guangtongxiao recipe in a non-everted gut sac in vitro model

BACKGROUND

The modern study of the traditional Chinese medicine (TCM) compound recipes is a complex issue because of the large number of components in the recipes that would produce several metabolites after entering the body. The TCM compound recipes are known to have the advantage of synergistic treatment by multiple targets due to diverse components. Therefore, a research method that can reflect the overall effect of compounds with multi-components is essential. The pharmacological studies of the classic TCM compound recipes mainly use the sero-pharmacological method. It is a semi-in vivo study method, and the drug to be tested in the in vitro experiment is the drug-containing serum from the model animals (the drug to be tested is a mixed drug system containing the prototype drugs in animal bodies that have pharmacodynamic effects and the metabolites). Herein, a safe and effective external TCM recipe was used to develop another semi-in vivo experimental method to reflect the overall effects of TCM.

AIM

To observe the effects of in-vitro intestinal absorption liquid of aqueous extracts of the TCM compound recipe-Guangtongxiao foam aerosol (Guangtongxiao)-on the tension of isolated rectal rings of mouse and investigate the underlying mechanisms of antispasmodic and amelioration of muscular spasm-induced pain.

METHODS

Intestinal absorption liquid of the Guangtongxiao aqueous extract at the five time points (30, 45, 75, 105, and 120 min) was prepared using a non-everted gut sac method. The isolated rectal rings of mice were prepared by pre-contraction using potassium chloride (KCl) or acetylcholine chloride (ACh) to make steady contraction. The intestinal absorption liquid were added cumulatively to the sink with the constricted rectal rings. The effects of the five groups of the intestinal absorption liquid with different drug concentration were observed on the tension of the isolated rectal rings. Then the ex vivo perfusion of the mouse rectal ring was performed as same as Guangtongxiao intestinal absorption liquid experiments, and the effects of two major components of Guangtongxiao, paeoniflorin (Pae) and tetrahydropalmatine (THP), on the rectal ring pre-treated with high concentration of KCl and ACh to induce contraction were studied.

RESULTS

The relaxation rate of the five groups of the intestinal canals increased significantly with 3200 μL cumulative sample volume as compared to the blank group (P < 0.01). It suggested that the relaxation activity of the intestinal absorption liquid enhanced significantly with the prolongation of the interaction between isolated rectal rings and intestinal absorption liquid in a time-dependent manner. Also, significant differences were detected while comparing between the 120-min intestinal absorption liquid group and the blank group with respect to various cumulative sampling volumes (P < 0.01). In addition, the intestinal relaxation rate elevated gradually with the increase in sampling volume, indicating that the concentrations of active substances in the intestinal absorption liquid prepared by the non-everted gut sac model increased and the intestinal relaxation activity was enhanced with the prolongation of the absorption time in a dose-dependent manner. And Pae and THP in a concentration-dependent manner caused relaxation of the rectal ring, which is pretreated with high K⁺(KCl) and ACh to induce contraction. The EC₅₀ of Pae and THP was 8.67 × 10^-5 M (6.68 × 10^-5-1.13 × 10^-4) and 1.41 × 10^-4 M (1.24 × 10^-4-1.61 × 10^-4) in the contraction model induced by KCl, and was 6.15 × 10^-5 M (4.47 × 10^-5-8.45 × 10^-5), and 1.31 × 10^-4 M(1.22 × 10^-4-1.42 × 10^-4) in the model induced by ACh, respectively.

CONCLUSION

The intestinal absorption liquid of Guangtongxiao exerted a remarkable relaxation activity for the rectal rings, and relaxation of the smooth muscle tension might be one of the antispasmodic mechanisms of Guangtongxiao compound recipe. Also, adopting a semi-in-vivo experimental method to study the efficacy of topical external TCM recipe medicine is optimal.

Short-Term Results of Sclerotherapy with 3% Polidocanol Foam for Symptomatic Second- and Third-Degree Hemorrhoidal Disease

