How we can improve patients’ comfort after Milligan-Morgan open haemorrhoidectomy

Hepatoprotective effects of diosmin: a narrative review

Liver diseases represent a formidable global health threat. Hesperidin, a flavonoid found in citrus fruits, is the source of diosmin (DS). The in vivo and in vitro investigations of the pharmacological effects of DS reveal that it exhibits tremendous beneficial effects, such as fighting against inflammation, oxidative stress, and fibrosis. These effects have been noticed in various disease models, emphasizing the potential therapeutic value of DS in tackling diverse pathological conditions. Interestingly, DS has promising liver-defense capabilities against a range of hepatic illnesses, such as radiation-induced hepatic injury, liver ischemia/reperfusion injury, alcoholic hepatic disease, nonalcoholic fatty liver disease (NAFLD), and hepatocellular carcinoma (HCC). Furthermore, DS demonstrates potential hepatoprotective effects against environmental toxins, such as heavy metals. DS activates PPAR-γ and Nrf2, leading to antioxidant effects that reduce oxidative stress. Moreover, DS suppresses NF-κB, NLRP3, MAPK activities, and cytokine production (TNF-α and IL-1β), resulting in inflammation suppression. These anti-inflammatory effects are attributed to the activation of PPAR-γ and Nrf2, which are NF-κB inhibitors. This review aims to comprehensively discuss the hepatoprotective capacity of DS, elucidating the underlying mechanisms and identifying several research avenues that warrant further exploration to ascertain the prospective clinical advantages of DS intake as a viable strategy for the treatment of hepatic illnesses.

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Evaluation of the efficacy and safety of an innovative flavonoid lotion in patients with haemorrhoid: a randomised clinical trial

OBJECTIVE

Haemorrhoids are one of the most common gastrointestinal and anal diseases. In olive oil and honey propolis, flavonoids have beneficial effects on improving vascular function and decreasing vascular resistance. In this study, we aimed to produce a combination of these two substances in the form of lotions and assess their healing and side effects in comparison with routine treatment, anti-haemorrhoid ointment (containing hydrocortisone and lidocaine).

DESIGN

In this randomised clinical trial study, 86 patients with grade 2 or more haemorrhoid degrees, diagnosed by colonoscopy, were divided into two groups, the case (n=44) and control (n=42). The case group was treated with flavonoid lotion, and the control group was treated with anti-haemorrhoid ointment two times per day for 1 month. Patients were followed weekly with history and physical examination. The data of the two groups were collected before and after the intervention and statistically analysed.

RESULTS

Post-treatment reduction in haemorrhoid grade was significant in the case group (p=0.02). This ratio was insignificant in the control group (p=0.139). Flavonoid lotion (p<0.05) significantly reduced the signs and symptoms of haemorrhoids more than anti-haemorrhoid ointment.

CONCLUSION

According to the results, flavonoid lotion can be an excellent alternative to topical chemical drugs, such as anti-haemorrhoid ointment, in treating haemorrhoid disease. Besides its effectiveness and safety, it can be easily manufactured and widely available to patien.

Efficacy and safety of micronized purified flavonoid fractions for the treatment of postoperative hemorrhoid complications: A systematic review and meta-analysis

BACKGROUND

Hemorrhoids, a common anorectal disease, seriously affects patients' quality of life. Micronized purified flavonoid fractions (MPFF) have been shown to improve hemorrhoid symptoms.

PURPOSE

To evaluate the efficacy and safety of MPFF in treating postoperative hemorrhoid complications.

STUDY DESIGN

A systematic review and meta-analysis of existing literature on natural compounds for treating postoperative complications of hemorrhoids.

METHODS

A literature search was conducted using five databases, namely PubMed, WanFang, CNKI, Embase, and the Cochrane Library, to identify randomized controlled trials (RCTs) on the effects of MPFF treatment on hemorrhoids. Stata 15.1 and Revman 15.4 were used to assess the data, while subgroup and sensitivity analyses were performed to evaluate potential heterogeneity, and trial sequential analysis (TSA) and Egger test were used to evaluate the reliability of each trial.

RESULTS

A total of 22 RCTs, including 2,335 participants were included in the analysis. MPFF improved the clinical efficacy of post-hemorrhoidectomy and reduced the bleeding rate, pain score, and edema score, although no substantial effect on adverse reactions was reported. Subgroup analyses showed a significant reduction in pain score and bleeding rate in trials with duration of 4-10 days and an improvement in clinical efficacy. Treatment for ≥ 10 days significantly improved the edema score; a dosage range of 1,800-2,700 mg/day of MPFF significantly reduced edema and pain scores, whereas < 1,800 mg/day significantly improved clinical efficacy.

