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Akinmoladun O, Oh W. Management of Hemorrhoids and Anal Fissures. Surg Clin North Am 2024; 104:473-490. [PMID: 38677814 DOI: 10.1016/j.suc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.
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Affiliation(s)
- Oladapo Akinmoladun
- General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA
| | - William Oh
- Colon and Rectal Surgery, Hoag Speicalty Clinic, 16305 Sand Canyon Avenue, Suite 260, Irvine, CA 92618, USA.
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2
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Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2024; 67:614-623. [PMID: 38294832 DOI: 10.1097/dcr.0000000000003276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University, Nashville, Tennessee
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Anuradha R Bhama
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Digestive Disease and Surgery Institute, Cleveland, Ohio
| | - Sandy H Fang
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Aaron J Dawes
- Department of Surgery, Section of Colon and Rectal Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Scripps Clinic Medical Group, Department of Surgery, La Jolla, California
| | - Ian M Paquette
- Department of Surgery Section of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Ihle C, Zawadzki A. Transanal open haemorrhoidopexy: a well-tolerated, minimally invasive surgical method for haemorrhoids grade II to IV. ANZ J Surg 2024; 94:714-718. [PMID: 38115561 DOI: 10.1111/ans.18823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/05/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND To determine 1-year postoperative recurrence rates, postoperative pain and complication rates of transanal open haemorrhoidopexy applied also in grade IV haemorrhoids. METHODS Single-centre retrospective observational study without control group. The primary outcome was recurrence rate after 1 year postoperatively. Secondary outcomes were length of postoperative pain, use of opiates and postoperative complications. The recurrence rate was assessed with the Sodergren haemorrhoid symptom severity score questionnaire. For information on the early postoperative period, a retrospective chart review based on the routine 3-month clinical follow-up was done. RESULTS 135 consecutive patients with haemorrhoids Goligher grades II-IV were operated with transanal open haemorrhoidopexy. 88 patients (65%) consented to participate in the study when approached later via mail. 23% of patients had haemorrhoids Goligher grade IV. 15 patients (17%) needed a second transanal open haemorrhoidopexy for residual haemorrhoidal prolapse. The recurrence rate of prolapsing haemorrhoids was 15% (13 patients) 1 year postoperatively. 21% of patients reported no postoperative pain, 54% described pain for a duration of up to 1 week and 22% for up to 2 weeks. Two patients reported a longer duration of pain of 3 and 4 weeks, respectively. No complications grade Clavien-Dindo III or higher were detected. CONCLUSION The results of our study indicate that transanal open haemorrhoidopexy has a recurrence rate comparable to traditional haemorrhoidectomy including grade IV haemorrhoids and is associated with less pain and tissue damage. A randomized controlled trial may provide further support for the routine application of this method, but may pose challenges.
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Affiliation(s)
- Christof Ihle
- Surgical Department, Torsby Hospital, Torsby, Sweden
| | - Antoni Zawadzki
- Pelvic Floor Center, Department of Surgery, Skånes University Hospital Malmö, Malmö, Sweden
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Amsriza FR, Fakhriani R, Pangki AA. Translation and validation of Indonesian hemorrhoidal disease symptom score (HDSS) and short health scale hemorrhoidal disease (SHSHD). Turk J Surg 2023; 39:336-343. [PMID: 38694532 PMCID: PMC11057928 DOI: 10.47717/turkjsurg.2023.6148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/20/2023] [Indexed: 05/04/2024]
Abstract
Objectives Hemorrhoidal disease, which affects nearly 40% of people, is characterized by pathological alterations and distal displacement of hemorrhoidal tissue. The short health scale (SHSHD) and the hemorrhoidal disease symptom score (HDSS) are two tools that can be utilized to assess the quality of life of hemorrhoidal patients. The present study aims to translate, modify, and validate the HDSS and SHSHD questionnaires in Indonesian. Material and Methods This cross-sectional study assessed the validity and reliability of the HDSS and SHSHD Indonesian adaptation instrument in hemorrhoidal patients from April 15, 2022, and April 1, 2023. Results There were 91 study subjects, 55 males and 36 females. The study showed that the subscale interpretations of the R-values and the full scale scored above 0.25, indicating weak to very strong correlations. These results mean that the HDSS and SHSHD questionnaires are valid for use. Based on the study's results, the R-value of each item, domain, and total score ≥0.8 (p <0.05) indicates that the HDSS and SHSHD instruments are reliable. Conclusion The Indonesian adaptation of the HDSS and SHSHD demonstrates validity and reliability as an assessment tool for measuring the healthrelated quality of life in Indonesian patients diagnosed with hemorrhoidal disease.
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Affiliation(s)
- Fadli Robby Amsriza
- Department of Surgery, Muhammadiyah University of Yogyakarta Faculty of Medicine and Health Sciences, Bantul, Indonesia
| | - Rizka Fakhriani
- Division of Head and Neck Surgery, Department of Otorhinolaryngology, Muhammadiyah University of Yogyakarta Faculty of Medicine and Health Sciences, Bantul, Indonesia
| | - Asmaya Aji Pangki
- Department of Surgery, Islam University of Indonesia Faculty of Medicine, Sleman, Indonesia
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Xiong K, Zhao Q, Li W, Yao T, Su Y, Wang J, Fang H. Comparison of the long-term efficacy and safety of multiple endoscopic rubber band ligations in a single session for varying grades of internal hemorrhoids. Ir J Med Sci 2023; 192:2747-2753. [PMID: 37059872 DOI: 10.1007/s11845-023-03367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND There is no consensus on the number of ligation bands for varying grades of internal hemorrhoids (IH) in a single session of endoscopic rubber band ligation (ERBL). AIMS The aims of this study were to investigate this issue. METHODS Patients with IH were treated with ERBL. The primary endpoint was no hemorrhoid symptoms 6 weeks after ERBL. The secondary endpoints were postoperative complications and recurrence. RESULTS One hundred twenty-three eligible patients met the inclusion criteria, and 3 patients were excluded. The average bands were 3.9 ± 1.1, and grade II hemorrhoids required significantly fewer bands than grade III hemorrhoids (3.45 ± 0.85 vs 4.35 ± 1.06, P = 0.000). 78.8% of patients achieved the primary endpoint. The efficacy of grade II hemorrhoids was higher than that of grade III hemorrhoids (87.8% vs 69.2%). The incidence of postoperative complications was not significantly correlated with the grade of hemorrhoids (P = 0.201) and the number of bands (P = 0.886). The median follow-up time was 14.3 ± 7.9 (1.3-30.9) months. The overall recurrence rate was 25.0%, with grade III significantly higher than grade I-II (32.8% vs 14.6%, P = 0.027). For grade III hemorrhoids, the recurrence rate was lower with more than 4 bands of ligation than with less than 4 bands (26.5% vs 53.3%). CONCLUSIONS The average ERBL treatment of IH requires nearly four bands, and grade II hemorrhoids require less banding than grade III hemorrhoids, while the efficacy was better. Increasing the number of bands improves the treatment efficacy for grade III IH, which could be a strategy to reduce the recurrence rate without increasing postoperative complications.
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Affiliation(s)
- Kangwei Xiong
- Department of Gastroenterology, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
- Center of Gut Microbiota, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
| | - Qian Zhao
- Department of Gastroenterology, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
- Center of Gut Microbiota, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
| | - Wanli Li
- Department of Pharmacology, School of Basic Medical Sciencesof, Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui Province, China
| | - Tingting Yao
- Department of Gastroenterology, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
- Center of Gut Microbiota, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
| | - Yuan Su
- Department of Gastroenterology, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
- Center of Gut Microbiota, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China
| | - Jiajia Wang
- Department of Pharmacology, School of Basic Medical Sciencesof, Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui Province, China.
| | - Haiming Fang
- Department of Gastroenterology, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China.
- Center of Gut Microbiota, the Second Hospital of Anhui Medical University, No. 678, Furong Road, Hefei, 230601, Anhui Province, China.
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De Gregorio MA, Guirola JA, Serrano-Casorran C, Urbano J, Gutiérrez C, Gregorio A, Sierre S, Ciampi-Dopazo JJ, Bernal R, Gil I, De Blas I, Sánchez-Ballestín M, Millera A. Catheter-directed hemorrhoidal embolization for rectal bleeding due to hemorrhoids (Goligher grade I-III): prospective outcomes from a Spanish emborrhoid registry. Eur Radiol 2023; 33:8754-8763. [PMID: 37458757 DOI: 10.1007/s00330-023-09923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES To evaluate the safety and efficacy of catheter-directed hemorrhoidal embolization (CDHE) by microcoil embolization for rectal bleeding due to hemorrhoids classified as Goligher grade I-III. METHODS Eighty patients (62.5% males) with a mean age of 48 ± 9 years were recruited prospectively. All patients had symptomatic bleeding hemorrhoids. All patients were classified according to Goligher classification: grade I (13.7%), grade II (71.1%), grade III (15%), and no grade IV were recruited in this study. In all cases, microcoils were used to embolize the superior rectal artery(SRA), and microspheres if recurrence of bleeding occurred. Follow-up evaluation (1, 3, 6, and 12 months) included clinical examination and anoscopy. A questionnaire was conducted to determine improvement regarding bleeding, quality of life before, and the degree of patient satisfaction of each participant. RESULTS Technical success was achieved in 100% of the cases. Fifty-five (68.7%) participants had the absence of rectal bleeding after 12 months of embolization. VAS and QL improved 4 points and 1.5 respectively after embolization. A total of 25/80 (31.3%) had a recurrence in rectal bleeding. Seventeen (21.3%) patients underwent a second embolization, and four patients (5%) were treated with open hemorrhoidectomy. No major complications were observed. Sixteen participants had minor complications. Subjective post-treatment symptom and QL surveys showed significant differences from the baseline survey. Likewise, the degree of satisfaction in the telephone survey at 12 months revealed a high degree of patient satisfaction (8.3±1.1). CONCLUSIONS The present study demonstrates that CDHE is a feasible, well-tolerated, ambulatory, anal sphincter-sparing procedure for the treatment of internal hemorrhoids. CLINICAL RELEVANCE STATEMENT CDHE is a simple procedure, well tolerated and accepted by patients, that preserves the anal sphincter and presents few complications when metal devices or microspheres are used as embolic agents. KEY POINTS • The technical success rate of CDHE, defined as the closure of all the SRA in their distal segment, was achieved 100% of all patients. However, a second embolization treatment was required since 21.25% of the patients experienced rectal bleeding. • Overall, CDHE's safety profile is acceptable. After the procedure and 1 year of follow-up, no significant complications were observed. • Encouraging clinical outcomes have demonstrated CDHE in individuals with hemorrhoids and mild prolapse Goligher grades I-III with persistent rectal bleeding.
