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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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Puigdollers A, de Balle M, Rovira-Argelagues M. Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance. Cir Esp 2024; 102:69-75. [PMID: 37949364 DOI: 10.1016/j.cireng.2023.09.006] [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: 07/01/2023] [Accepted: 09/09/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. METHODS The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. RESULTS In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. CONCLUSIONS While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.
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Affiliation(s)
- Anicet Puigdollers
- Proctology and Pelvic Floor Unit, Hospital de Barcelona, Avinguda Diagonal 660, 08034 Barcelona, Spain.
| | - Mercedes de Balle
- Proctology and Pelvic Floor Unit, Hospital de Barcelona, Avinguda Diagonal 660, 08034 Barcelona, Spain
| | - Montserrat Rovira-Argelagues
- Coloproctology Unit, Department of General Surgery, Hospital de Mollet, Ronda Pinetons 6, 08100 Mollet del Vallès, Barcelona, Spain
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Giuliani A, Romano L, Necozione S, Cofini V, Di Donato G, Schietroma M, Carlei F. Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study. Dis Colon Rectum 2023; 66:e1254-e1263. [PMID: 37616177 DOI: 10.1097/dcr.0000000000002885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN Multicenter retrospective study. SETTINGS Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Antonio Giuliani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Lucia Romano
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Stefano Necozione
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Vincenza Cofini
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giada Di Donato
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Mario Schietroma
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Francesco Carlei
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
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Yuan XG, Wu J, Yin HM, Ma CM, Cheng SJ. Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis. Tech Coloproctol 2023; 27:799-811. [PMID: 37634164 DOI: 10.1007/s10151-023-02855-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids. METHODS PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January 15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis. RESULT A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h. CONCLUSION Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24 h.
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Affiliation(s)
- Xue Gang Yuan
- Chengdu University of Traditional Chinese Medicine, Chengdu, China.
- Sixth People's Hospital of Chengdu, Chengdu, China.
| | - Jia Wu
- Sixth People's Hospital of Chengdu, Chengdu, China
| | - Hong Mei Yin
- Sixth People's Hospital of Chengdu, Chengdu, China
| | | | - Si Jun Cheng
- Sixth People's Hospital of Chengdu, Chengdu, China
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Trenti L, Biondo S, Espin-Basany E, Barrios O, Sanchez-Garcia JL, Landaluce-Olavarria A, Bermejo-Marcos E, Garcia-Martinez MT, Alias Jimenez D, Jimenez F, Alonso A, Manso MB, Kreisler E. Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids: Long-term Outcomes From the THDLIGA Randomized Controlled Trial. Dis Colon Rectum 2023; 66:e818-e825. [PMID: 35239526 DOI: 10.1097/dcr.0000000000002272] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Both transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy are safe for grade III to IV hemorrhoid treatment. Whether one of them is superior regarding long-term results remains unclear. OBJECTIVE To compare long-term results after transanal hemorrhoidal dearterialization and vessel-sealing device hemorrhoidectomy. DESIGN Multicenter randomized controlled trial. SETTINGS This study was conducted at 6 centers. PATIENTS Patients ≥18 years of age with grade III to IV hemorrhoids were included in the study. INTERVENTIONS Patients were randomly assigned to transanal hemorrhoidal dearterialization (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41). MAIN OUTCOME MEASURES The primary outcome was hemorrhoid symptom recurrence assessed by a specific questionnaire 2 years postoperatively. Secondary outcomes included long-term