CONCLUSIONS

Based on searching the relevant literatures, this is the first meta-analysis on MPFF treatment of postoperative hemorrhoid complications. Our findings, validated by TSA, suggest that MPFF is safe and effective in reducing postoperative hemorrhoid complications, and that dose and duration are key factors in its efficacy, as illustrated by subgroup analysis. However, due to the small sample size, the standardized treatment regimen of MPFF could not be obtained; therefore, further research is warranted.

PREOPERATIVE USE OF MICRO-FLAVONOID FRACTION (MMF) AS PART OF A MULTIMODAL ANALGESIA IN ANORECTAL SURGERY: PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED, DOUBLE-BLIND STUDY PROTOCOL

Aim: To assess the efficiency of the micro-flavonoid fraction (MMF) administration prior to anorectal surgery with spinal anesthesia on postoperative pain severity reduction.Methods: Patients of our clinic who meet the following inclusion criteria are included: they must be diagnosed with surgical treatment of anorectal diseases. All participants are randomly divided into 2 groups: the first one gets a tablet with 1000 mg MFF (Detralex®), the second one gets a tablet containing starch per os 14 days before surgery (72 participants per arm). Then patients of each group will continue MFF administration for 30 days after surgery. Patients of both arms receive spinal anesthesia and undergo surgery. Following the procedure the primary and secondary outcomes are evaluated: frequency of the opioid drugs intake, the severity of the postoperative pain syndrome, duration and frequency of other drugs intake, readmission rate, overall quality of life, time from the procedure to returning to work and the complications rate, C-reactive protein level.Discussion: the MFF intake allows reducing the severity of the hemorrhoidal disease symptoms during conservative treatment. In addition, the Detralex® efficacy has been proven in postoperative pain reduction for patients diagnosed with varicose veins of the lower extremities. We intend to evaluate the feasibility of the preoperative MFF administration for the postoperative pain reduction and the decrease of the postoperative complications in patients with hemorrhoidal disease.

A Prospective Study on the Efficacy of Two Different Phlebotonic Therapies as a Bridge to Surgery in Patients with Advanced Hemorrhoidal Disease

The aims of this study were to evaluate the efficacy of two different phlebotonic therapies, preoperatively administered in advanced hemorrhoidal disease (HD) patients with recommendation for surgery, and to assess patient satisfaction after treatment. In this prospective observational study, 100 patients were preoperatively treated either with micronized purified flavonoid fraction (group A) or sublingual nano-emulsion flavonoid (group B). HD symptoms, local inflammation signs and patients' satisfaction were evaluated at baseline visit (T0), after 4 weeks of therapy (T1) and 8 weeks after its discontinuation (T2). In group A, a significant improvement for all HD symptoms and inflammation signs was observed after therapy (T1), followed by a reduction of efficacy in T2, except for itching and edema. In group B, therapy had a significant benefit on symptoms and local inflammation at T1, which persisted after its discontinuation for all symptoms, and edematous hemorrhoids. In both groups, the satisfaction rate was "good" in 60% of patients and patients were statistically significant more satisfied at T1 compared with T2 (p = 0.0001). No adverse events were recorded. Preoperative treatment was safe and useful to optimize patients' clinical condition prior to surgery.

Role of micronize purified flavonoid fraction and ethanol Graptophyllum pictum extract on experimental anal ulcer healing. Study on Wistar rat

Aim of the study To evaluate the role of micronized purified flavanoid fraction and ethanol Graptophyllum pictum extract in the treatment of anal ulcer.

Method Twenty-eight Wistar rats were randomly allocated into four groups. Groups 2, 3 and 4 the anus were induced with croton oil, but was not induced on group 1. Groups 1 and 2 were treated with normal saline, while groups 3 and 4 were treated with micronized purified flavanoid fraction, and ethanol G. pictum extract, respectively. On 9th days blood sample were taken from the retro-orbital region, and Wistar was killed by cervical dislocation under ether anesthesia. The anal canal was resected up 2 cm from anal opening, weighted, photographically taken to measure the percentage of residual ulcer, and then prepared for microscopic examination. Elisa methods were done for superoxide dismutase and malondialdedhyde. The total leukocyte in the anal specimen was counted under 400 magnification power. superoxide dismutase, anal coefficient, and total leukocyte for statistical analysis were using ANOVA and LSD, while malondialdedhyde and percentage of ulcers were using Kruskal–Wallis and Mann–Whitney.