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Affiliation(s)
- Miguel A De Gregorio
- Interventional Radiology, Hospital Clínica Quiron, University of Zaragoza, Zaragoza, Spain
| | - Jose A Guirola
- GITMI, Hospital Clínico Universitario Lozano Blesa, University of Zaragoza, Zaragoza, Spain.
| | | | - José Urbano
- Interventional Radiology, Hospital Ramon y Cajal, GITMI, Madrid, Madrid, Spain
| | - Carolina Gutiérrez
- Interventional Radiology, Hospital de Denia Marina Salud, Alicante, Spain
| | - Abel Gregorio
- Interventional Radiology, Hospital de Denia Marina Salud, Alicante, Spain
| | - Sergio Sierre
- Interventional Radiology, Hospital Prof JP Garrahan, Buenos Aires, Argentina
| | | | - Roman Bernal
- GITMI, Interventional Radiology, Hospital Clínica Quiron, Zaragoza, Spain
| | - Ismael Gil
- Department of Surgery, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Alfonso Millera
- Department of Surgery, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
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Gachabayov M, Angelos G, Orangio G, Abcarian H, Bergamaschi R. Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Ferguson Hemorrhoidectomy for Prolapsed Internal Hemorrhoids: A Multicenter Prospective Study. Ann Surg 2023; 278:376-382. [PMID: 37325897 DOI: 10.1097/sla.0000000000005961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To compare transanal hemorrhoidal dearterialization (THD) with mucopexy to Ferguson hemorrhoidectomy in terms of recurrence rates and quality of life. BACKGROUND There is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared with Ferguson hemorrhoidectomy in terms of recurrence rates. METHODS This was a multicenter prospective study. Participating surgeons performed the operation they knew best enrolling 10 patients each. Surgeons' unedited videos were reviewed by an independent expert. Patients with prolapsed internal hemorrhoids in at least 3 columns were eligible. The primary endpoint was recurrence rates defined as prolapsing internal hemorrhoids. Patient-reported outcomes and satisfaction were evaluated with Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, Short-Form 12 scores, and Patient satisfaction (4-point Likert) scale. RESULTS Twenty surgeons enrolled 197 patients. THD patients had lower Visual pain scores at postoperative day (POD) 1 (6.2 vs 8.3, P =0.047), POD7 (4.5 vs 7.7, P =0.021), POD14 (2.8 vs 5.3, P <0.001), and medication use at POD14 (23% vs 58%, P <0.001). Median follow-up was 3.1 (1.0-5.5) years. Recurrence rates did not differ between the study arms (5.9% vs 2.4%, P =0.253). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, P =0.031) and 3 months (95.1% vs 63.3%, P =0.029), but did not differ at 6 months (91.7% vs 88%, P =0.228) and 1 year (94.2% vs 88%, P =0.836). CONCLUSION THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared with Ferguson hemorrhoidectomy with nonsignificantly different recurrence rates.
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Affiliation(s)
- Mahir Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - George Angelos
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY
| | - Guy Orangio
- Division of Colon and Rectal Surgery, Louisiana State University, New Orleans, LA
| | - Herand Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
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Abstract
One of the most common reasons to consult a coloproctologist is symptomatic haemorrhoids. Typical signs and symptoms as well as a specialised examination, including proctoscopy, are essential for the correct diagnosis. The vast majority of patients can be treated conservatively with excellent results in terms of quality of life. Sclerotherapy provides good control of symptoms at any stage of haemorrhoidal disease. If conservative treatment fails, there are various surgical options. A tailored approach is mandatory. Besides well-known procedures such as Fergusson, Milligan-Morgan procedure or haemorrhoidopexy (Longo) there are less invasive options such as HAL-RAR, IRT, LT and RFA. Postoperative bleeding, pain and faecal incontinence are rare complications after surgery.
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Affiliation(s)
- Christian Pfeil
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, St. Bernward Krankenhaus GmbH, Hildesheim, Deutschland
| | - Jörg Pelz
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, St. Bernward Krankenhaus GmbH, Hildesheim, Deutschland
| | - Niloufar Dusch
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, St. Bernward Krankenhaus GmbH, Hildesheim, Deutschland
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Gambardella C, Brusciano L, Brillantino A, Parisi S, Lucido FS, Del Genio G, Tolone S, Allaria A, Di Saverio S, Pizza F, Sturiale A, Docimo L. Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend. Langenbecks Arch Surg 2023; 408:140. [PMID: 37020091 PMCID: PMC10076349 DOI: 10.1007/s00423-023-02879-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE Hemorrhoidal disease (HD) is a common condition, and several surgical techniques have been proposed to date without being able to achieve definitive consensus on their use and indications. Laser hemorrhoidoplasty (LHP) is a minimally invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser limiting the postoperative discomfort and pain. The aim of the current study was to evaluate the postoperative outcomes of HD patients undergoing LHP vs conventional Milligan-Morgan hemorrhoidectomy (MM). METHOD Postoperative pain, wound care management, symptoms' resolution, patients' quality of life, and length of return to daily activity of grade III symptomatic HD patients undergoing LHP vs MM were retrospectively evaluated. The patients were followed-up for recurrence of prolapsed hemorrhoid or symptoms. RESULT From January 2018 to December 2019, 93 patients received conventional Milligan Morgan as control group and 81 patients received laser hemorrhoidoplasty treatment using a 1470-nm diode laser. No significant intraoperative complications occurred in both groups. Laser hemorrhoidoplasty patients experienced lower postoperative pain score (p < 0.0001) and smoother wound management. After 25 ± 8 months follow-up, the recurrence of symptoms occurred in 8.1% after Milligan-Morgan and 21.6% after laser hemorrhoidoplasty (p < 0.05) with a similar Rorvik score (7.8 ± 2.6 in LHP group vs 7.6 ± 1.9 in MM group, p = 0.12). CONCLUSION LHP demonstrated high efficacy in selected HD patients guaranteeing lower postoperative pain, easier wound care, higher rate of symptoms resolution, and greater patient appreciation compared to MM, even though it had a higher recurrence rate. Larger comparative studies are needed to address this issue.
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Affiliation(s)
- Claudio Gambardella
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy.
| | - Luigi Brusciano
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Antonio Brillantino
- Department of Emergency Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, Naples, Italy
| | - Simona Parisi
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Francesco Saverio Lucido
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Gianmattia Del Genio
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Alfredo Allaria
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 OQQ, UK
| | - Francesco Pizza
- Division of General and Emergency Surgery, Asl Napoli 2 nord, Frattamaggiore, Naples, Italy
| | - Alessandro Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Via Paradisa 2, Pisa, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", via Luigi Pansini n° 5, 80131, Naples, Italy
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Neves S, Falcão D, Povo A, Castro-Poças F, Oliveira J, Salgueiro P. 3% polidocanol foam sclerotherapy versus hemorrhoidal artery ligation with recto anal repair in hemorrhoidal disease grades II-III: a randomized, pilot trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:115-120. [PMID: 35638762 DOI: 10.17235/reed.2022.8568/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Polidocanol foam sclerotherapy (SP) versus doppler-guided hemorrhoidal artery ligation with recto-anal repair (HAL-RAR) in the treatment of hemorrhoidal disease (HD) was analyzed. METHODS A prospective, randomized study including patients with HD grades II and III was performed. Participants were randomly assigned (1:1) into SP or HAL-RAR, during a recruitment period between September 2019 and February 2020. Therapeutic success (Sodergren's and bleeding scores) was the primary outcome. Other outcomes evaluated included complications and implication in the professional life. Efficacy and safety outcomes were evaluated during the 8 weeks after surgery or the final SP session. RESULTS Forty-six patients were allocated either to SP (n=22) or HAL-RAR (n=24). Most patients achieved therapeutic success (SP 100% vs. HAL-RAR 90.9%, p=0.131). Complete success was higher in the SP group (91.7% vs. 68.2%, p=0.045) and SP patients had less complications (25% vs. 68.2%, p=0.003). HAL-RAR had a greater negative impact on work activity of the patient. CONCLUSION SP was more effective and safer than HAL-RAR. SP patients had less impact on their work activity. Clinical trials identifier NCT04675177.
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Affiliation(s)
- Sara Neves
- Instituto Ciências Biomédicas Abel Salazar
| | - Daniela Falcão
- Gastroenterology, Centro Hospitalar Universitário do Porto, Portugal
| | - Ana Povo
- General Surgery, Centro Hospitalar Universitário do Porto
| | | | | | - Paulo Salgueiro
- Gastroenterology, Centro Hospitalar Universitário do Porto, Portugal
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Bagla S, Pavidapha A, Lerner J, Kasimcan MO, Piechowiak R, Josovitz K, Marathe A, Isaacson A, Sajan A. Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center. J Vasc Interv Radiol 2023; 34:745-749. [PMID: 36736822 DOI: 10.1016/j.jvir.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. MATERIALS AND METHODS Retrospective analysis of 134 patients who underwent hemorrhoidal artery embolization (HAE) for symptomatic internal hemorrhoids between August 2021 and June 2022 (76 men and 58 women) was performed. The mean age was 54.9 years, with a mean Goligher hemorrhoid grade (HG) of 2.1. Branches of the superior rectal artery (SRA) or middle rectal artery supplying the corpus cavernosum recti were embolized with both spherical particles and microcoils. Standard-of-care evaluations were performed at baseline and the 1 month follow-up, which included hemorrhoid-related pain (HRP) (0-10), hemorrhoid symptoms score (HSS) (5-20), quality of life (QoL) (0-4), French bleeding score (FBS) (0-9), and HG (0-4). Clinical success was defined as improvement of symptoms without additional treatment. RESULTS Embolization of at least 1 hemorrhoidal artery was achieved in 133 (99%) of the 134 patients. The mean number of SRA branches embolized per patient was 2.9 ± 1.0. Clinical success was seen in 93% (124 of 134) of patients at the 1-month follow-up, with 10 patients requiring repeat embolization. There were significant improvements in all mean outcomes at 1 month: HSS (11-7.8; P < .01), HRP (4.1-1.3; P < .01), QoL (2.2-0.8; P < .01), FBS (4.4-2.2; P < .01), and HG (2.3-1.2; P < .05). There were no severe adverse events. CONCLUSIONS HAE is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids in the short term.