complications, reoperations, fecal continence, and patient satisfaction and quality of life. RESULTS Five of the 80 patients included in the study were lost to follow-up. Thirty-six patients randomly assigned to transanal hemorrhoidal dearterialization and 39 patients randomly assigned to vessel-sealing device hemorrhoidectomy were included in the long-term analysis. The differences between mean baseline and mean 2-year score in the 2 groups were similar (-11.0, SD 3.8 vs -12.5, SD 3.6; p = 0.080). Three patients in the transanal hemorrhoidal dearterialization group underwent supplementary procedures for hemorrhoid symptoms, compared with none in the vessel-sealing device hemorrhoidectomy group ( p = 0.106). Four patients in the vessel-sealing hemorrhoidectomy group and none in the transanal hemorrhoidal dearterialization group experienced chronic opened wound ( p = 0.116). LIMITATIONS Lack of stratification for hemorrhoid grade and power calculation based on the main outcome trial but not on the end point of this long-term study. CONCLUSIONS Transanal hemorrhoidal dearterialization with mucopexy is associated with hemorrhoid symptom recurrence similar to vessel-sealing device hemorrhoidectomy at 2 years. See Video Abstract at http://links.lww.com/DCR/B933 . REGISTRATION Clinicaltrials.gov ; ID: NCT02654249. DESARTERIALIZACIN HEMORROIDAL TRANSANAL CON MUCOPEXIA VERSUS HEMORROIDECTOMA CON DISPOSITIVO DE SELLADO DE VASOS PARA HEMORROIDES DE GRADO IIIIV RESULTADOS A LARGO PLAZO DEL ENSAYO CLNICO ALEATORIZADO THDLIGARCT ANTECEDENTES:Tanto la desarterialización hemorroidal transanal como la hemorroidectomía con dispositivo de sellado de vasos son seguras y bien toleradas para el tratamiento de las hemorroides de grado III-IV. La primera se asocia con una necesidad más breve de analgesia posoperatoria que la hemorroidectomía con dispositivo de sellado de vasos. No está claro si uno de ellos es superior con respecto a los resultados a largo plazo.OBJETIVO:El objetivo fue comparar los resultados a largo plazo después de la desarterialización hemorroidal transanal y la hemorroidectomía con dispositivo de sellado de vasos.DISEÑO:Se realizó un ensayo clínico aleatorizado multicéntrico.AJUSTE:Este estudio se realizó en 6 centros.PACIENTES:Se incluyeron en el estudio pacientes de ≥18 años con hemorroides de grado III-IV.INTERVENCIONES:Los pacientes fueron asignados al azar a desarterialización hemorroidal transanal (n = 39) o hemorroidectomía con dispositivo de sellado de vasos (n = 41).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia de los síntomas de hemorroides evaluada mediante un cuestionario específico 2 años después de la operación. Los resultados secundarios incluyeron complicaciones a largo plazo, reoperaciones, continencia fecal, satisfacción del paciente y calidad de vida.RESULTADOS:Cinco de los 80 pacientes incluidos en el estudio se perdieron durante el seguimiento. En el análisis a largo plazo se incluyeron 36 pacientes aleatorizados a desarterialización hemorroidal transanal y 39 aleatorizados a hemorroidectomía con dispositivo de sellado de vasos. Las diferencias entre la puntuación inicial media y la puntuación media a los 2 años en los dos grupos fueron similares (-11,0, DE 3,8 frente a -12,5, DE 3,6; p = 0,080). Tres pacientes en el grupo de desarterialización hemorroidal transanal se sometieron a procedimientos complementarios por síntomas de hemorroides, en comparación con ninguno en el grupo de hemorroidectomía con dispositivo de sellado de vasos (p = 0,106). Cuatro pacientes en el grupo de hemorroidectomía con sellado de vasos y ninguno en el grupo de desarterialización hemorroidal transanal experimentaron herida abierta crónica (p = 0,116). No se encontraron diferencias en cuanto a continencia fecal (p = 0,657), satisfacción del paciente (p = 0,483) y calidad de vida.LIMITACIONES:No hay estratificación para el grado de hemorroides ni el cálculo del poder basado en el resultado principal del ensayo, pero no en el criterio de valoración de este estudio a largo plazo.CONCLUSIONES:La desarterialización hemorroidal transanal con mucopexia se asocia con una recurrencia de síntomas de hemorroides similar a la hemorroidectomía con dispositivo de sellado de vasos a los dos años. See Video Abstract at http://links.lww.com/DCR/B933 . (Traducción- Dr. Francisco M. Abarca-Rendon )REGISTRO DE PRUEBA:Clinicaltrials.gov (NCT02654249).