Result Treatment with ethanol G. pictum extract dose of 100 mg/kg BW significantly reduces the percentage of anal ulcer, the edema, leukocyte infiltration, and malondialdedhyde, and increase the superoxide dismutase in comparison without treatment. Treatment with micronized purified flavanoid fraction did not reduce the leukocyte, anal coefficient, and percentage of anal ulcer, only increase malondialdedhyde and decrease superoxide dismutase significantly.

Impact of post-haemorrhoidectomy pain relief checklists on pain outcomes: a randomized controlled trial

BACKGROUND

Haemorrhoidectomy is associated with significant post-operative pain which is primarily managed pharmacologically. Whether a non-pharmacological adjunct such as a checklist can improve pain outcomes after an open haemorrhoidectomy has yet to be studied. The purpose of this study was to determine if a patient-completed checklist of prescribed post-haemorrhoidectomy pain medications would improve pain management after surgery.

METHODS

We conducted a dual-centre randomized controlled trial of patients undergoing a Milligan-Morgan haemorrhoidectomy for symptomatic third or fourth degree haemorrhoids. Thirty-five patients were randomized into either a control group which received post-operative pain medication plus a visual analogue scale (VAS) form, or an intervention group which received a post-operative medication checklist in addition to the items the control group received. Both groups recorded their pain levels on the VAS forms at 10.00, 14.00 and 20.00 hours each day for 14 days post-operatively.

RESULTS

Patients in the checklist group reported a significantly greater reduction in mean VAS pain score of 2.51 (95% confidence interval (CI) 1.34-3.68; P < 0.001) between day 1 post-op and day 14 post-op compared to 1.86 (95% CI 0.77-2.95; P = 0.001) for the control group. There was no significant difference between mean pain experienced by patients in either group over each of the 14 days individually or overall (P = 0.07).

CONCLUSION

The pain medication checklist lead to a greater reduction in pain between day 1 and 14 after an open haemorrhoidectomy compared to standard care but did not significantly reduce mean pain across any individual days or overall.

Metabolism and pharmacological activities of the natural health-benefiting compound diosmin

Diosmin is a famous natural flavonoid for treating chronic venous insufficiency and varicose veins.

Flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) in the treatment of I-III degree hemorroidal disease: a double-blind multicenter prospective comparative study

PURPOSE

We evaluated the efficacy of new flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from I-III degrees hemorrhoidal disease in the short and medium time.

METHODS

One hundred fifty-four consecutive patients with hemorrhoidal disease recruited in four colorectal units were enrolled to the study. Exclusion criteria were allergy to the flavonoids, inflammatory bowel disease, obstructed defecation syndrome, pregnancy and puerperium, associated anal disease or hemorrhoidal thrombosis, proctologic surgical procedures within 1 year before recruitment, contemporary cancer or HIV, previous pelvic radiotherapy, patients receiving oral anticoagulant therapy, or contemporary administration of other therapy for hemorrhoids. Patients with inability to understand the study or mental disorders were also excluded.

RESULTS

Seventy-eight were randomized to receive the mixture of diosmin, troxerutin, rutin, hesperidin, and quercetin (study group, SG), and 76 a mixture of diosmin in combination with hesperidin, diosmetin, isoroifolin, and linarin in purified micronized fraction (control group, CG). Bleeding, number of pathological piles, and Golligher's grade were assessed at each scheduled visit and compared using the Chi-square test. During the study period, bleeding improved after 1 and 6 months both in the SG (79.5 and 70.5%) and in the CG (80.2 and 75%) without significant differences between two groups. Satisfaction degree after 6 months was greater in the patients of the SG (4.05) towards the CG (3.25): this result was statistical significant (p 0.003).

CONCLUSIONS

Use of flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) is a safe and effective mean of managing bleeding from hemorrhoidal disease and minimal adverse events are reported.

Topical diltiazem ointment in post-hemorrhoidectomy pain relief: A meta-analysis of randomized controlled trials

BACKGROUND

Hemorrhoidectomy is commonly associated with postoperative pain. Calcium channel blockers are known to cause relaxation of gastrointestinal smooth muscle and oral diltiazem has also been shown to reduce the resting anal pressure.