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Affiliation(s)
| | | | - Jade Lerner
- St. George's University, Great River, New York
| | | | | | | | | | | | - Abin Sajan
- Department of Radiology (A.S.), Columbia University Irving Medical Center, New York, New York
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Wee IJY, Koo CH, Seow-En I, Ng YYR, Lin W, Tan EJKW. Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis. Ann Coloproctol 2023; 39:3-10. [PMID: 36593573 PMCID: PMC10009065 DOI: 10.3393/ac.2022.00598.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE This study compared the short- and long-term clinical outcomes of laser hemorrhoidoplasty (LH) vs. conventional hemorrhoidectomy (CH) in patients with grade II/III hemorrhoids. METHODS PubMed/Medline and the Cochrane Library were searched for randomized and nonrandomized studies comparing LH against CH in grade II/III hemorrhoids. The primary outcomes included postoperative use of analgesia, postoperative morbidity (bleeding, urinary retention, pain, thrombosis), and time of return to work/daily activities. RESULTS Nine studies totaling 661 patients (LH, 336 and CH, 325) were included. The LH group had shorter operative time (P<0.001) and less intraoperative blood loss (P<0.001). Postoperative pain was lower in the LH group, with lower postoperative day 1 (mean difference [MD], -2.09; 95% confidence interval [CI], -3.44 to -0.75; P=0.002) and postoperative day 7 (MD, -3.94; 95% CI, -6.36 to -1.52; P=0.001) visual analogue scores and use of analgesia (risk ratio [RR], 0.59; 95% CI, 0.42-0.81; P=0.001). The risk of postoperative bleeding was also lower in the LH group (RR, 0.18; 95% CI, 0.12- 0.28; P<0.001), with a quicker return to work or daily activities (P=0.002). The 12-month risks of bleeding (P>0.999) and prolapse (P=0.240), and the likelihood of complete resolution at 12 months, were similar (P=0.240). CONCLUSION LH offers more favorable short-term clinical outcomes than CH, with reduced morbidity and pain and earlier return to work or daily activities. Medium-term symptom recurrence at 12 months was similar. Our results should be verified in future well-designed trials with larger samples.
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Affiliation(s)
- Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chee Hoe Koo
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Yvonne Ying Ru Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - Wenjie Lin
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
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Picking Up the Threads: Long-Term Outcomes of the Sutured Haemorrhoidopexy: A Retrospective Single-Centre Cohort Study. J Clin Med 2023; 12:jcm12010391. [PMID: 36615189 PMCID: PMC9821446 DOI: 10.3390/jcm12010391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/27/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study aimed to assess the short- and long-term safety and efficacy of the sutured haemorrhoidopexy (SH) in patients with haemorrhoidal disease (HD). METHODS A retrospective study was performed, assessing the following treatment characteristics: number of sutures needed; operation time; perioperative complications; postoperative pain; hospital stay. The short- and long-term postoperative complications, HD recurrence and data on current HD symptoms were assessed according to the Core Outcome Set for HD. RESULTS Between January 2009 and December 2021, 149 patients with HD underwent a SH. One-hundred and forty-five patients were included, with a mean age of 61 years (±12.8), of which 70 were women (48.3%). Patients were predominantly diagnosed with grade III (37.2%) HD and the median follow-up was nine years (5-11). Perioperative complications occurred in four cases (2.8%). In two patients (1.4%), short-term postoperative complications were reported, and in seven patients (6.2%), long-term complications were reported. The cumulative efficacy in terms of freedom of recurrence was 88.3% (95% CI, 83.1-93.5) at six months, 80.0% (95% CI, 73.5-86.5) at one year, and 67.7% (95% CI, 59.7-75.7) at five years. CONCLUSIONS Sutured haemorrhoidopexy is a safe treatment for patients with HD and can be proposed as a minimally invasive surgical treatment if basic and outpatient procedures fail.
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Protocol for the ORION trial (RadiO fRequency ablatION for haemorrhoids): a randomised controlled trial. Tech Coloproctol 2023; 27:117-124. [PMID: 36352146 PMCID: PMC9839800 DOI: 10.1007/s10151-022-02724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Haemorrhoids are common and can significantly impact the personal and working lives of individuals. Those with more severe symptoms and those not responding to conservative management may require surgery. Current surgical techniques are associated with a degree of postoperative discomfort which may delay return to normal activity. Recurrence is lower in more radical procedures but resulting pain is higher. Radiofrequency ablation (RFA) is a new technique that is gaining popularity and has several hypothesised benefits, including reduced pain and recurrence. However, available evidence is limited. A recent overview from the National Institute for Health and Clinical Excellence recommended more research, in the form of randomised controlled trials, be carried out before further investment is made by national health services. Our aim is to assess whether RFA is at least as good in terms of recurrence as existing surgical interventions, but superior in terms of pain, for patients with symptomatic grade II and III haemorrhoids. METHODS The RadiO fRequency ablatION for haemorrhoids (ORION) trial will be a pragmatic multicentre patient/assessor-blind parallel group-controlled trial with economic evaluation. The target sample size is 376 participants (188 per arm) and is based on two co-primary endpoints: (i) a non-inferiority design for recurrence and (ii) superiority design for pain at seven days. Participants with grade II or III haemorrhoids will be recruited in 16 National Health Service hospitals and randomised (1:1) to either RFA or surgeon's choice of surgery. CONCLUSIONS Results will inform future practice for the treatment of grade II-III haemorrhoids and provide evidence for national health services on future investments in RFA. TRIAL REGISTRATION ISRCTN14474552.
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Verre L, Gallo G, Grassi G, Bussolin E, Carbone L, Poto GE, Carpineto Samorani O, Marano L, Marrelli D, Roviello F. Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review. Front Surg 2022; 9:1088546. [PMID: 36620384 PMCID: PMC9811001 DOI: 10.3389/fsurg.2022.1088546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Methods Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2 weeks, 1 month and 6 months after surgery. Results Forty-seven out of 75 patients were male, and the mean age was 50 (± 17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. Conclusions THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.
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Affiliation(s)
- Luigi Verre
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy,Correspondence: Luigi Verre
| | - Gaetano Gallo
- Department of Surgical Sciences, La Sapienza University of Roma, Roma, Italy
| | - Giulia Grassi
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Edoardo Bussolin
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Osvaldo Carpineto Samorani
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
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Symeonidis D, Spyridakis M, Zacharoulis D, Tzovaras G, Samara AA, Valaroutsos A, Diamantis A, Tepetes K. Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study. BMC Surg 2022; 22:416. [PMID: 36474223 PMCID: PMC9724411 DOI: 10.1186/s12893-022-01861-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan-Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) technique. METHODS A retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL-RAR group. Primary end points were recurrence rates and patients' satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables. RESULTS A total of 124 patients were identified, submitted either to HAL-RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females-male / female ratio: 3.6) with a median age of 47 years old (range 18-69) were included in the HAL-RAR group while 47 patients (40 males and 7 females-male / female ratio: 5.7) with a median age of 52 years old (range 32-71) comprised the MM group. At a median follow up of 41 months (minimum 24 months-maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL-RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL-RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99-p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70-p 0.0013) in the HAL-RAR group. CONCLUSIONS In patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL-RAR. In patients with bleeding as the main presenting symptom of HD, HAL-RAR was associated with better patients' satisfaction rates and similar recurrence rates compared to MM.
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Affiliation(s)
- Dimitrios Symeonidis
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Michail Spyridakis
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Dimitrios Zacharoulis
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - George Tzovaras
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Athina A. Samara
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Alexandros Valaroutsos
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Alexandros Diamantis
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Konstantinos Tepetes
- grid.411299.6Department of Surgery, University Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
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Campos FG, Cavalari-Mancuzo D, Bustamante-Lopez LA, Morais PGM, Martinez CAR. IS IT POSSIBLE TO OPTIMIZE STAPLED HEMORRHOIDOPEXY OUTCOMES BY ENLARGING OPERATIVE CRITERIA INDICATIONS? RESULTS OF A TAILORED PROCEDURE WITH ASSOCIATED RESECTION IN A COMPARATIVE PERSONAL SERIES. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1696. [PMID: 36449865 PMCID: PMC9704851 DOI: 10.1590/0102-672020220002e1696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Since its introduction, stapled hemorrhoidopexy has been increasingly indicated in the management of hemorrhoidal disease. AIM Our primary end point was to evaluate the incidence of recurrent disease requiring another surgical intervention. On a secondary analysis, we also compared pain, complications, and patient's satisfaction after a tailored surgery. METHODS We retrospectively reviewed 196 patients (103 males and 93 females) with a median age of 47.9 years (range, 17-78) who were undergoing stapled hemorrhoidopexy alone (STG; n=65) or combined surgery (CSG; n=131, stapled hemorrhoidopexy associated with resection). RESULTS Complications were detected in 11 (5.6%) patients (4.6% for STG vs. 6.1% for CSG; p=0.95). At the same time, symptoms recurrence (13.8% vs. 8.4%; p=034), reoperation rate for complications (3.1% vs. 3.0%; p=1.0), and reoperation rate for recurrence (6.1% vs. 4.6%; p=1.0) were not different among groups. Grade IV patients were more commonly managed with simultaneous stapling and resection (63% vs. 49.5%), but none of them presented symptoms recurrence nor need reoperation due to recurrence. Median pain score during the first week was higher in CSG patients (0.8 vs. 1.7). After a follow-up of 24.9 months, satisfaction scores were similar (8.6; p=0.8). CONCLUSION Recurrent symptoms were observed in 10% of patients, requiring surgery in approximately half of them. Even though the association of techniques may raise pain scores, a tailored approach based on amplified indication criteria and combined techniques seems to be an effective and safe alternative, with decreased relapse rates in patients suffering from more advanced hemorrhoidal disease. Satisfaction scores after hemorrhoidopexy are high.