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Affiliation(s)
- Loris Trenti
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Sebastiano Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Eloy Espin-Basany
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
| | - Oriana Barrios
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Jose L Sanchez-Garcia
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
| | | | | | | | - David Alias Jimenez
- Department of Surgery, Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Fernando Jimenez
- Department of Surgery, Galdakao Usansolo Hospital, Vizcaya, Spain
| | - Adolfo Alonso
- Department of Surgery, La Princesa University Hospital, Madrid, Spain
| | - Maria B Manso
- Department of Surgery, Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Esther Kreisler
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
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Alemrajabi M, Akbari A, Sohrabi S, Rezazadehkermani M, Moradi M, Agah S, Masoodi M. Simple mucopexy and hemorrhoidal arterial ligation with and without Doppler guide: a randomized clinical trial for short-term outcome. Ann Coloproctol 2023; 39:351-356. [PMID: 35570403 PMCID: PMC10475797 DOI: 10.3393/ac.2022.00017.0002] [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: 01/01/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Hemorrhoids are the most common benign anorectal diseases. Mucopexy strengthens the anal canal mucosa, which can be performed alone or in combination with Doppler-guided hemorrhoidal artery ligation (DG-HAL). In this study, we compared the postoperative complications between simple mucopexy plus HAL with and without a Doppler guide. METHODS This study was performed as a single-blinded randomized clinical trial. Patients referred to a tertiary colorectal referral clinic with grades 3 and 4 hemorrhoids who were candidates for surgical intervention entered the study. Thirty-six patients were randomly divided into 2 groups. Group A including 18 patients underwent mucopexy and DG-HAL and the other 18 patients (group B) underwent standard mucopexy and HAL without a Doppler guide. Postoperative pain score and the duration of oral analgesic consumption were recorded. Additionally, postoperative symptoms and complications were recorded and compared between the 2 methods. RESULTS There was no significant difference between the 2 groups in terms of pain score and the duration of postoperative analgesic consumption as well as the incidence of postoperative complications. Besides, the primary grade of hemorrhoids was not significantly associated with recurrence, but there was a significant association between body mass index and Wexner score (WS) with recurrence. The mean WS of patients showed a significant decrease in both groups postoperatively. However, the rate of WS reduction was not remarkably different between the 2 groups. CONCLUSION Simple mucopexy with blind HAL (without Doppler guide) might be considered for the treatment of grades 3 and 4 hemorrhoids effectively.
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Affiliation(s)
- Mahdi Alemrajabi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Akbari
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Sohrabi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Moradi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
- Colorectal Research Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Masoodi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
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Balciscueta Z, Balciscueta I, Uribe N. Post-hemorrhoidectomy pain: can surgeons reduce it? A systematic review and network meta-analysis of randomized trials. Int J Colorectal Dis 2021; 36:2553-2566. [PMID: 34417639 DOI: 10.1007/s00384-021-04013-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Hemorrhoidectomy remains the gold standard treatment for grade III-IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery, post-operative pain has been a limitation to the widespread inclusion of this condition in day surgery programs. The aims of the study were to analyze and compare the post-operative pain of conventional open hemorrhoidectomy, considered the reference technique, against other surgical procedures such as closed hemorrhoidectomy, open hemorrhoidectomy using bipolar or ultrasonic sealant, hemorrhoidopexy, or HAL-RAR, when performed exclusively as outpatients. METHODS A systematic review and meta-analysis was conducted according to PRISMA methodology. All prospective and randomized studies of patients operated on for hemorrhoids in day surgery and specifying the value of post-operative pain, using a validated scale, were included. Conventional meta-analyses and a random-effects network meta-analysis were carried out. RESULTS Twenty-nine studies were included (3309 patients). None of the procedures described severe pain in the post-operative period. Hemorrhoidopexy was the least painful. Conventional open hemorrhoidectomy was the most painful on the first and seventh post-operative days. Pain was reduced after closed hemorrhoidectomy technique and when bipolar or harmonic scalpel was used. Furthermore, transfixive ligation of the hemorrhoidal pedicle was associated with increased post-operative pain. CONCLUSION Hemorrhoidal surgery is feasible in day surgery units and post-operative pain can be adequately managed in an outpatient setting. Hemorrhoidopexy was the least painful; however, data should be carefully evaluated by the high rate of long-term recurrence described in literature. Closed hemorrhoidectomy, performed with bipolar or ultrasonic sealing, avoiding transfixive ligation of the hemorrhoidal pedicle, may improve post-operative pain control. TRIAL REGISTRATION CRD42020185160.