OBJECTIVE

We attempted to analyze efficacy and side effects of topical diltiazem oint. in post-operative pain control.

METHODS

This is a meta-analysis of patients who underwent hemorrhoidectomy using topical diltiazem oint. versus placebo (Vaseline) for pain control. Patients with third or fourth degree hemorrhoids undergoing traditional hemorrhoidectomy were included. Procedures took place in the colorectal division of a hospital in 5 countries. Five randomized control trials (RCTs) published between 2005 and 2016 including 227 patients were included our meta-analysis (Diltiazem (calcium channel block) group = 137; Placebo (Vaseline) group = 90). Pain assessment was performed using a standardized Visual Analogue Scale. Any side effects of surgery or medication use, which were noted by the patient or the surgeon, also were recorded.

RESULTS

A total of 227 patients were included in the meta-analysis. The results revealed that Diltiazem ointment was statistically significant in reducing pain within 48 h, at 72 h, and more than 96 h after operation compared to the placebo group. Regarding overall complications (including headache), there was no statistical significance between diltiazem and placebo group.

CONCLUSIONS

Topical application of diltiazem effectively relieves pain after hemorrhoidectomy with minimal side effects. Further large studies are needed to substantiate its value in clinical practice.

Efficacy of metronidazole versus placebo in pain control after hemorrhoidectomy. Results of a controlled clinical trial

INTRODUCTION

Hemorrhoidal disease occurs in 50% of people aged > 40 years and is the most common reason for anorectal surgery. Pain is the main complication. Multiple topical and systemic drugs have been investigated for pain control, but there is no ideal treatment. Metronidazole has been shown to decrease postoperative pain but is not used widely.

OBJECTIVE

To evaluate the effect of oral metronidazole versus placebo and to assess postoperative pain following hemorrhoidectomy.

MATERIAL AND METHODS

Controlled clinical trial in adult patients who underwent elective hemorrhoidectomy for grade III/IV hemorrhoids. Patients were assigned to receive metronidazole (500 mg q8 h orally; study group, SG) or placebo (control group, CG) for 7 days after surgery. Pain was assessed using a visual analog scale after surgery. Analgesic administration (time and use of analgesics) and resumption of daily life activities were also assessed.

RESULTS

Forty-four patients were included, 22 in each group. Postoperative pain differed significantly between the SG and CG at 6 h (3.86 ± 0.56, 6.64 ± 1.49), 12 h (5.59 ± 1.33, 8.82 ± 0.79), 24 h (6.86 ± 1.49, 9.73 ± 0.45), day 4 (5.32 ± 2.10, 9.50 ± 0.59), day 7 (3.14 ± 1.03, 7.36 ± 1.39), and day 14 (2.14 ± 0.46, 5.45 ± 1.29). The first analgesia dose was required at 21.27 ± 5.47 h in the CG and 7.09 ± 2.36 h in the SG (p < 0.05), the time of analgesic use was 6.86 ± 1.61 days in the CG and 13.09 ± 2.48 days in the SG (p < 0.05), and resumption of daily activities occurred at 7.59 ± 1.56 days in the CG and 14.73 ± 3.76 days in the SG (p < 0.05).

CONCLUSION

Oral administration of metronidazole is effective in pain management after hemorrhoidectomy.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

Direct current electrotherapy for internal haemorrhoids: experience in a tertiary health institution

Introduction

Haemorrhoids disease is one of the most frequently occurring disabling conditions of the anorectum. We re-present the method, advantages and results of using direct current electrotherapy in the treatment of haemorrhoids.

Methods

Symptomatic grades 1, 2 or 3 internal and mixed haemorroids were treated. Exposure and evaluation was with an operative proctoscope which visualized one-eighth of the anal canal at a time. All diseased segments were treated per visit, indicators of successful treatment were, darkening of the treated segment, immediate shrinking of the haemorrhoid and ceasation of popping sound of gas release at the probe tip. Patients were followed up for two weeks. No bowel preparations, medications, anesthesia nor admission was required.

Results

Four hundred and fifty six segments were exposed, 252(55.3%) were diseased. eight patients with either grades 2 or 3 diseases required two treatment visits. The most common symptom was rectal bleeding (94.7%), followed by prolapsed but manually reduced hemorrhoids (68%). Prolapse of tuft of haemorrhoidal tissue with spontaneous return was seen in 59.6%, anal pain in 29.8%, and itching in 3.5%. the median number treated segments per patient was 4. No complication was encountered. All patients treated remained symptom free at a mean duration of follow up of 16 months.