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Affiliation(s)
| | - Daiane Cavalari-Mancuzo
- Universidade Municipal de São Caetano do Sul, Gastroenterology – São Caetano do Sul (SP), Brazil
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Prevalent Technique and Results of Hemorrhoidal Embolization. J Clin Med 2022; 11:jcm11226631. [PMID: 36431108 PMCID: PMC9698593 DOI: 10.3390/jcm11226631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022] Open
Abstract
Hemorrhoids are blood cushions located in the anus and lower rectum, acknowledged as a common cause of bleeding, which can reduce quality of life. The development of minimally invasive techniques such as endovascular embolization of superior rectal artery, "Emborrhoid technique", is an effective treatment, with no pain or ischemic complications, and allows quick patient recovery. Our purpose is to describe the general technique and discuss the results of the current literature.
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Panneau J, Mege D, Di Biseglie M, Duclos J, Habert P, Bartoli A, Vidal V, Tradi F. Rectal Artery Embolization for Hemorrhoidal Disease: Anatomy, Evaluation, and Treatment Techniques. Radiographics 2022; 42:1829-1844. [DOI: 10.1148/rg.220014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Deng K, Ding Z, Li J. Medical insurance and physician-induced demand in China: the case of hemorrhoid treatments. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:257-294. [PMID: 34773531 DOI: 10.1007/s10754-021-09318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 10/24/2021] [Indexed: 06/13/2023]
Abstract
In October 2015, the Guangdong government of China enacted a so-called unified medical insurance payment for patients residing in Guangdong province, which fundamentally simplifies reimbursement procedures of medical insurance for the involved cross-city in-patients. Using a unique confidential dataset from 2013 to 2018 on hemorrhoid treatments at a renowned hospital in Guangzhou, the provincial capital of Guangdong, and exploiting difference-in-differences estimations based on the abovementioned policy, we document that the physicians' incentives are a negative externality of the full medical insurance policy for cross-city in-patients and account for a 49% probability increase in improper treatments; and neither increasing the communication between physicians and patients nor enhancing the education level of patients reduces the physician-induced demand for improper treatments. A series of robustness tests indicate our findings are solid. In summary, we highlight the substantial roles of medical insurance as a driver of physician-induced demand in an emerging economy such as China.
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Affiliation(s)
- Kebin Deng
- School of Economics and Finance, South China University of Technology, Guangzhou, China
| | - Zhong Ding
- School of Accounting, Guangdong University of Foreign Studies, Guangzhou, China.
| | - Jieni Li
- School of Economics and Finance, South China University of Technology, Guangzhou, China
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21
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Jiang YD, Liu Y, Wu JD, Li GP, Liu J, Hou XH, Song J. Massive gastrointestinal bleeding after endoscopic rubber band ligation of internal hemorrhoids: A case report. World J Clin Cases 2022; 10:6656-6663. [PMID: 35979294 PMCID: PMC9294870 DOI: 10.12998/wjcc.v10.i19.6656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/23/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rubber band ligation (RBL) using rigid anoscope is a commonly recommended therapy for grade I-III symptomatic internal hemorrhoids. Severe complications of RBL include pain, hemorrhage and sepsis. Flexible endoscopic RBL (ERBL) is now more commonly used in RBL therapy but few severe complications have been reported. Here we report on a case of massive bleeding after ERBL.
CASE SUMMARY A 31-year-old female was admitted to the department of gastroenterology with a chief complaint of discontinuous hematochezia for 2 years. No previous history, accompanying diseases or drug use was reported. Physical examination and colonoscopy showed grade II internal hemorrhoids. The patient received ERBL therapy. Five days after ligation, the patient presented with mild hematochezia. On days 7 and 9 after ligation, she presented with a large amount of rectal bleeding, dizziness and weakness. Emergency colonoscopy revealed active bleeding and an ulcer in the anal wound. The patient received two sessions of hemoclipping on days 7 and 9 to treat the bleeding. No further bleeding was reported up to day 15 and she was discharged home. Although the hemorrhoid prolapse disappeared after ERBL, she was dissatisfied with the subsequent complications.
CONCLUSION ERBL therapy is an effective treatment for symptomatic internal hemorrhoids with satisfactory short and long-term recovery. Pain and anal bleeding are the most frequently reported postoperative complications. Coagulation disorders complicate the increased risk of bleeding. Although rarely reported, our case reminds us that those patients without coagulation disorders are also at risk of massive life-threatening bleeding and need strict follow-up after ligation.
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Affiliation(s)
- Yu-Dong Jiang
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ying Liu
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jian-Di Wu
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Gang-Ping Li
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiao-Hua Hou
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jun Song
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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22
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Yu J, Zhong J, Peng T, Jin L, Shen L, Yang M. Modified rubber band ligation for treatment of grade II/III hemorrhoids: clinical efficacy and safety evaluation-a retrospective study. BMC Surg 2022; 22:238. [PMID: 35725452 PMCID: PMC9210638 DOI: 10.1186/s12893-022-01688-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Massive, delayed bleeding (DB) is the most common major complication of Rubber Band Ligation (RBL) for internal hemorrhoids caused by premature band slippage. In this study we modified conventional RBL to prevent early rubber band slippage and evaluated its clinical efficacy and safety. Methods Study participants were consecutive patients with grade II or III internal hemorrhoids treated with RBL at Ningbo Medical Center of Lihuili Hospital from January 2019 to December 2020. Postoperative minor complications such as pain, swelling, anal edema, prolapse recurrence and major complications like DB were retrospectively reviewed. Results A total of 274 patients were enrolled, including 149 patients treated with modified RBL and 125 treated with conventional RBL. There was no statistically significant difference between the two groups at baseline. Five cases of postoperative DB have been observed in the conventional RBL group, compared to none in the modified ones, with a significant difference (P < 0.05). Within three months after surgery, 8 cases in the modified RBL group experienced a recurrence rate of 5.4%, whereas 17 patients in the conventional RBL group experienced a recurrence rate of 13.6%. The difference was statistically significant (P < 0.05). The VAS score, edema, and incidence of sensation of prolapse between the two groups were not significantly different at 3 and 7 days after surgery (P < 0.05). There were also no significant differences in HDSS and SHS scores between the two groups after surgery (P > 0.05). Conclusion Modified RBL may be associated with a lower rate of complications, especially with lower DB rate in comparison with standard RBL. Further studies in larger samples and different design are necessary to confirm these results.
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Affiliation(s)
- Jiazi Yu
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Jie Zhong
- Department of General Surgery, Qianhu Hospital, Ningbo, 315020, China
| | - Tao Peng
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Liangbin Jin
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Leibin Shen
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China.,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China
| | - Mian Yang
- Department of General Sugury, Ningbo Medical Treatment Centre Li Huili Hospital, 1111 Jiangnan Road, Ningbo, 315000, People's Republic of China. .,Li Huili Hospital of Ningbo University, Ningbo, 315000, People's Republic of China.
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Hernández‐Alava M, Pudney S. Mapping between EQ-5D-3L and EQ-5D-5L: A survey experiment on the validity of multi-instrument data. HEALTH ECONOMICS 2022; 31:923-939. [PMID: 35229404 PMCID: PMC9303872 DOI: 10.1002/hec.4487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/06/2021] [Accepted: 12/22/2021] [Indexed: 05/14/2023]
Abstract
EQ-5D is a 5-item questionnaire instrument designed to measure health-related quality of life. It is extremely important, since it is used to measure health benefits in many studies providing evidence for reimbursement decisions by the National Institute for Health and Care Excellence in England and similar policy bodies in other countries. EQ-5D has been redesigned in a more detailed form (EQ-5D-5L), but much existing cost-effectiveness evidence is based on the older version (EQ-5D-3L). Statistical mapping from one version to another is widely used, exploiting data from multi-instrument surveys incorporating both variants. However, little is known about the robustness of data from such multi-instrument surveys. We design a randomized experiment to investigate whether inclusion of both versions at different stages in a single interview gives a reliable picture of the relationship between health measures from the two instruments and embed it in individual interviews from the UK Understanding Society household panel. We find that sequencing of the two versions of EQ-5D within an interview has a significant impact not only on the resulting data but also on the estimated mapping models. We illustrate the non-negligible effects in two real-world cost-effectiveness examples and discuss the implications for future multi-instrument survey design.
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Affiliation(s)
| | - Stephen Pudney
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
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Brown S, Girling C, Thapa Magar H, Chaudry A, Bhatti B, Sayers A, Hind D. Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff. Colorectal Dis 2022; 24:764-772. [PMID: 35119707 PMCID: PMC9310584 DOI: 10.1111/codi.16078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/21/2022] [Accepted: 01/30/2022] [Indexed: 01/15/2023]
Abstract
AIM Guidelines benefit patients and clinicians by distilling evidence into easy-to-read recommendations. The literature around the management of haemorrhoids is immense and guidelines are invaluable to improve treatment integrity and patient outcomes. We identified current haemorrhoid guidelines and assessed them for quality and consistency. METHODS A systematic search of the literature from January 2011 to October 2021 was carried out. Guidelines identified were assessed for quality using the AGREE II instrument and for consistency in terms of tabulated treatment recommendations. RESULTS During this period nine guidelines were identified worldwide. The general quality was poor with only one guideline considered of high enough quality for use. In general, expert selection criteria for guideline development groups were vaguely defined. There were inconsistencies in the interpretation of the published evidence leading to variation in treatment recommendations. DISCUSSION Fewer, higher quality guidelines, with more consistent results, are needed. Particular attention should be given to defining the selection of experts involved.