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Affiliation(s)
- Zutoia Balciscueta
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/ San Clemente n° 12, 46015, Valencia, Spain.
| | - Izaskun Balciscueta
- Department of General and Digestive Surgery, La Ribera University Hospital, Alzira, Valencia, Spain
| | - Natalia Uribe
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/ San Clemente n° 12, 46015, Valencia, Spain
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Huang H, Gu Y, Li Y, Ji L. Modified tissue-selecting therapy stapler combined with complete anal canal epithelial preservation operation for the treatment of circumferential mixed haemorrhoids: a protocol for single-blind randomised controlled study. BMJ Open 2021; 11:e052982. [PMID: 34819287 PMCID: PMC8614140 DOI: 10.1136/bmjopen-2021-052982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION This protocol designed a randomised controlled trial (RCT) to evaluate the effectiveness, safety and prognostic outcomes of modified tissue selecting technique (M-TST) combined with complete anal canal epithelial preservation (CACP) among patients with circumferential mixed haemorrhoids. METHODS AND ANALYSIS This study will be single-blinded, and recruit 348 patients who are admitted to the Changshu Hospital Affiliated to Nanjing University of Chinese Medicine and fulfil the inclusion criteria from January 2022 to December 2022. Patients will be randomly assigned to the treatment group and the control group in a 1:1 ratio. The statistician will be blinded for the allocation. The treatment group will receive M-TST combined with CACP (M-TST-CACP), while the control group will receive the procedure for prolapse and haemorrhoids. The two groups will receive the same preoperative and postoperative care. The primary outcome will be recurrence rate. The secondary outcomes will be operation time, intraoperative bleeding, incontinence, pain, postoperative complications (severe bleeding, perianal oedema, urinary retention, faecal urgency, skin tags and anal stenosis), prolapse, recovery time, quality of life, Haemorrhoid Severity Score, and Symptom Severity Score. ETHICS AND DISSEMINATION This protocol has been approved by the Clinical Ethics Committee of the Changshu Hospital Affiliated to Nanjing University of Chinese Medicine (approval no. 202102001). TRIAL REGISTRATION NUMBER ChiCTR2100042750.
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Affiliation(s)
- Hua Huang
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu, China
| | - Yunfei Gu
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Youran Li
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Lijiang Ji
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu, China
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Corrigendum. Dis Colon Rectum 2021; 64:e672. [PMID: 34321429 DOI: 10.1097/dcr.0000000000002226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Aibuedefe B, Kling SM, Philp MM, Ross HM, Poggio JL. An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:2041-2049. [PMID: 34101003 DOI: 10.1007/s00384-021-03953-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments. METHODS A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS. RESULTS A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser. CONCLUSION There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.