Conclusion

Direct current electrotherapy is an effective, painless and safe out-patient treatment method for grades 1 to 3 internal and mixed hemorrhoid disease.

Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review

Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.

Postoperative topical analgesia of hemorrhoidectomy with policresulen and cinchocaine: a prospective and controlled study

OBJECTIVE: To evaluate the effects of topical policresulen and cinchocaine in the postoperative pain behavior of open hemorrhoidectomy.METHODS: We conducted a prospective, double-blinded, controlled study. The control group received the usual guidelines with oral medications. The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo). Pain intensity was recorded with the visual analogue scale.RESULTS: 43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15. The mean age was 45.98 years and 37.2% were men. The average pain intensity was 4.09 (immediate postoperative), 3.22 (hospital discharge), 5.73 (day 1) , 5.77 (day 2), 5.74 (day 3), 5.65 (day 7), 5.11 (day 10), 2.75 (day 15) and 7.70 (first bowel movement), with no difference between groups in all periods.CONCLUSION: This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine.

Pharmacological treatment of hemorrhoids: a narrative review

INTRODUCTION

Hemorrhoid disease is the cause of most proctologic complaints and hundreds of medical and surgical therapies have been proposed to relieve symptoms. However, the role and the correct indication of medical treatments are still controversial. Further, the utility of conservative measures are rarely scientifically supported by adequate trials.

AREAS COVERED

This narrative review is based on the search and analysis of full papers in English language selected from PubMed in the past 30 years using the following MeSH Editing: hemorrhoids, conservative treatment, medical treatment and hemorrhoids, pregnancy and hemorrhoids, thrombosed hemorrhoids, randomized trials and hemorrhoids, postoperative pain and hemorrhoids.

EXPERT OPINION

Early stages (I/II degrees) of this disease could be effectively managed conservatively with several approaches as lifestyle changes, fiber supplement, topical ointments and phlebotonic drugs. The more advanced hemorrhoid stages (III/IV degrees) need some type of surgery, but medical therapy is still useful to minimize anal symptoms as a bridge-to-surgery treatment. Further, post-hemorrhoidectomy pain, hemorrhoidal crisis even in pregnancy could benefit from the adjunct of local and systemic medical treatment. This expert opinion, based also on long-lasting clinical practice, also supports the use of medical treatment in symptoms relief in patients with hemorrhoid disease.

Comparison of vessel sealing systems with conventional

Background

Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Haemorrhoidal disease is a common anorectal disorder which has symptoms of bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Haemorrhoidectomy is one of most frequently performed anorectal operation worldwide.

Objectives

The aim of this study was to compare the effectiveness of the LigaSure tissue sealing device, Harmonic Scalpel and conventional MM open haemorrhoidectomy.

Materials and Methods

Sixty-nine patients with newly diagnosed symptomatic grade three or grade four haemorrhoidal disease, from July 2011 to December 2011 were recruited for the study. Patients were prospectively randomized to LigaSure, Harmonic Scalpel and conventional haemorrhoidectomy. Patients were evaluated on the basis of the mean operative time, postoperative pain, day of discharge, early and late complications.

Results

Each group has twenty-three patients. Ten (14.5 %) were female and fifty-nine (85.5 %) were male. Mean age were 44.5 ± 10.8 for LigaSure group, 39.5±14.4 for Harmonic Scalpel group and 39.8 ± 13.6 for conventional haemorrhoidectomy group. Mean operative time was 12.6 ± 2.9 for LigaSure group, 12.6 ± 2.5 for Harmonic Scalpel group and 22.3 ± 4.5 for conventional haemorrhoidectomy group. Postoperative pain and required analgesic dose were significantly lower for conventional haemorrhoidectomy. Wound healing was also more rapid in conventional haemorrhoidectomy than both LigaSure and Harmonic Scalpel.

Conclusions

Lateral heat dissipation of energy based cautery such as Harmonel Scalpel and LigaSure is considerably high when compared with conventional methods. More thermal damage which is generated on tissue seems to be the reason for increased degree of postoperative pain and delay in wound healing.

Phlebotonics for haemorrhoids

BACKGROUND

Haemorrhoids are variceal dilatations of the anal and perianal venous plexus and often develop secondary to the persistently elevated venous pressure within the haemorrhoidal plexus (Kumar 2005). Phlebotonics are a heterogenous class of drugs consisting of plant extracts (i.e. flavonoids) and synthetic compounds (i.e. calcium dobesilate). Although their precise mechanism of action has not been fully established, they are known to improve venous tone, stabilize capillary permeability and increase lymphatic drainage. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphoedema and haemorrhoids.Numerous trials assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease suggest that there is a potential benefit.