Background: Hemorrhoidal disease (HD) is defined as the symptomatic enlargement and/or distal displacement of anal cushions and is one of the most common proctological diseases. Sclerotherapy (ST) with 3% polidocanol foam induces an inflammatory reaction with sclerosis of the submucosal tissue and consequent suspension of the hemorrhoidal tissue. The aim of this study was to evaluate the short-term effectiveness and safety of ST with 3% polidocanol foam for the treatment of symptomatic second- and third-degree HD.Methods: A total of 66 patients with symptomatic second- and third-degree HD underwent a single ST session between March 2017 and July 2018. A visual analog scale score was used to assess post-operative pain and patient satisfaction. The symptoms severity and anal continence were investigated through the Hemorrhoid Severity Score (HSS) and Vaizey score, respectively, at baseline, at 4 weeks and after 1 year.Results: Fifty-seven out of 66 patients were male (86.3%), and the mean age was 52 (29-75; SD ± 12) years. The mean operative time was 4.5 (2-6; SD ± 1.23) minutes. No intraoperative complications and no drug-related side effects occurred. The overall success rate was 78.8% (52/66 patients) after a single ST session and 86% after two ST sessions (57/66 patients). The mean treatment effect, obtained comparing preoperative and 12 months symptom scores in each patient, showed a median change of 8 (p < 0.001). All patients resumed their normal daily activities the day after the procedures.Conclusions: ST with 3% polidocanol foam is a safe, cost-effective and repeatable conservative treatment.

Pathophysiology of internal hemorrhoids

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries’ of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers’ quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision.

Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study

INTRODUCTION

This study was conducted to determine the frequency of complaints in a cohort of patients with symptomatic hemorrhoidal disease (HD) treated with micronized purified flavonoid fraction (MPFF, Detralex). MPFF was selected for conservative treatment in this population owing to its proven effects on hemorrhoidal symptoms in a large number of patients.

METHODS

This multicenter, non-interventional study was part of the international CHORUS survey (Chronic venous and HemORrhoidal diseases evalUation for improvement of Scientific knowledge), conducted in nine centers in different regions of Russia with the participation of 80 coloproctologists. The study enrolled consecutive patients with complaints of hemorrhoids. All were prescribed MPFF-based conservative treatment. The effect of treatment on HD clinical signs and symptoms was assessed at two follow-up visits performed 5-7 days and 25-30 days after enrollment. Surgical and minimally invasive treatment could be performed from day 7 onwards if required.

RESULTS

A total of 1952 patients were enrolled. Over the entire period of observation, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes. Invasive treatment was performed in 68 (3.5%) patients with grade IV hemorrhoids and was combined with MPFF conservative treatment in 395 (20.2%) patients with grades I-III hemorrhoids.

CONCLUSION

Conservative therapy with MPFF was beneficial for relieving hemorrhoidal symptoms in the majority of patients. MPFF-based treatment was most effective in patients with grade I and II hemorrhoids before irreversible degenerative changes in ligaments of the hemorrhoidal plexuses have occurred. It was also beneficial in preventing disease relapse in patients with more advanced HD and for promoting optimal conditions in the postoperative period.

FUNDING

Servier.

Factors influencing patient delay in individuals with haemorrhoids: A study based on theory of planned behavior and common sense model

AIMS

This study aimed to describe the status of patient delay and examine related factors affecting patient delay in individuals with haemorrhoids in mainland China, based on theory of planned behaviour and common sense model.

BACKGROUND

Studies on patient delay have mainly focused on cancer, tuberculosis and myocardial infarction, but studies on patient delay in individuals with haemorrhoids have yet to be conducted. Compared with other diseases, haemorrhoids are initially considered benign. However, if patients with haemorrhoids seek delayed medical assistance, they pay a large cost for worse symptoms because they fail to seek timely treatments compared with those who receive appropriate treatments at early stages.

DESIGN

A cross-sectional study design was used.

METHODS

The current study was performed on 306 patients with haemorrhoids from June - October 2017. Data were collected via a self-administered pencil-and-paper survey that consisted of a multi-item questionnaire. Stepwise logistic regression analysis was conducted to explore the factors of patient delay.

RESULTS

Middle-aged participants were more than twice more likely to report patient delay than participants in other age groups. A high level of perceived self-efficacy, a high level of illness perceptions and perceived social impact were associated with prolonged delay.

CONCLUSION

This study showed that patient delay is common among patients with haemorrhoids in China. The influencing factors of patient delay were middle-aged, illness perceptions, perceived self-efficacy, and perceived social impact.

Regional Distribution of Nitric Oxide Synthase in Human Anorectal Tissue: A Pilot Study on the Potential Role for Nitric Oxide in Haemorrhoids

OBJECTIVE

To study the distribution of nitric oxide synthase (NOS) isoforms and protein levels in human haemorrhoids and rectal tissue.

METHODS

Protein expression of NOS1, NOS2 and NOS3 was compared between haemorrhoids (n=14) and normal rectal submucosa (n=6) using Western blot analysis. The localisation of all NOS isoforms to specific structures was determined by immunohistochemistry.