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Affiliation(s)
- Steven Brown
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Carla Girling
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | | | - Adeeb Chaudry
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Brian Bhatti
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Adele Sayers
- NHS Foundation TrustSheffield Teaching HospitalSheffieldUK
| | - Daniel Hind
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
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Safety and Effectiveness of a New Electrical Detachable Microcoil for Embolization of Hemorrhoidal Disease, November 2020–December 2021: Results of a Prospective Study. J Clin Med 2022; 11:jcm11113049. [PMID: 35683436 PMCID: PMC9181639 DOI: 10.3390/jcm11113049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/05/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
Purpose: The purpose of this study was to prospectively evaluate the efficacy and safety of a new, bare platinum, detachable microcoil as a metallic embolization agent in the treatment of hemorrhoidal disease. Material and Methods: This prospective single-center study evaluated a new, bare platinum, electrical, detachable microcoil (Prestige plus coil (Balt Montmorency France)) for use in vascular embolization in patients with hemorrhoidal disease. Between January 2020 and January 2021, 24 embolization procedures were performed in 21 patients (12 males, 9 females; mean age 44.3 ± 7.3). The inclusion criteria were: (a) participants with grade I, II and III hemorrhoidal disease on the Goligher classification; (b) patients older than 18 years of age with a score of greater than 4 on the French bleeding score (FBS) scale; (c) patients with scores greater than 2 on the scale of discomfort proposed by Tradi and Farfallah. (d) patients who underwent treatment that included the use of the new novel coil (Prestige plus coil (Balt)) as an embolic material. The exclusion criteria were participants who failed to provide informed consent and participants diagnosed with rectal bleeding due to other causes (cancer, fissures or others). Participants with severe renal insufficiency, non-correctable coagulation abnormalities and adverse reactions to the contrast medium not correctable with medication were also excluded. The symptoms, technical aspects, the transarterial approach, clinical and technical success complications and short-term outcomes were assessed. Results: Technical success was obtained in 100% of the cases. Seventeen (80.9%) patients experienced improvements in their hemorrhoidal disease. The VAS and QL scores improved by 4 and 1.5 points (81.2% and 87.5%), respectively, after embolization (pV: 0001). Three (14.2%) patients underwent a second embolization due to rebleeding. One patient (4.7%) underwent surgery. No major complications were observed. Three patients had minor complications. The assessment of subjective post-treatment symptoms and QL surveys showed significant differences from the baseline survey. Likewise, the measurement of the degree of satisfaction using a telephone survey at 12 months revealed a high degree of patient satisfaction over 10 points (mean 8.3 ± 1.1). Conclusions: The present study demonstrates that the use of the new, platinum, detachable, electrical microcoil is safe and well-tolerated in the treatment of hemorrhoidal disease. Key points: Catheter-directed hemorrhoidal dearterialization (CDHD) is the procedure of embolization with embolic agents for the treatment of internal hemorrhoids. CDHD is a simple and safe procedure that is accepted by patients and preserves the anal sphincter; it presents few complications when metal devices or microspheres are used as embolic agents. As the recommended embolization agent in treatments, the Prestige electrical, detachable coil is a safe, easy-to-use and effective arterial embolic device.
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Recurrent bleeding after rubber band ligation diagnosed as mild hemophilia B: a case report and literature review. BMC Surg 2022; 22:124. [PMID: 35365158 PMCID: PMC8973564 DOI: 10.1186/s12893-022-01553-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/09/2022] [Indexed: 11/22/2022] Open
Abstract
Background Hemophilia is a recessive hemorrhagic disease relevant to X chromosome. In mild hemophilia cases, spontaneous bleeding is rare and the blood clotting function is normal, but severe bleeding may occur after trauma or surgery. Therefore, missed diagnosis of hemophilia before operation may contribute to bleeding after hemorrhoid operation. Case presentation A 21-year-old male was hospitalized in the anorectal department because of repeated bleeding after hemorrhoid surgery. Despite several suture hemostasis procedures, the patient still suffered from recurrent bleeding. He had no family history of hemophilia or bleeding tendency, and had not been diagnosed with hemophilia before this admission. The diagnosis of mild hemophilia B was made after further examination of coagulation indexes. By using frozen plasma and coagulation factor complex to supplement coagulation factors, the patient’s bleeding was stopped and he was discharged after 23 days in hospital. During the follow-up, lower-than-normal coagulation factors were still found in him, but no bleeding occurred again. Conclusions The undiagnosed patient with mild hemophilia B has an increased risk of bleeding after hemorrhoid surgery because of the consumption of coagulation factors. This case report aims to address the importance of hemophilia screening before operation and reduce the risk of postoperative bleeding. For patients with recurrent bleeding after hemorrhoid surgery, hemophilia should be further excluded. Wound bleeding may recur in hemophilia patients after suture hemostasis. Therefore, prompt supplementation of coagulation factors is needed to help stop bleeding once the diagnosis of hemophilia is made.
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Early and midterm results of radiofrequency ablation (Rafaelo ® procedure) for third-degree haemorrhoids: a prospective, two-centre study. Tech Coloproctol 2022; 26:479-487. [PMID: 35305182 PMCID: PMC9072280 DOI: 10.1007/s10151-022-02608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/26/2022] [Indexed: 11/19/2022]
Abstract
Background The aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years. Methods We conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine. Results Ninety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization. Conclusions RFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years.
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Yang H, Shi Z, Chen W, Chen T, Ding P, Wang J, Gao J. OUP accepted manuscript. BJS Open 2022; 6:6585159. [PMID: 35552375 PMCID: PMC9099087 DOI: 10.1093/bjsopen/zrac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background The aim of this study was to compare a modified ligation procedure versus stapled haemorrhoidectomy (SH) in patients with symptomatic haemorrhoids. Methods This randomized trial included patients with symptomatic haemorrhoids treated in Shanghai from May 2018 to September 2021. Eligible patients were randomly 1:1 assigned the modified ligation procedure for prolapsed haemorrhoids (MLPPH) and SH groups. The primary outcome was the assessment of efficacy at 6 months after the intervention. The operating time, incidence of complications, clinical effectiveness (pain, Wexner incontinence, haemorrhoid symptom severity (HSS) scores, and 6-month cure rate) were collected, and quality-adjusted life years (QALYs) were adopted as indicator for the cost-effectiveness analysis (CEA). Results Out of 187 patients screened, 133 patients were randomized (67 for MLPPH and 66 for SH). One patient in the MLPPH group was excluded, and two patients were lost to follow-up. The mean operating time was longer in MLPPH than in SH (57.42 min versus 30.68 min; P < 0.001). The median pain score was higher in SH than in MLPPH at postoperative day 3 (P = 0.018), day 7(P = 0.013), and day 14 (P = 0.003). The median Wexner incontinence score was higher in SH than in MLPPH at postoperative month 1 (P = 0.036) and month 3 (P = 0.035), but was similar in the two groups at month 6. In addition, the median HSS score was lower in MLPPH than in SH 6 months after surgery (P = 0.003). The 6-month cure rate was higher in MLPPH than in SH (P = 0.003). CEA showed lower mean costs in MLPPH than in SH (EUR 1080.24 versus EUR 1657.97; P < 0.001) but there was no significant difference in effectiveness (P = 0.181). However, MLPPH was cost-effective (incremental cost-effectiveness ratio, −120 656.19 EUR/QALYs). Conclusion MLPPH was documented as a longer but cost-effective procedure, it provided lower short-term pain, and Wexner and HSS scores. Registration number: Chinese Clinical Trial Registry ChiCTR1800015928 (http://www.chictr.org.cn/searchproj.aspx).
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Affiliation(s)
- Haibo Yang
- Departments of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Zhan Shi
- Departments of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Wei Chen
- Correspondence to: Wei Chen, Department of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, 164 Lanxi Road, Putuo, Shanghai 200062, P.R. China (e-mail: )
| | - Teng Chen
- Departments of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Peilin Ding
- Departments of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Jandong Wang
- Departments of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Jiazhi Gao
- Departments of Anorectal Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
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Pata F, Bracchitta LM, D’Ambrosio G, Bracchitta S. Sclerobanding (Combined Rubber Band Ligation with 3% Polidocanol Foam Sclerotherapy) for the Treatment of Second- and Third-Degree Hemorrhoidal Disease: Feasibility and Short-Term Outcomes. J Clin Med 2021; 11:218. [PMID: 35011962 PMCID: PMC8745462 DOI: 10.3390/jcm11010218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Sclerobanding is a novel technique combining rubber band ligation with 3% polidocanol foam sclerotherapy for the treatment of hemorrhoidal disease (HD). The aim of this study is to evaluate the feasibility, safety and short-term outcomes of sclerobanding in the treatment of second- and third-degree HD. METHODS A retrospective analysis of second- and third-degree HD cases from November 2017 to August 2021 was performed. Patients on anticoagulants or with other HD degrees were excluded. Follow-up was conducted at 1 month, 3 months, 6 months, 1 year and then every 12 months. RESULTS 97 patients with second- (20 pts; 20.6%) and third-degree (77 pts; 79.4%) HD with a mean age of 52 years (20-84; SD ± 15.5) were included. Fifty-six patients were men (57.7%) and forty-one women (42.3%). Median follow-up was 13 months (1-26 months). No intraoperative adverse events or drug-related side effects occurred. Minor complications occurred in four patients (4.1%) in the first 30 postoperative days and all resolved after conservative treatment at the 3-month follow-up visit. No mortality or readmissions were observed. CONCLUSIONS Sclerobanding is a safe technique with a low rate of minor postoperative complications. Further studies on larger samples are necessary to establish the effectiveness and long-term outcomes of the technique.