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Affiliation(s)
- Bianca Aibuedefe
- Temple University Lewis Katz School of Medicine, 3500 N Broad St, Philadelphia, PA, 19140, USA.
| | - Sarah M Kling
- Department of General Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th floor, Philadelphia, PA, 19140, USA
| | - Matthew M Philp
- Department of General Surgery, Department of Colon and Rectal Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th Floor, Philadelphia, PA, 19140, USA
| | - Howard M Ross
- Department of General Surgery, Department of Colon and Rectal Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th Floor, Philadelphia, PA, 19140, USA
| | - Juan Lucas Poggio
- Department of General Surgery, Department of Colon and Rectal Surgery, Temple University Lewis Katz School of Medicine, 3401 N. Broad St., Zone C, 4th Floor, Philadelphia, PA, 19140, USA
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Kurihara A, Yoshino Y, Sakai Y, Miura Y, Kagami S, Kaneko T, Ushigome M, Shiokawa H, Kaneko H, Funahashi K. Linear Pinched Hemorrhoidectomy: A Retrospective Observational Study (An Innovative, Simplified Hemorrhoidectomy). J Anus Rectum Colon 2021; 5:261-267. [PMID: 34395938 PMCID: PMC8321580 DOI: 10.23922/jarc.2020-076] [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: 10/13/2020] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES There was an urgent need to create a simple, reliable hemorrhoidectomy procedure for high-risk cases in our university hospital. We performed linear pinched hemorrhoidectomy (LPH) and evaluated its effectiveness compared to conventional hemorrhoidectomy (CH). METHODS We included 215 Goligher grade 3 and 4 hemorrhoid cases in this study. Of these cases, 167 were in the CH group, and 48 patients were in the LPH group. We retrospectively compared the lengths of hospital stay, operative times, blood loss, and complications. RESULTS The age tended to be higher in the LPH group (mean: CH 60 years, LPH 68 years). In the univariate analysis, LPH had more resections, shorter operative times, and less blood loss. LPH had shorter operative times in the multivariate analysis, less blood loss, and more anticoagulant use. There were no significant differences between the two groups in terms of complications. Five and two patients in the CH and LPH groups, respectively, had postoperative hemorrhage requiring hemostasis. Only the CH group had three and four cases of anal stenosis and wound edema, respectively. CONCLUSIONS We studied simplified hemorrhoidectomy using an ultrasonic scalpel and cylindrical proctoscope in a university hospital. We found that it a useful procedure with few complications and was easy for residents to learn. We believe that advances in surgical devices will make it possible to perform safer and simpler hemorrhoidectomy in the future.
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Affiliation(s)
- Akiharu Kurihara
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yu Yoshino
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yu Sakai
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yasuyuki Miura
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Satoru Kagami
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Tomoaki Kaneko
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Mitsunori Ushigome
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Hiroyuki Shiokawa
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Hironori Kaneko
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Kimihiko Funahashi
- Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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12
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Non-Doppler hemorrhoidal artery ligation and hemorrhoidopexy combined with pudendal nerve block for the treatment of hemorrhoidal disease: a non-inferiority randomized controlled trial. Int J Colorectal Dis 2021; 36:353-363. [PMID: 33025104 DOI: 10.1007/s00384-020-03768-8] [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] [Accepted: 10/01/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND In this study, we proposed a combined outpatient treatment modality for hemorrhoidal disease. METHODS This study was a prospective non-inferiority randomized controlled trial (RCT). The experimental group included the dearterialization and hemorrhoidopexy under pudendal nerve block, whereas the comparator consisted of the standard Doppler guided hemorrhoidal artery ligation and hemorrhoidopexy, under spinal anesthesia. As primary hypothesis, we considered the non-inferiority of the proposed modality in terms of the presenting symptom remission rate (non-inferiority margin: 10%). Randomization was based on a 1:1 ratio. Blinding was confined to the patient and the investigator. RESULTS Overall, 60 patients were enrolled. The primary hypothesis of this RCT (96.7% vs 73.3%) was validated. The experimental group was associated with a lower operation duration and an expedited onset of mobilization and feeding. Moreover, a favorable profile regarding short-term morbidity and analgesia was identified. The control group displayed a higher pile recurrence rate and a suboptimal patient satisfaction. A significant effect of the treatment modality in most of the SF-36 components was confirmed. CONCLUSIONS The proposed treatment modality was associated with favorable short and long-term outcomes. Due to specific limitations, further RCTs, with a larger sample size, are required. Trial Registration ClinicalTrials.gov : NCT03298997.