RESULTS

Western blot analysis showed median (interquartile range) protein levels of all NOS isoforms were 1.5-2.4 times higher in haemorrhoids than rectal tissue; 121.4 (55.2-165.5) vs 50.0 (25.5-73.7) for NOS1 (p=0.020), 32.2 (23.8-140.6) vs 14.8 (9.6-34.0) for NOS2 (p=0.109), and 80.1 (62.0-139.5) vs 54.3 (48.7 -61.7) for NOS3 (p=0.015). Immunohistochemistry revealed a different distribution and location of all NOS isoforms in vascular and non-vascular structure of haemorrhoids and rectal tissues. The number of haemorrhoid specimens showing positive immunoreactivity of NOS in the vascular endothelium was significantly higher than that in rectal tissue for NOS1 (11/14 (79%) vs 1/6 (17%); p=0.018) and NOS3 (8/14 (57%) vs 0/6 (0%); p=0.042), but not for NOS2 (6/14 (43%) vs 4/6 (67%); p=0.63).

CONCLUSION

Haemorrhoids have significantly higher protein levels of NOS1 and NOS3 than rectal tissue. The vascular endothelium of haemorrhoids also has significantly higher positive immunoreactivity of NOS1 and NOS3 than rectal tissue suggesting that blood vessels in haemorrhoids are exposed to higher NO concentrations than those of rectal tissue. Since haemorrhoids exhibit marked vascular dilatation and present with bleeding or swelling, a reduction in NOS - by applying NOS inhibitors - may potentially improve the symptoms of haemorrhoids.

Traditional and modern aspects of hemorrhoid treatment in Iran: a review

Hemorrhoidal disease is a prevalent anorectal condition which is generally not managed well with current pharmacologic interventions. However, in Iranian traditional medicine (ITM) there are numerous plants with hemorrhoid-healing properties. The present research assembled plants with hemorrhoid-healing properties in ITM; their related pharmacological effects, phytochemical constituents and mechanisms of action in the modern medicine were also gathered. For this purpose, leading ITM textbooks were searched for plants with hemorrhoid-healing effects. Further, in vitro, in vivo and clinical studies on the most cited species were considered using scientific databases. Studying ITM textbooks revealed 37 medicinal plants with hemorrhoid-healing effects. Among the mentioned herbal medicines, six species, including Allium ampeloprasum, Phyllanthus emblica, Aloe vera, Terminalia chebula, Vitis vinifera and Commiphora mukul, had the largest number of related pharmacological effects documented in scientific databases. These herbs from ITM should be considered as important resources for producing novel drugs for hemorrhoid treatment.

Association of chronic obstructive pulmonary disease and hemorrhoids: A nationwide cohort study

According to traditional Chinese medicine (TCM) theory, a specific physiological and pathological relationship exists between the lungs and the large intestine. The aim of this study is to delineate the association of chronic obstructive pulmonary disease (COPD) and hemorrhoids in order to verify the "interior-exterior" relationship between the lungs and the large intestine. A retrospective cohort study is conceived from the National Health Insurance Research Database, Taiwan. The 2 samples (COPD cohort and non-COPD cohort) were selected from the 2000 to 2003 beneficiaries of the NHI, representing patients age 20 and older in Taiwan, with the follow-up ending on December 31, 2011. The COPD cohort (n = 51,506) includes every patient newly diagnosed as having Chronic Obstructive Pulmonary Disease (COPD, ICD-9-CM: 490-492, 494, 496), who have made at least 2 confirmed visits to the hospital/clinic. The non-COPD cohort (n = 103,012) includes patients without COPD and is selected via a 1:2 (COPD: non-COPD) matching by age group (per 5 years), gender, and index date (diagnosis date of COPD for the COPD cohort). Compared with non-COPD cohorts, patients with COPD have a higher likelihood of having hemorrhoids and the age-, gender- and comorbidies-adjusted hazard ratio (HR) for hemorrhoids is 1.56 (95% confidence intervals [CI]:1.50-1.62). The adjusted HR of hemorrhoids for females is 0.79 (95% CI: 0.77-0.83), which is significantly less than that for males. The elderly groups, 40 to 59 years and aged 60 or above, have higher adjusted HRs than younger age groups (20-39 years), 1.19 (95% CI: 1.14-1.26), and 1.18 (95% CI: 1.12-1.24), respectively. Patients with COPD may have a higher likelihood to have hemorrhoids in this retrospective cohort study. This study verifies the fundamental theorem of TCM that there is a definite pathogenic association between the lungs and large intestine.