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Affiliation(s)
- Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, 87064 Corigliano-Rossano, Italy
- La Sapienza University, 00185 Rome, Italy
| | | | - Giancarlo D’Ambrosio
- Department of General Surgery, Surgical Specialties and Organ Transplantation, La Sapienza University, 00161 Rome, Italy;
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Popovtsev MA, Alekberzade AV, Krylov NN. [Hemorrhoidal artery ligation without Doppler navigation in surgical treatment of hemorrhoidal disease]. Khirurgiia (Mosk) 2021:49-55. [PMID: 34941209 DOI: 10.17116/hirurgia202112149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the immediate and long-term results of surgical treatment of hemorrhoidal disease (GD) stage II-III using two methods of identification of hemorrhoidal arteries (HA) with their subsequent ligation and mucopexy. MATERIAL AND METHODS A prospective, randomized, controlled, single-center study was conducted to evaluate the effectiveness of HA ligation with and without Doppler navigation. The study included 120 patients: group A - Doppler-guided ligation (n=60) and group B - ligation without ultrasound (n=60). RESULTS GD stage II was found in 27 patients of the group A and 30 patients of the group B (p=0.4). Mean number of ligated HA in the group A was 3.36, in the group B - 2.83 (p=0.062). Mean number of mucopexy was 3.2 and 3.5, respectively (p=0.8). Mean follow-up period was 8.3±2.1 and 8.1±1.9 months, respectively (p=0.96). Relapse of all preoperative symptoms was registered in 1 patient (1.6%) in the group A. Intermittent bleeding was observed in 5 (8.3%) and 3 (5%) patients, respectively (p=0.71). Periodic hemorrhoid prolapse (GP) occurred in 6 (10%) and 4 (6.6%) respondents, respectively (p=0.74). VAS score of pain syndrome after 2 months and later was 0 - 1 points (p=1.0). Most of patients in both groups (group A - 89%, group B - 94%; p=0.7) noted that surgery did not disrupt their usual lifestyle and relieved from symptoms of GD. CONCLUSION There are no significant advantages of Doppler-guided HA ligation compared to palpation regarding incidence of hemorrhoid prolapse (p=0.74) and hemorrhoidal bleeding (p=0.71). Pain syndrome (p=0.24), incidence of postoperative complications (p=0.51) and relapses (p=0.31) showed comparable safety of both techniques.
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Affiliation(s)
- M A Popovtsev
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Alekberzade
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - N N Krylov
- Sechenov First Moscow State Medical University, Moscow, Russia
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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A Randomized Clinical Study to Compare the Outcome of Hemorrhoidal Artery Ligation (HAL) Procedure with and without Doppler Guidance in Grades I–III Hemorrhoidal Disease. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kuiper SZ, Kimman ML, Rørvik HD, Olaison G, Breukink SO. Making Use of Patient-Reported Outcome Measures for Haemorrhoidal Disease in Clinical Practice: A Perspective. Front Surg 2021; 8:728532. [PMID: 34513917 PMCID: PMC8424037 DOI: 10.3389/fsurg.2021.728532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/26/2021] [Indexed: 11/14/2022] Open
Abstract
Haemorrhoidal disease (HD) affects millions of people around the world and for most it is a recurring problem. Increasingly, clinicians broaden their focus on the patient's experiences with haemorrhoidal symptoms, including their impact on daily life. The patient's experience can be assessed using a patient-reported outcome measure (PROM). A PROM facilitates a deeper understanding of the disease-burden and allows a clinician to obtain information directly from the patients about their experiences with the ailment. Over the last years, PROMs have shown their additional role to traditional outcomes for several diseases and have earned their place in the daily consultation room. In order to improve and personalize the treatment of HD, we endorse the use of validated PROMs in clinical care.
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Affiliation(s)
- Sara Z Kuiper
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Merel L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Håvard D Rørvik
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | | | - Stephanie O Breukink
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
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Dekker L, Bak MTJ, Bemelman WA, Felt-Bersma RJF, Han-Geurts IJM. Hemorrhoidectomy Versus Rubber Band Ligation in Grade III Hemorrhoidal Disease: A Large Retrospective Cohort Study With Long-term Follow-up. Ann Coloproctol 2021; 38:146-152. [PMID: 34314581 PMCID: PMC9021858 DOI: 10.3393/ac.2020.01011.0144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/01/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose Standard therapy for grade III hemorrhoids is rubber band ligation (RBL) and hemorrhoidectomy. The long-term clinical and patient-reported outcomes of these treatments in a tertiary referral center for proctology were evaluated. Methods A retrospective analysis was performed in all patients with grade III hemorrhoids who were treated between January 2013 and August 2018. Medical history, symptoms, reinterventions, complications, and patient-reported outcome measurements (PROM) were retrieved from individual electronic patient files, which were prospectively entered as standard questionnaires in our clinic. Results Overall, 327 patients (163 males) were treated by either RBL (n=182) or hemorrhoidectomy (n=145). The median follow-up was 44 months. The severity of symptoms and patient preference led to the treatment of choice. The most commonly experienced symptoms were prolapse (83.2%) and blood loss (69.7%). Hemorrhoidectomy was effective in 95.9% of the cases as a single procedure, while a single RBL procedure was only effective in 51.6%. In the RBL group, 34.6% received a second RBL session. Complications were not significantly different, 11 (7.6%) after hemorrhoidectomy versus 6 (3.3%) after RBL. However, 4 fistulas developed after hemorrhoidectomy and none after RBL (P<0.05). The pre-procedure PROM score was higher in the hemorrhoidectomy group whereas the post-procedure PROM score did not significantly differ between the groups. Conclusion Treatment of grade III hemorrhoids usually requires more than one session RBL whereas 1-time hemorrhoidectomy suffices. Complications were more common after hemorrhoidectomy. The patient-related outcome did not differ between procedures.
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Affiliation(s)
- Lisette Dekker
- 1Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands.,Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Michiel T J Bak
- 1Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands.,Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Richelle J F Felt-Bersma
- 1Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Dekker L, Han-Geurts IJM, Rørvik HD, van Dieren S, Bemelman WA. Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials. Tech Coloproctol 2021; 25:663-674. [PMID: 33683503 PMCID: PMC8124052 DOI: 10.1007/s10151-021-02430-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/15/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to review clinical outcome of haemorrhoidectomy and rubber band ligation in grade II-III haemorrhoids. METHODS A systematic review was conducted. Medline, Embase, Cochrane Library, Clinicaltrials.gov, and the WHO International Trial Registry Platform were searched, from inception until May 2018, to identify randomised clinical trials comparing rubber band ligation with haemorrhoidectomy for grade II-III haemorrhoids. The primary outcome was control of symptoms. Secondary outcomes included postoperative pain, postoperative complications, anal continence, patient satisfaction, quality of life and healthcare costs were assessed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS Three hundred and twenty-four studies were identified. Eight trials met the inclusion criteria. All trials were of moderate methodological quality. Outcome measures were diverse and not clearly defined. Control of symptoms was better following haemorrhoidectomy. Patients had less pain after rubber band ligation. There were more complications (bleeding, urinary retention, anal incontinence/stenosis) in the haemorrhoidectomy group. Patient satisfaction was equal in both groups. There were no data on quality of life and healthcare costs except that in one study patients resumed work more early after rubber band ligation. CONCLUSIONS Haemorrhoidectomy seems to provide better symptom control but at the cost of more pain and complications. However, due to the poor quality of the studies analysed/it is not possible to determine which of the two procedures provides the best treatment for grade II-III haemorrhoids. Further studies focusing on clearly defined outcome measurements taking patients perspective and economic impact into consideration are required.
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Affiliation(s)
- L Dekker
- Department of Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands.
| | - I J M Han-Geurts
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
| | - H D Rørvik
- Department of Surgery, Holbæk Hospital, Holbæk, Denmark
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | - S van Dieren
- Department of Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Karkalemis K, Chalkias PL, Kasouli A, Chatzaki E, Papanikolaou S, Dedemadi G. Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease. Langenbecks Arch Surg 2021; 406:2489-2495. [PMID: 33959805 DOI: 10.1007/s00423-021-02190-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE A wide variety of methods has been proposed for treating hemorrhoidal disease. The aim of the study is to assess the safety and effectiveness of hemorrhoidal artery ligation with rectoanal repair (HAL-RAR). METHODS Retrospective study from January 2010 to November 2019 of patients who underwent HAL-RAR for grade II, resistant to conservative treatment, and grades III and IV hemorrhoidal disease. Demographics, degree of disease, hospital stay, postoperative pain, complications, and recurrence were recorded. Patients were followed up at postoperative days 1 and 8 and at 1, 6, and 12 months. RESULTS A total of 105 patients (60 men, 45 women) underwent HAL-RAR. Median age was 49 (range, 20-86) years. Two patients with hemorrhoidal thrombosis underwent emergent excision of the hemorrhoid. Median length of hospital stay was 2 (range, 1-13) days. Patients reported median visual analog scale pain score 3 (range, 1-5) on the 1st postoperative day. At 1 month, no patient reported pain, 84.76% of patients confirmed complete resolution of symptoms, while complication rate was 7.61%: 2 patients presented urinary retention, 3 dyschezia, 2 bleeding, and 1 hemorrhoidal necrosis. At 6 months, 2 patients presented mild symptoms and 7 recurrence. At 12 months, 92.4% of patients experienced complete resolution of symptoms, 2 patients intermittent bleeding, and 2 recurrence. Overall recurrence and re-intervention rate were 8.57% rate and 10.5%, respectively. CONCLUSION HAL-RAR is a safe and effective minimal invasive operative technique related to a high percentage of success, low complication, and recurrence rates. Long-term follow-up is lacking and would better establish the results of this technique. TRIAL REGISTRATION Trial registration number NCT04778124 Date of registration 26/02/2021 "retrospectively registered".
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Affiliation(s)
- Konstantinos Karkalemis
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Petros Loukas Chalkias
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Anna Kasouli
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Elina Chatzaki
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Spilios Papanikolaou
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece
| | - Georgia Dedemadi
- Amalia Fleming Surgical Department, Sismanoglio - Amalia Fleming General Hospital, Athens, Greece.
