Advantages and limits of hemorrhoidal dearterialization in the treatment of symptomatic hemorrhoids

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance

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.

Challenges and Prospects of Laser Haemorrhoidoplasty in a Low Resource Setting: The LUTH Experience

Background

Haemorrhoids are the most common condition of the anal canal causing significant disability. Traditional excisional haemorrhoidectomy and its various modifications, while effective, may be attended by severe postoperative pain and other complications. Laser haemorrhoidoplasty is reported to be effective with fewer complications and shorter hospital stay.

Objectives

The aim of this study was to report the outcome of intrahaemorrhoidal coagulation with 1470-nm diode laser at the Lagos University Teaching Hospital.

Patients and Methods

The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, grade of the haemorrhoids, duration of the procedures, and postoperative complications were evaluated.

Results

Eleven patients had laser haemorrhoidoplasty. There were seven males and four females. The age range was 23-71 years, with a median age of 47 years and an interquartile range (IQR) of 28-57 years. Duration of surgery ranged from 20 to 90 min, with a median of 33 min and IQR of 25-53 min. Postoperative pain was mild in eight patients and moderate in three. Ten patients were discharged as day cases and one 3 days later due to spinal anaesthesia-related headache and acute urinary retention. One patient later had an anal ulcer probably due to too much energy delivered during the procedure, this was managed conservatively. There was no postoperative wound infection, anal incontinence, anal stenosis, subcutaneous abscess, and fistula or recurrence.

Conclusion

The advantages of laser haemorrhoidoplasty make it a readily acceptable form of treatment for haemorrhoids in our setting.

Hemorrhoid laser dearterialization: systematic review and meta-analysis

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

The effects of laser procedure in symptomatic patients with haemorrhoids: A systematic review

Purpose

Haemorrhoids are normal structures in the human body, only seen as pathological when symptomatic. Nowadays, new techniques have surfaced using a diode laser which, after locating the target arteries, blocks the blood flow while hitting and shrinking the local mucosa/submucosa at a depth of 4 mm. Our work aimed to give a broad view over this new technique and its consequences in the post-operative follow-up with a systematic review.

Methods

EMBASE and MEDLINE databases were consulted, retrieving clinical trials, which mentioned the use of 980 nm diode laser on the treatment of haemorrhoids.

Results

Ten clinical trials analyzing the post-operative effects of laser haemorrhoidectomy were selected, including 2 randomized controlled clinical trials and 1 controlled clinical trial. The overall quality of the trials was low, indicating a high risk of bias.

Conclusion

The laser haemorrhoidectomy procedure revealed a high therapeutic potential, considering the reduced number of postoperative complaints (bleeding/pain), the high symptom resolution and the reduced recurrence, albeit the high heterogeneity between the studies in terms of reported results. Future investigations with higher quality and controlled double-blinded studies obtaining better-categorized results should be conducted in order to better evaluate this procedure and compare it to the current paradigm.

Comparison of post-operative bleeding incidence in laser hemorrhoidoplasty with and without hemorrhoidal artery ligation: a double-blinded randomized controlled trial

Introduction

The effectiveness of hemorrhoidal artery ligation supplementation in reducing the incidence of post laser hemorrhoidoplasty bleeding has not been investigated.

Methods

This was a double-blind, randomized controlled trial comparing post-operative bleeding incidence in patients undergoing laser hemorrhoidoplasty (LHP) only versus LHP with hemorrhoidal artery ligation (HAL). Outcome measures included post-operative bleeding and its severity (i.e. verbal rating scale and Clavien-Dindo classification), presence of perianal swelling and pain score (visual analog score) at 1-day, 1-week and 6-weeks post-operatively. Statistical tests were performed and a value of P < 0.05 was considered significant.

Results

Seventy-six patients were randomized. There was no difference in median operating time. The bleeding incidence was highest at 1-week post-operatively (17.1%), and decreased to 1.3% at 6-weeks. There was no significant difference in bleeding incidence between both groups at any of the measured timepoints (P > 0.05). Severity of bleeding and incidence of post-operative perianal swelling were similar in both groups (P > 0.05). There was no difference in median pain scores.

Conclusion

Supplementation of HAL to LHP does not reduce the post-operative bleeding incidence. LHP is sufficient as a stand-alone procedure for treating haemorrhoids.

Trial registration: National Registration Number is NMRR-15-1112-24065 (IIR). The trial start date was 1st January 2015 with the ClinicalTrials.gov identifier and registration number as NCT04667169.

Safety and effectiveness of hemorrhoidal artery ligation using the HAL-RAR technique for hemorrhoidal disease

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".

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY

Background:

Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades.

Aim:

To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades.

Method:

Seven hundred and five consecutive patients with Goligher’s grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48).

Results:

Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively.

Conclusion:

The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

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.

Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam

INTRODUCTION

Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment.

METHODS

This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure.

RESULTS

A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence.

CONCLUSION

The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Comparison of Doppler-Guided Transanal Hemorrhoidal Dearterialization for Grade III and IV Hemorrhoids in Vietnam

INTRODUCTION

This study aimed to assess the short- and long-term outcomes of Doppler-guided transanal hemorrhoidal dearterialization (THD) for grade III and IV hemorrhoidal disease in Vietnam.

METHODS

In a prospective observational design, patients treated for grade III and IV hemorrhoidal disease with the THD method at the National Hospital of Traditional Medicine (Hanoi, Vietnam) were included between June 2012 and December 2013. Patients were evaluated postoperatively at the time they were discharged from the hospital (short-term outcome) and 6 months after surgery (long-term outcome).

RESULTS

A total of 128 patients were enrolled in the study, 94 were classified with grade III disease and 34 with grade IV. Grade IV hemorrhoidal patients reported on average 18.2 years of disease symptom duration, while grade III hemorrhoidal patients reported 11.2 years. All patients with grade III and grade IV hemorrhoidal disease had good outcomes at discharge day and reported to return to work in a median of 6 days after THD. At long-term follow-up, the results were good for 80.9% of patients from grade III hemorrhoidal disease and 61.8% of patients from grade IV hemorrhoidal disease. Patient satisfaction with the procedure and outcomes was 93.6% for grade III and 85.3% for grade IV hemorrhoidal patients.

CONCLUSIONS

The THD technique was shown to be safe for both grade III and IV hemorrhoidal patients. The THD technique showed better results with grade III hemorrhoidal patients as compared to grade IV hemorrhoidal patients.

Doppler-guided transanal hemorrhoidal dearterilization versus conventional hemorrhoidectomy for treatment of hemorrhoids - early and long-term postoperative results

Background

A variety of effective methods for treatment of hemorrhoids has been proposed. In recent years, there has been an increasing number of studies comparing transanal hemorrhoidal dearterilization (THD) and conventional hemorrhoidectomy (CH), but the focus of most studies has been about the early postoperative results. The data about long-term outcomes is still limited. We aimed to compare Doppler-guided THD and CH with regard to early and long-term postoperative results.

Methods

The conducted prospective research included 287 patients who underwent CH (167 cases) or Doppler-guided THD with mycopexy (120 patients) between November 2010 and December 2015. Information on hemorrhoidal stage, demographic data, presenting symptoms, complications, duration of hospital stay, postoperative pain, patients’ satisfaction and follow-up were obtained. Statistical tests were performed by SPSS 19.0.

Results

There was no significant difference between the studied groups according to gender, mean age, preoperative prolapse, pain and pruritus, hemorrhoidal stage and postoperative complications. Preoperative bleeding was more frequent in THD group (p = 0,002). The mean visual analog scale (VAS) pain scores in CH and THD groups on days 1, 2 and 7 were 7.01 vs 5.03, 5.07 vs 2.98, 2.39 vs 0,57 (p = 0,000). Practically, there was no difference in VAS on day 30 and patients’ satisfaction at the 18th month. Mean hospital stay was 5,13 (CH) and 3,38 days (THD), p = 0,000. The postoperative follow-up was between 18 and 78 months (mean 46 ± 16 months). During this stage, 5 patients (2,99%) in CH group required surgery for recurrence. In THD group, 3 patients (2,5%), all with 4th-degree hemorrhoids underwent additional procedures (p 0,802).

Conclusions

Doppler-guided THD seems to be an efficient and safe option for treatment of hemorrhoids, related to lower postoperative pain and excellent, similar long-term outcomes compared to CH. For advanced grades of hemorrhoids, Doppler-guided THD could be a valuable alternative, but there is a need for patients’ selection.

Trial registration

(retrospectively registered) researchregistry3090.

Modified Doppler-guided laser procedure for the treatment of second- and third-degree hemorrhoids

Background

Hemorrhoids are a common anorectal condition with a major medical and socioeconomic impact. Owing to the high incidence of symptomatic hemorrhoids in the adult population together with the risk of complications of traditional surgery, researchers are seeking less invasive methods of hemorrhoidal treatment.The aim of this study was to present our experience with the mini-invasive Doppler guided hemorrhoidal laser procedure (HeLP) in symptomatic 2nd and 3rd degree hemorrhoids with absent or minimal mucosal prolapse.

Methods

The cohort included 62 patients with symptomatic hemorrhoids who underwent the HeLP at a tertiary medical center in 2014-2016. Data were collected on clinical and perioperative characteristics and outcome. Findings were compared between patients with second- and third-degree hemorrhoids.