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids

The aim of the present study was to examine the clinical value of ‘tying, binding and fixing operation’ in treating severe mixed hemorrhoids. A total of 160 patients with severe mixed hemorrhoids were selected and randomly divided into the experimental (n=80) and control (n=80) groups. The groups were treated using ‘tying, binding and fixing operation’ and Doppler ultrasound-guided hemorrhoidal artery ligation (DG-HAL), respectively. The results showed that the average operative time of the experimental group (35.57±6.17) was significantly higher than that of the control group (12.73±4.92). There was no significant difference of blood loss during the operation between the two groups (P>0.05). There was also no significant difference in improving the hemorrhage symptom between the two groups (P>0.05). In addition, concerning improvement of prolapse symptoms and reduction of the volume of hemorrhoids, the experimental group were significantly improved as compared to the control group. No anal function damage in the two groups was identified, and the length of stay in hospital for the two groups was not significantly different (P>0.05). However, the hospitalization cost in the experimental group (5,334.77±875.54) was significantly lower than that of the control group (8,551.81±1,806.54) and satisfaction degree was significantly higher than that of the control group. The incidences of perianal pain, anal edema and dysuria between two groups were not significantly different (P>0.05). There were 10 cases of secondary hemorrhage and 18 cases of infection in the experimental group, and 12 cases of secondary hemorrhage and 14 cases of infection in the control group, although the differences between the two groups were not statistically significant (P>0.05). The incidence rate of local hematoma in the experimental group (1.2%) was significantly lower than that in the control group (15.0%). The recurrence rate of the control group (22.5%) was also significantly higher than that of the experimental group (2.5%). In conclusion, tying, binding and fixing operation is a promising method that may be employed for the treatment of sever mixed hemorrhoids, and it is better than DG-HAL in improving the prolapse and reducing the volume of hemorrhoids.

[Comparison of Doppler-assisted dearterialization with mucopexy and hemorrhoidectomy]

AIM

To compare two methods of hemorrhoid treatment.

MATERIAL AND METHODS

This prospective study included 240 patients with hemorrhoids stage III-IVA. Stages III and IVA were diagnosed in 156 (65%) and 84 (35%) patients respectively. Randomization was performed using envelopes method in one to one distribution. In group 1 (n=120) Doppler-assisted dearterialization of internal hemorrhoids with mucopexy was performed (DDM), in group 2 (n=120) - hemorrhoidectomy using harmonic scalpel (HE).

RESULTS

Duration of surgery was 17.9±6.1 and 34.5±10.1 minutes in DDM and HE groups respectively (p<0.01). Postoperative pain severity was higher in group 2 (4.8 compared with 2.5 scores of the first group (p<0.01). Narcotic analgesics were used less often in DDM group (1.3 doses compared with 6.1 doses in HE group (p<0.01). Disability period was 14.4±5.2 and 30.3±5.4 days in both groups respectively (p<0.01). Immediate postoperative complications occurred in 9 (7.5%) and 19 (15.8%) patients of DDM and HE groups respectively. Recurrent prolapse of internal hemorrhoids was diagnosed in 2 (1.7%) patients of the 1st group in terms of up to 45 days.

CONCLUSION

DDM is reliable minimally invasive method of hemorrhoids stage III-IVA treatment and has similar efficacy with HE. DDM reduces postoperative pain severity, hospital stay and disability period.

Anal cushion lifting method is a novel radical management strategy for hemorrhoids that does not involve excision or cause postoperative anal complications

AIM: To describe the anal cushion lifting (ACL) method with preliminary clinical results.

METHODS: Between January to September 2007, 127 patients who received ACL method for hemorrhoid was investigated with informed consent. In this study, three surgeons who specialized in anorectal surgery performed the procedures. Patients with grade two or more severe hemorrhoids according to Goligher’s classification were considered to be indicated for surgery. The patients were given the choice to undergo either the ACL method or the ligation and excision method. ACL method is an original technique for managing hemorrhoids without excision. After dissecting the anal cushion from the internal sphincter muscle, the anal cushion was lifted to oral side and ligated at the proper position. Clinical characteristics and outcomes of patients were recorded including complications after surgery.

RESULTS: A total of 127 patients were enrolled. Their median age was 42 (19-84) years, and 74.8% were female. In addition, more than 99% of the patients had grade 3 or worse hemorrhoids. The median follow-up period was 26 (0-88) mo, and the median operative time was 15 (4-30) min. After surgery, analgesics were used for a median period of three days (0-21). Pain control was achieved using extra-oral analgesic drugs, although some patients required intravenous injections of analgesic drugs. The median duration of the patients’ postoperative hospital stay was 7 (2-13) d. A total of 10 complications (7.9%) occurred. Bleeding was observed in one patient and was successfully controlled with manual compression. Urinary retention occurred in 6 patients, but it disappeared spontaneously in all cases. Recurrent hemorrhoids developed in 3 patients after 36, 47, and 61 mo, respectively. No anal stenosis or persistent anal pain occurred.