OBJECTIVES

The aim of this review was to investigate the efficacy of phlebotonics in alleviating the signs, symptoms and severity of haemorrhoidal disease and verify their effect post-haemorrhoidectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 2011 issue 9 , MEDLINE (1950 to September 2011) and EMBASE (1974 to September 2011).

SELECTION CRITERIA

Only randomised controlled trials evaluating the use of phlebotonics in treating haemorrhoidal disease were used. No cross-over or cluster-randomized trials were included for analysis and any trial which had a quasi-random method of allocation was excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and analysed the eligibility of the data for inclusion. Disagreements were resolved by meaningful discussion.

MAIN RESULTS

We considered twenty-four studies for inclusion in the final analysis. Twenty of these studies (enrolling a total of 2344 participants) evaluated the use of phlebotonics versus a control intervention. One of these twenty studies evaluated the use of phlebotonics with a medical intervention and another study with rubber band ligation.The remaining four studies included two which compared different forms of phlebotonics with each other, one study which evaluated phlebotonics with a medical intervention and one study which compared the use of phlebotonics with infrared photocoagulation. Eight studies were excluded for various reasons including poor methodological quality.Phlebotonics demonstrated a statistically significant beneficial effect for the outcomes of  pruritus (OR 0.23; 95% CI 0.07 to 0.79) (P=0.02), bleeding (OR 0.12; 95% CI 0.04 to 0.37) (P=0.0002), bleeding post-haemorrhoidectomy (OR 0.18; 95% 0.06 to 0.58)(P=0.004), discharge and leakage (OR 0.12; 95% CI 0.04 to 0.42) (P=0.0008) and overall symptom improvement (OR 15.99 95% CI 5.97 to 42.84) (P< 0.00001), in comparison with a control intervention. Although beneficial they did not show a statistically significant effect compared with a control intervention for pain (OR 0.11; 95% CI 0.01 to 1.11) (P=0.06), pain scores post-haemorrhoidectomy (SMD -1.04; 95% CI -3.21 to 1.12 ) (P= 0.35) or post-operative analgesic consumption (OR 0.54; 95% CI 0.30 to 0.99)(P=0.05).

AUTHORS' CONCLUSIONS

The evidence suggests that there is a potential benefit in using phlebotonics in treating haemorrhoidal disease as well as a benefit in alleviating post-haemorrhoidectomy symptoms. Outcomes such as bleeding and overall symptom improvement show a statistically significant beneficial effect and there were few concerns regarding their overall safety from the evidence presented in the clinical trials.However methodological limitations were encountered. In order to enhance our conclusion further, more robust clinical trials which take into account these limitations will need to be performed in the future.

Stapled and conventional Milligan-Morgan haemorrhoidectomy: different solutions for different targets

PURPOSE

Haemorrhoidal disease is one of the most common anorectal disorders. The aim of this study is to compare the results, over the last 10 years, of stapled haemorrhoidopexy (SH) with those of standard Milligan-Morgan haemorrhoidectomy (M&M). Furthermore, we discuss the proper indications for each technique in terms of the lowest rate of complications and long-term results.

METHODS

Three hundred forty-three patients with different degrees of symptomatic haemorrhoids underwent SH or M&M from January 2005 to December 2007. Patients were divided into two groups, age and sex matched. The administration of painkillers drugs, antibiotics and laxatives, complication symptoms and hospital stay in all the patients were recorded after surgical treatment.

RESULTS

The mean operative time was shorter in the stapled group compared to that in the open group (31 min versus 40 min). Postoperative pain, hospital stay and return to full activity were shorter in the stapled group. There was a significant difference in the wound healing time between the two groups. We noticed a higher rate of recurrence in patients treated with stapled haemorrhoidectomy for fourth-degree haemorrhoids.

CONCLUSIONS

According to our experience, the Longo technique is indicated for the treatment of haemorrhoids of second- and third degree. In the latter grades of prolapse, the Milligan-Morgan haemorrhoidectomy can also be applied with good outcomes. We believe that, in case of irreducible prolapse, the M&M is to be preferred. However, operative management varies according to surgeon's interest and is tailored to meet the individual patient's need.