Results

The cohort included 41 male and 21 female patients of mean age 41.5 years. Fifty-one had bleeding and 11 had hemorrhoidal syndrome. Mean operative time was 16.6 ± 3.7 minutes. A total of 8-12 arterial branches were treated. Patients were discharged home within a mean of 91.95 ± 20.48 minutes and allowed to resume normal activities. Compared to patients with second-degree hemorrhoids, patients with third-degree hemorrhoids had a significantly higher rate of recto-anal repair (18.2% vs 0, p < 0.05), intraoperative bleeding (11.3% vs 5%, p < 0.05), and thrombus formation in the hemorrhoids (11.3 % vs 0, p < 0.01). At the six-month follow-up, no complications were reported, and there was significant improvement in symptoms.Using the visual analog scale, no pain was reported by 82.3% of patients at one week after surgery and 95.2% of patients at one month after surgery.

Conclusion

Patients with hemorrhoids treated with Doppler-guided laser had an excellent outcome in terms of resolution of symptoms and postoperative pain. Only Minor short-term complications were noted. Doppler-guided laser seems to be an effective and painless technique for the treatment of symptomatic second- to third grade hemorrhoids with minimal mucosal prolapse.

Hemorrhoids: what are the options in 2018?

PURPOSE OF REVIEW

Efforts continue to improve the treatment of patients with symptomatic hemorrhoidal disease by interventions designed to improve efficiency and effectiveness, including by reducing intraoperative and postoperative pain, decreasing operating times, minimizing blood loss and controlling symptoms and recurrence rates. Simultaneously, there are also renewed efforts to minimize the number of patients who will require procedural intervention by focusing on conservative measures that encourage better bowel regulation and habits. The purpose of this brief report is to review the current status of the diagnosis and treatment of patients with hemorrhoidal disease. Overall, new procedures or procedural refinements to existing techniques continue to be introduced with promising short-term outcomes - at least in some instances. In most instances, long-term follow-up or equivalency data are still being accumulated such that a definitive, unequivocal answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial. One of the challenges is heterogeneity as regards diagnosis, intervention and, especially, outcomes measures such that comparing therapies is too difficult. A recent initiative to standardize metrics has promise.

RECENT FINDINGS

Recent studies largely appear to suggest that conservative treatment approaches and managing patient expectations are critically important in which a primary objective should be to minimize the progression to symptomatic disease and complications in patients who are diagnosed with hemorrhoids. The pace of change as regards the development of new or improved surgical techniques appears may be accelerating.

SUMMARY

Progress is being made and the knowledge base is being expanded as regards the treatment options for patients with hemorrhoids and expected outcomes. A key initiative to standardize the approaches to diagnosis and treatment about staging, procedural interventions and outcomes will facilitate comparative analytics, if successful.

Treatment of hemorrhoids with individualized homeopathy: An open observational pilot study

Aim:

Controversies and disagreement exist on conventional treatment strategies of hemorrhoids due to relapse, inefficacy, and complications. We intend to evaluate the role of individualized homeopathic treatment in hemorrhoids.

Materials and Methods:

In this prospective, open, observational trial, hemorrhoids patients were treated using five standardized scales measuring complaints severity and anoscopic score. It was conducted at two homeopathic hospitals in India, during from mid-July 2014 to mid-July 2015. Patients were intervened as per individualized homeopathic principles and followed up every month up to 6 months.

Results:

Total 73 were screened, 52 enrolled, 38 completed, 14 dropped out. Intention to treat population (n: = 52) was analyzed in the end. Statistically significant reductions of mean bleeding (month 3: −21.8, 95% confidence interval [CI]: −30.3, −13.3, P: < 0.00001, d = 0.787; month 6: −25.5, 95% CI −35.4, −15.6, P: < 0.00001, d = 0.775), pain (month 3: −21.3, 95% CI −28.6, −14.0, P: < 0.00001, d = 0.851; month 6: −27.6, 95% CI −35.6, −19.6, P: < 0.00001, d = 1.003), heaviness visual analog scales (VASs) (month 3: −8.1, 95% CI −13.9, −2.3, P: = 0.008, d = 0.609; month 6: −12.1, 95% CI −19.1, −5.1, P: = 0.001, d = 0.693), and anoscopic score (month 3: −0.4, 95% CI −0.6, −0.2, P: < 0.0001, d = 0.760; month 6: −0.5, 95% CI −0.7, −0.3, P: < 0.0001, d = 0.703) were achieved. Itching VASs reduced significantly only after 6 months (−8.1, 95% CI −14.6, −1.6, P: = 0.017, d = 0.586). No significant lowering of discharge VASs was achieved after 3 and 6 months.

Conclusion:

Under classical homeopathic treatment, hemorrhoids patients improved considerably in symptoms severity and anoscopic scores. However, being observational trial, our study cannot provide efficacy data. Controlled studies are required. Trial Reg. CTRI/2015/07/005958.