CONCLUSION: We consider that the ACL method might be better than all other current methods for managing hemorrhoids.

Recombinant streptokinase vs hydrocortisone suppositories in acute hemorrhoids: A randomized controlled trial

AIM: To compare the efficacy and safety of recombinant streptokinase (rSK) vs hydrocortisone acetate-based suppositories in acute hemorrhoidal disease.

METHODS: A multicenter (11 sites), randomized (1:1:1), open, controlled trial with parallel groups was performed. All participating patients gave their written, informed consent. After inclusion, patients with acute symptoms of hemorrhoids were centrally randomized to receive, as outpatients, by the rectal route, suppositories of rSK 200000 IU of one unit every 8 h (first 3 units) and afterwards every 12 h until 8 administrations were completed (schedule A), one unit every 8 h until 6 units were completed (schedule B), or 25 mg hydrocortisone acetate once every 8 h up to a maximum of 24 administrations. Evaluations were performed at 3, 5, and 10 d post-inclusion. The main end-point was the 5^th-day response (disappearance of pain and bleeding, and ≥ 70% reduction of the lesion size). Time to response and need for thrombectomy were secondary efficacy variables. Adverse events were also evaluated.

RESULTS: Groups were homogeneous with regards to demographic and baseline characteristics. Fifth day complete response rates were 156/170 (91.8%; 95%CI: 87.3-96.2), 155/170 (91.2%; 95%CI: 86.6%-95.7%), and 46/170 (27.1%; 95%CI: 20.1%-34.0%) with rSK (schedule A and B) and hydrocortisone acetate suppositories, respectively. These 64.6% and 63.9% differences (95%CI: 56.7%-72.2% and 55.7%-72.0%) were highly significant (P < 0.001). This advantage was detected since the early 3^rd day evaluation (68.8% and 64.1% vs 7.1% for the rSK and active control groups, respectively; P < 0.001) and was maintained even at the late 10^th day assessment (97.1% and 93.5% vs 67.1% for rSK and hydrocortisone acetate, respectively; P < 0.001). Time to response was 3 d (95%CI: 2.9-3.1) for both rSK groups and 10 d (95%CI: 9.3-10.7) in the hydrocortisone acetate group. This difference was highly significant (P < 0.001). All subgroup stratified analyses (with or without thrombosis and hemorrhoid classification) showed a statistically significant advantage for the rSK groups. Thrombectomy was necessary in 4/251 and 14/133 patients with baseline thrombosis in the rSK and hydrocortisone acetate groups, respectively (P < 0.001). There were no adverse events attributable to the experimental treatment.

CONCLUSION: rSK suppositories showed a significant advantage over a widely-used over-the-counter hydrocortisone acetate preparation for the treatment of acute hemorrhoidal illness, as well as having an adequate safety profile.

Evidence-based review of gastrointestinal bleeding in the chronic kidney disease patient

Patients with end-stage renal disease are more likely to suffer from gastrointestinal (GI) problems, including bleeding from upper and lower sources. Peptic ulcer disease is the most common cause of upper GI bleeding, and although there is some debate in the literature regarding whether the frequency of ulcer disease is higher in patients with kidney disease, it is well established that outcomes are worse in patients with compromised renal function. Angioectasias can be found throughout the GI tract and are another common cause of bleeding; management can be divided into localized endoscopic therapy and systemic hormonal treatment, or surgery for refractory cases. The most frequent causes of lower GI bleeding in this population, in addition to angioectasias, are diverticulosis, hemorrhoids, and ischemic colitis.

Evaluation of the incidence of haemorrhoidal disease in patients with ankylosing spondylitis

Haemorrhoidal disease (HD) is one of the most common diseases encountered by the clinicians of general surgery. Chronic constipation, pushing during defecation and increased abdominal pressure play an important role in development of haemorrhoidal disease. Patients with ankylosing spondylitis (AS) frequently use the Valsalva manoeuvre in their daily lives, which may increase the abdominal pressure, leading to formation of haemorrhoids. The purpose of this study was to evaluate the incidence of haemorrhoidal disease in patients with AS. A total of 221 individuals were included in this study in three groups as follows: 72 patients with ankylosing spondylitis (AS), 75 patients with chronic low back pain (LBP) and 74 healthy control subjects. Patients were examined both physically and anoscopically, and their histories were taken. The incidence of HD was 45.8% in patients with AS, 16% in patients with chronic LBP and 9.5% in healthy control subjects. The incidence of HD was significantly higher in patients with AS compared to the other groups. Patients with AS have a high incidence of HD, which should be taken into consideration by clinicians during routine examination of these patients.