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Keong SYJ, Tan HK, Lamawansa MD, Allen JC, Low ZL, Østbye T. Improvement in quality of life among Sri Lankan patients with haemorrhoids after invasive treatment: a longitudinal observational study. BJS Open 2021; 5:6261799. [PMID: 33960376 PMCID: PMC8088290 DOI: 10.1093/bjsopen/zrab014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/09/2020] [Accepted: 02/03/2021] [Indexed: 11/14/2022] Open
Abstract
Background Haemorrhoids is a common chronic disease that can significantly impact patients’ quality of life. Yet, few studies have evaluated health-related quality of life (HRQoL) of patients with haemorrhoids before and after treatment. This study investigated the HRQoL of patients with haemorrhoids before and after treatment and the change in HRQoL from baseline. Methods A prospective observational study of patients with haemorrhoids was conducted at two public hospitals in Kandy, Sri Lanka. Two questionnaires assessing symptom severity and haemorrhoid-specific QoL were administered at initial consultation and at 4- and 8-week follow-ups after treatment (sclerotherapy, rubber band ligation (RBL), haemorrhoidectomy or evacuation of haematoma). The primary outcome was the least squares (LS) change of HRQoL score from baseline, measured using the Short Health Scale adapted for Haemorrhoidal Disease (4 domains: symptom load, interference with daily activities, concern, general well-being). Results In 48 patients selected for this study, LS mean change from baseline showed significant improvement in HRQoL across all domains and total Short Health Scale adapted for Haemorrhoidal Disease score at 4- and 8-week follow-ups (P < 0.001). Difference in LS mean change from baseline also showed continued improvement of HRQoL from week 4 to week 8 (P < 0.010). ‘Concern’ showed greatest improvement at 4 and 8 weeks (P < 0.001). Averaged LS mean changes from baseline showed RBL had greater improvement of HRQoL compared with sclerotherapy (P = 0.004). Conclusion Patients with haemorrhoids had improved HRQoL after invasive treatment. Haemorrhoid-specific QoL is an important component of the extent of disease and can serve as an aid to guide treatment, assess outcomes and monitor disease.
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Affiliation(s)
| | - H K Tan
- Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
| | - M D Lamawansa
- Department of Surgery, Teaching Hospital Peradeniya, Kandy, Sri Lanka
| | | | - Z L Low
- Duke-NUS Medical School, Singapore
| | - T Østbye
- Duke-NUS Medical School, Singapore
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Mongelli F, Lucchelli M, La Regina D, Christoforidis D, Saporito A, Vannelli A, Di Giuseppe M. Ultrasound-Guided Pudendal Nerve Block in Patients Undergoing Open Hemorrhoidectomy: A Post-Hoc Cost-Effectiveness Analysis from a Double-Blind Randomized Controlled Trial. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:299-306. [PMID: 33953578 PMCID: PMC8088981 DOI: 10.2147/ceor.s306138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 12/19/2022] Open
Abstract
Background Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy. Methods From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed. Results Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482±386 vs 613±543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606±816 vs 2769±1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of −243 ± 881 EUR/pain unit on the VAS. Conclusion Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.
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Affiliation(s)
- Francesco Mongelli
- Department of Surgery, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Massimo Lucchelli
- Financial Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Davide La Regina
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | | | - Andrea Saporito
- Department of Anesthesia, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | | | - Matteo Di Giuseppe
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
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Landolfi V, Brusciano L, Gambardella C, Tolone S, Del Genio G, Grossi U, Gualtieri G, Lucido FS, Docimo L. Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients. Surg Innov 2021; 29:27-34. [PMID: 33830810 DOI: 10.1177/15533506211007292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis. METHODS Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work. RESULTS We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2. CONCLUSIONS The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.
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Affiliation(s)
- Vincenzo Landolfi
- Division of General Surgery, "Agostino Landolfi Hospital" of Solofra, Avellino, Italy
| | - Luigi Brusciano
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Gambardella
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Salvatore Tolone
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gianmattia Del Genio
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ugo Grossi
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giorgia Gualtieri
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Saverio Lucido
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ludovico Docimo
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
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Dekker L, Han-Geurts IJM, van Dieren S, Bemelman WA. HollAND trial: comparison of rubber band ligation and haemorrhoidectomy in patients with symptomatic haemorrhoids grade III: study protocol for a multicentre, randomised controlled trial and cost–utility analysis. BMJ Open 2021. [PMCID: PMC8039253 DOI: 10.1136/bmjopen-2020-046836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction Haemorrhoidal disease is one of the most common anorectal disorders, which affects nearly half of the general population. Treatment of grade III haemorrhoids consists initially of conservative measures, followed by rubber band ligation and haemorrhoidectomy when unsuccessful. Given the current guidelines and numerous modalities the obvious question which needs to be answered is which treatment is the best for grade III haemorrhoids. There is a need for evaluating treatment from the patient’s point of view and transparency in surgical and non-surgical treatment outcome. Methods and analysis This multicentre, randomised controlled, non-inferiority trial with cost–utility analysis compares haemorrhoidectomy with rubber band ligation. Patients aged 18 years and older with symptomatic haemorrhoids grade III are recruited. Primary outcome measure is quality of life at 24 months measured with the EQ-5D-5L and in-hospital (in)direct costs and out-of-hospital postoperative costs. A key secondary outcome is recurrence at 1-year postprocedure. Secondary outcomes are complaint reduction with proctology-specific patient-reported outcome measurements (Haemorrhoid Severity Score, ProctoPROM, PROM-HISS, vaizey score), resumption of work, pain and complication rates. Data are collected at seven different time points. Standard postprocedural care is followed. A sample size has been calculated using a one sided alpha of 0.025 and a power of 80% with an SD of 0.15 and a non-inferiority limit of 0.05. With stratification by centre and to adjust for 10% lost to follow-up the total sample size will be 360 patients in total (180 per group). Data will be analysed according to the intention-to-treat and the per-protocol principle. Ethics and dissemination The protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centres, location AMC. Findings will be disseminated in peer-reviewed journals and presented at conferences, whether they are positive, negative or inconclusive. Trial registration numbers NCT04621695, NTR8020
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Affiliation(s)
- Lisette Dekker
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Susan van Dieren
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Nikam V, Deshpande A, Chandorkar I, Sahoo S. A prospective study of efficacy and safety of rubber band ligation in the treatment of Grade II and III hemorrhoids – a western Indian experience. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Abstract
Background Hemorrhoids are one of the most frequent diseases of the anal region with high prevalence involving all age groups. Multiple treatment options exist with none being perfect. Rubber band ligation of hemorrhoids is a non-operative treatment which can be performed on outpatient basis.
Objective The study was undertaken to determine efficacy of banding in treatment of Grade II and III hemorrhoids and to follow-up patients treated by banding to evaluate for symptomatic relief, recurrence and complications.
Study design A prospective, interventional study with clearance from the institutional ethics committee was undertaken over the period of 2 years in a tertiary referral center with a sample size of 60.
Result Out of 60 patients, 41 patients (68.30%) had Grade II and 19 patients (31.7%) had Grade III hemorrhoids. At first follow up, success rate for Grade II hemorrhoids was 85% (35/41) as compared to 21% (4/19) in Grade III. The unsuccessful 20 patients were re-banded, however only 2 of them responded to procedure. At the end of 6 weeks, 36 patients with Grade II hemorrhoids (88%) were cured. Failure rate was higher for Grade III hemorrhoids (68.42%, n = 13). Success rate was 86.6% for single hemorrhoid. There were no major complications. Anemia reverted significantly with successful band ligation.
Conclusion Rubber band ligation is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an outpatient procedure. It gives better results for Grade II and single hemorrhoids. Recurrence rate after successful band ligation is low.
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Affiliation(s)
- Vinayak Nikam
- Seth G.S. Medical College & K.E.M. Hospital, Department of Surgery, Mumbai, Maharashtra, India
| | - Aparna Deshpande
- Seth G.S. Medical College & K.E.M. Hospital, Department of Surgery, Mumbai, Maharashtra, India
| | - Iti Chandorkar
- Seth G.S. Medical College & K.E.M. Hospital, Department of Surgery, Mumbai, Maharashtra, India
| | - Siddharth Sahoo
- Seth G.S. Medical College & K.E.M. Hospital, Department of Surgery, Mumbai, Maharashtra, India
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Experiences of patients with haemorrhoidal disease – a qualitative study. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Purpose To obtain a better understanding of the patients’ experiences with haemorrhoidal disease’ impact on their daily life and results of treatment by performing a qualitative study.
Method Individually interviews were conducted among patients with haemorrhoidal disease between 2016 and 2017. Each interview was recorded using an audio recorder and transcribed verbatim. A semi-structured interview guide was used with pre-specified topics, based on a previous conducted literature review. Transcripts were coded and the analysis consisted highlighting passages in the text and assigning each passage a code representing the predefined themes from the interview guide. This resulted in a three-level theme hierarchy: overarching theme, mid-level sub-theme and issues.
Results Fifteen participants underwent individual interviews of whom thirteen were conducted by telephone. The mean age was 60.7 years (35–78); five of them were female (33.3%). Pain and blood loss were the most frequently reported symptoms. Participants indicated that these symptoms were directly associated with emotional burden, daily adjustments and social impact. Before diagnosis with haemorrhoidal disease blood loss resulted in feelings of fear and next in embarrassment during social activities. In daily life participants needed to get up early, used sanitary pads for blood loss and anal ice sticks to reduce pain. Participants were often not completely satisfied with the process and outcome of treatment.
Conclusion This first qualitative study provides detailed insight into the patients’ experiences with haemorrhoidal disease, impact on daily life and results of treatment. This information may be used in daily practice to create awareness among clinicians.
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Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review. World J Surg 2021; 45:1222-1236. [PMID: 33469736 DOI: 10.1007/s00268-020-05923-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment. METHODS We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed. RESULTS Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis. CONCLUSION Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.
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Sirakaya M, O'Balogun A, Kassamali RH. Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far? Cardiovasc Intervent Radiol 2021; 44:675-685. [PMID: 33388875 DOI: 10.1007/s00270-020-02733-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/27/2020] [Indexed: 01/02/2023]
Abstract
Haemorrhoids are abnormally enlarged anal cushions within the lower rectum. They are common, and have potential to significantly impact patients' quality of life. Superior rectal artery embolisation is a technique which has been discussed in the literature as far back as 40 years ago. More recently, there has been interest in the role of embolisation in the treatment for haemorrhoids, as an alternative to established minimally invasive and conventional surgical techniques. In this review, we discuss the current literature on the topic, with particular focus on technique, clinical outcomes and complications. Emerging procedural and technical considerations are discussed, with further review of the role of coil vs. particle embolisation.