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13
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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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14
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Ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy: a double-blind randomized controlled trial. Int J Colorectal Dis 2020; 35:1741-1747. [PMID: 32474710 DOI: 10.1007/s00384-020-03630-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE In this double-blind randomized trial, we aimed to compare the postoperative pain, complications, and length of hospital stay in patients undergoing open hemorrhoidectomy under spinal anesthesia with or without the pudendal nerve block. METHODS Patients undergoing Milligan-Morgan hemorrhoidectomy under spinal anesthesia were randomized to undergo a pudendal nerve block or no intervention. Postoperative pain on the visual analogue scale (VAS) at 6, 12, 24, and 48 h; opioid administration; and length of hospital stay were recorded and analyzed. RESULTS Over the study period, 49 patients were included and 23 randomized in the treatment arm. No differences in terms of age, gender, and preoperative risk factors were noted between groups. The pain on the VAS at 6, 12, 24, and 48 h was 2.8 vs. 4.6 (p = 0.046), 3.4 vs. 4.7 (p = 0.697), 1.4 vs. 3.1 (p = 0.016), and 1.0 vs. 2.1 (p = 0.288) in the treatment and control groups respectively. No differences in opioids use or complications were noted. Length of hospital stay was 1.2 vs. 1.8 days respectively (p = 0.046). No complications directly associated to the pudendal nerve block were observed. Multivariate analysis revealed that the pudendal nerve block was an independent factor reducing the postoperative pain. CONCLUSIONS The ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy under spinal anesthesia showed a statistically significant reduction in postoperative pain and length of hospital stay. The proposed technique appeared to be safe and feasible and may be recommendable in patients undergoing open hemorrhoidectomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04251884.
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15
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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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Longchamp G, Liot É, Meyer J, Longchamp A, Toso C, Buchs NC, Ris F. Scoring systems as outcomes assessment of the treatments for haemorrhoidal disease: a systematic review of the literature. Int J Colorectal Dis 2020; 35:1015-1024. [PMID: 32382836 DOI: 10.1007/s00384-020-03603-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The comparison between haemorrhoidal treatments is still unclear. Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials. We aimed to systematically review the available outcome scores of haemorrhoidal treatment. METHODS MEDLINE/Pubmed, Web of science, Embase and Cochrane were searched from database implementation until the December 6th 2019. All studies describing or referencing a score to assess haemorrhoidal disease treatment were included. Likert scale alone, incontinence score alone, general assessment of quality of life or scores developed for other proctologic disorders were excluded. The main outcome measures were validation of the scores and correlation of the score items to the core outcome set for haemorrhoidal disease developed by the European Society of Coloproctology. RESULTS From the 633 records initially screened, 22 studies were included: 8 original articles describing a scoring system and 14 referencing a previously described scoring system. Only 1 score was validated by an external prospective cohort. All the scores evaluated the symptoms of haemorrhoidal disease. No score integrated the disease recurrences or patient's satisfaction. Scores values tended to decrease postoperatively. CONCLUSIONS The scores described by Gerjy et al. and by Shanmugan et al. are available questionnaires, which have been validated and used in various studies. These scores might help researchers for comparative studies between treatment modalities and optimize haemorrhoids treatment.
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Affiliation(s)
- Gregoire Longchamp
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Émilie Liot
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Jérémy Meyer
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, Geneva University Hospitals and Medical School, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
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Scientific Surgery March 2020 BJS. Br J Surg 2020; 107:472. [PMID: 32129487 DOI: 10.1002/bjs.11540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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