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Affiliation(s)
| | | | - Rahil H Kassamali
- Department of Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
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45
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Herold A. [Standards and New Developments in Proctology]. Dtsch Med Wochenschr 2020; 145:1742-1747. [PMID: 33254247 DOI: 10.1055/a-1155-8286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
During the last years there was quite a lot of new developments in the international literature. Mostly these were technical methods and instruments. The results were from acceptable improvements to disappointing outcomes. Their focus was haemorrhoidal disease, anorectal fistulas and anal fissures. Despite these new developments all current standards remain on a high level of value.
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Jin J, Xia W, Connolly A, Hill AG. Symptom-based scoring for haemorrhoidal disease: a systematic review. Colorectal Dis 2020; 22:1518-1527. [PMID: 32639663 DOI: 10.1111/codi.15253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/23/2020] [Indexed: 12/31/2022]
Abstract
AIM Haemorrhoidal disease can severely affect a patient's quality of life. Its classification is commonly based on morphology of the degree of prolapse; however, this does not take into account the symptoms and impact on the quality of life. The aim of this systematic review was to determine the most appropriate instruments that classify the severity of disease according to symptoms. METHOD A PRISMA-compliant search was conducted in December 2019 to identify studies that described the validation of a haemorrhoidal symptom score. The measurement properties of the scoring systems were assessed based on the consensus-based standards for the selection of health status measurement instruments (COSMIN) methodology for systematic reviews for patient-reported outcome measures. RESULTS A total of 5288 articles were identified, with five articles included. Three studies developed a scoring system based on a set of core symptoms for a cohort of patients and validated the score against treatment outcomes. One study developed a disease-specific quality of life questionnaire based on symptoms to evaluate disease burden. One study combined both quality of life and symptom measures and tested measurement properties on two cohorts of patients. Only one study demonstrated satisfactory valid, reliable and responsive measurement criteria. CONCLUSION A single study demonstrated sufficient quality in measurement properties to be recommended for clinical use. Further studies in this area should utilize consensus-based standards for designing and reporting validation research to ensure that the appropriate evidence base is acquired if any further patient-reported outcome measures are to be recommended.
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Affiliation(s)
- J Jin
- Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
| | - W Xia
- Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
| | - A Connolly
- Department of Surgery, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
| | - A G Hill
- Department of Surgery, South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
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Kuiper SZ, Dirksen CD, Kimman ML, Van Kuijk SMJ, Van Tol RR, Muris JWM, Watson AJM, Maessen JMC, Melenhorst J, Breukink SO. Effectiveness and cost-effectiveness of rubber band ligation versus sutured mucopexy versus haemorrhoidectomy in patients with recurrent haemorrhoidal disease (Napoleon trial): Study protocol for a multicentre randomized controlled trial. Contemp Clin Trials 2020; 99:106177. [PMID: 33080380 DOI: 10.1016/j.cct.2020.106177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Currently, there is no consensus regarding the best treatment option in recurrent haemorrhoidal disease (HD), due to a lack of solid evidence. The Napoleon trial aims to provide high-level evidence on the comparative effectiveness and cost-effectiveness of repeat rubber band ligation (RBL) versus sutured mucopexy versus haemorrhoidectomy in patients with recurrent HD. METHODS This is a multicentre randomized controlled trial. Patients with recurrent HD grade II and III, ≥18 years of age and who had at least two RBL treatments in the last three years are eligible for inclusion. Exclusion criteria include previous rectal or anal surgery, rectal radiation, pre-existing sphincter injury or otherwise pathologies of the colon and rectum, pregnancy, presence of hypercoagulability disorders, and medically unfit for surgery (ASA > III). Between June 2020 and May 2022, 558 patients will be randomized to receive either: (1) RBL, (2) sutured mucopexy, or (3) haemorrhoidectomy. The primary outcomes are recurrence after 52 weeks and patient-reported symptoms measured by the PROM-HISS. Secondary outcomes are impact on daily life, treatment satisfaction, early and late complication rates, health-related quality of life, costs and cost-effectiveness, and budget impact. Cost-effectiveness will be expressed in societal costs per Quality Adjusted Life Year (QALY) (based on EQ-5D-5L), and healthcare costs per recurrence avoided. DISCUSSION The best treatment option for recurrent HD remains unknown. The comparison of three generally accepted treatment strategies in a randomized controlled trial will provide high-level evidence on the most (cost-) effective treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04101773.
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Affiliation(s)
- Sara Z Kuiper
- Department of Surgery, Maastricht University, School of Nutrition and Translational Research in Metabolism (NUTRIM), Universiteitssingel 50, 6229, ER, Maastricht, the Netherlands.
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Oxfordlaan 10, 6202, AZ, Maastricht, the Netherlands
| | - Merel L Kimman
- Department of Clinical Epidemiology and Medical Technology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Oxfordlaan 10, 6202, AZ, Maastricht, the Netherlands
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Oxfordlaan 10, 6202, AZ, Maastricht, the Netherlands
| | - Robin R Van Tol
- Department of Surgery, Diakonessenhuis Medical Centre, Bosboomstraat 1, 3582, KE, Utrecht, the Netherlands
| | - Jean W M Muris
- Department of Family Medicine, Maastricht University, Care and Public Health Research Institute (CAPHRI), Universiteitssingel 40, 6229, ER, Maastricht, the Netherlands
| | - Angus J M Watson
- Department of Surgery, Raigmore Hospital, Old Perth Road, IV2 3UJ Inverness, United Kingdom
| | - Jose M C Maessen
- Department of Quality and Safety, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Stéphanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; Department of Surgery, Maastricht University, School of Nutrition and Translational Research in Metabolism (NUTRIM), School for Oncology and Developmental Biology (GROW), Universiteitssingel 50, 6229, ER, Maastricht, the Netherlands
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Lehmann JP, Johansson HÖ, Graf W. Long-term functional results after excisional haemorrhoidectomy. Colorectal Dis 2020; 22:824-830. [PMID: 31912937 DOI: 10.1111/codi.14954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/03/2019] [Indexed: 12/22/2022]
Abstract
AIM The aim of this work was to perform a long-term evaluation of a randomized trial focusing on functional aspects after excisional haemorrhoidectomy with a minimum follow-up of 9 years. METHOD A questionnaire-based study including patients operated on for haemorrhoids in Sweden between 1999 and 2003. A total of 225 patients were randomized to Milligan's or Ferguson's operation. Twenty-six patients had died and 151 (76%) participated after a median follow-up of 10.7 years (range 9.2-12.6 years). RESULTS Seventy-seven patients were in the Milligan group and 74 in the Ferguson group. Forty-eight (32%) reported recurrence. Anal bleeding was reported in 80% at baseline but in 28% at long-term follow-up (P < 0.0001). At baseline, 49% had spontaneous anal pain and 25% pain at defaecation. At follow-up, these figures were 17% and 11%. At follow-up, 19% described a sense of anal stenosis. At baseline, soiling was reported in 51% but in 20% at long-term follow-up (P < 0.001). Nineteen per cent used pads preoperatively and 6% at follow-up (P < 0.0001). Straining at defaecation was reported by 35% at baseline. At follow-up, this figure was 25% (P = 0.055). CONCLUSION Symptoms associated with haemorrhoids were reduced at long-term follow-up. The most common problems were perceived recurrence and a sense of anal stenosis.
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Affiliation(s)
- J-P Lehmann
- Department of Surgery, Östersunds Hospital, Östersund, Sweden
| | | | - W Graf
- Department of Surgical Sciences, Akademiska Sjukhuset Uppsala, Uppsala University, Uppsala, Sweden
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Ng KS, Holzgang M, Young C. Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020. Ann Coloproctol 2020; 36:133-147. [PMID: 32674545 PMCID: PMC7392573 DOI: 10.3393/ac.2020.05.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.
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Affiliation(s)
- Kheng-Seong Ng
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Melanie Holzgang
- Department of Colorectal Surgery, St. James's University Hospital, Leeds, UK
| | - Christopher Young
- Institute of Academic Surgery, University of Sydney, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Isakov DV, Tsarkov PV, Markaryan DR, Garmanova TN, Kazachenko EA, Knorring GY. [E.coli bacterial suspension in the treatment of hemorrhoids]. Khirurgiia (Mosk) 2020:102-108. [PMID: 32500699 DOI: 10.17116/hirurgia2020051102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hemorrhoidal disease is the most common proctologic disease and the search for new treatment methods, as well as an in-depth understanding of the mechanisms underlying effects of well-known agents on disease pathogenesis still remain relevant. There have been long recognized the effects of the E.coli bacterial culture suspension (BCS) as a therapeutic means eliciting decreased exudation during inflammation, wound healing, tissue regeneration, and stimulated immunity. Here, based on recent findings related to innate and adaptive immune cells, we set out to present mechanisms accounting for some effects coupled to commensal bacteria, particularly inactivated E.coli BCS, which are important for understanding pathogenesis-related action of drug Posterisan and Posterisan forte, and outline their broad application in therapy of hemorrhoids. Based on the analysis, it was concluded that such effects are mediated via multi-pronged and complementary interactions between diverse human receptors expressed in the anorectal region cells and microbial components: NOD ligands, metabolites, enzymes, heat shock proteins and nucleic acids, which lead to production of pro-inflammatory cytokines by anodermal colonocytes, innate and adaptive immune cells, neurons in the submucosal plexus covered by transitional zone epithelium, and hemorrhoid plexus endothelium. Based on current concepts, it may be plausible that E.coli BCS-derived biologically active components contained in drug Posterisan are capable of exerting both positive local and systemic effects, which extend our understanding and substantiate its use in hemorrhoidal disease. The effectiveness of using Posterisan and Posterisan forte is corroborated by their indications in real-life clinical practice, both as a conservative therapy as well as after surgical interventions.
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Affiliation(s)
- D V Isakov
- Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia.,Institute of Experimental Medicine, Saint Petersburg, Russia
| | - P V Tsarkov
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - D R Markaryan
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - T N Garmanova
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - E A Kazachenko
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - G Yu Knorring
- A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia, Moscow, Russia
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