Comprehensive Review on Hemorrhoids: From Epidemiology to Preclinical Assessment of Anti-Hemorrhoidal Agents

The review discusses the etiology, epidemiology, classification, risk factors, assessment, the role of biomarkers in the development of hemorrhoids, operative and non-operative treatment options, post-operative complications of hemorrhoids, preclinical evaluation methods of anti-hemorrhoidal drugs, and different medicinal plants that exhibit anti-hemorrhoidal activity. The dilation and dislocation of normal anal cushions characterizes hemorrhoids. One of the most significant discoveries regarding hemorrhoids is the atypical enlargement and distortion of blood vessels, along with damage and modifications to the anal cavity’s supporting connective tissue. Hemorrhoids are categorized into different classifications based on various factors, Golingher’s classification commonly used, which divides the hemorrhoidal condition into four grades according to prolapse and the development of hemorrhoids. Hemorrhoids are recognized as one of the leading causes of morbidity, affecting millions of populations worldwide and also increasing the economic burden on the healthcare system. Current treatment options for hemorrhoids often involve conservative approaches, including fiber supplements, anti-inflammatory medications, lifestyle changes, and venotonic medicines. Additionally, operative treatments like rubber band ligation, hemorrhoidectomy, and injection sclerotherapy are utilized. Various biomarkers are responsible for the occurrence of hemorrhoids, such as matrix metalloproteinase (MMP), vascular endothelial growth factor (VEGF), inducible nitric oxide synthase (iNOS), and C-reactive protein (CRP). These biomarkers hold potential as targets for developing new anti-hemorrhoidal agents.

Analysis of the Therapeutic Effect of Hemorrhoids Suppositories Plus Fumigation and Hip Bath with Chinese Medicine on Postoperative Pain and Edema of Patients with Mixed Hemorrhoids / 广州中医药大学学报

Objective To investigate the clinical efficacy of hemorrhoids suppositories plus fumigation and hip bath with Chinese medicine on postoperative pain and edema of patients with mixed hemorrhoids.Methods A total of 62 cases of mixed hemorrhoids to be treated surgically were randomly divided into the trial group and the control group,with 31 cases in each group.Both groups of patients were given the surgery of mixed hemorrhoids(high ligation of hemorrhoids or Milligan-Morgan hemorrhoidectomy)and routine postoperative nursing.Additionally,the control group was treated with rectal hemorrhoids suppository,and the trial group was treated with rectal hemorrhoids suppository plus fumigation and hip bath with Chinese medicines of Carthami Flos,Persicae Semen,Corydalis Rhizoma,Talcum,Toosendan Fructus,Aurantii Fructus,Phellodendri Chinensis Cortex,Myrrha,and Olibanum.The course of treatment for the two groups covered 2 weeks.The changes of pain score and edema score in the two groups were observed before and after treatment,and time for the relief of the symptoms,clinical efficacy and therapeutic satisfaction were also compared.Results(1)After 2 weeks of treatment,the total effective rate of the trial group was 96.77%(30/31),and that of the control group was 80.65%(25/31).The intergroup comparison(tested by chi-square test)showed that the therapeutic efficacy of the trial group was significantly superior to that of the control group,and the difference was statistically significant(P＜0.05).(2)After treatment,the pain scores and edema scores of patients in the two groups were significantly decreased compared with those before treatment(P＜0.05),and the decrease of the scores in the trial group was significantly superior to that in the control group with statistically significant difference(P＜0.01).(3)The time for pain relief and time for edema subsidence in the trial group were significantly shorter than those of the control group,and the differences were statistically significant(P＜0.01).(4)The total satisfaction rate of the trial group was 96.77%(30/31),while that of the control group was 77.42%(24/31).The intergroup comparison(tested by chi-square test)showed that the therapeutic satisfaction of the trial group was significantly superior to that of the control group,and the difference was statistically significant(P＜0.05).Conclusion The therapeutic effect of hemorrhoids suppository plus fumigation and hip bath with Chinese medicine in treating postoperative pain and edema of mixed hemorrhoids is remarkably,and the therapy can effectively improve the degree of edema and pain,promote the recovery of the patients,and improve the patient's therapeutic satisfaction.

Meta-analysis of Ruiyun procedure for hemorrhoids combined with milligan-morgan hemorrhoidectomy(MMH)in the treatment of mixed hemorrhoids / 沈阳医学院学报

Objective:To systematically evaluate the clinical efficacy of Ruiyun procedure for hemorrhoids(RPH)combined with milligan-morgan hemorrhoidectomy(MMH)in the treatment of mixed hemorrhoids compared with MMH alone.Methods:Relevant literature was retrieved from China National Knowledge Infrastructure(CNKI),Wanfang,and VIP databases from their establishment to Jan 2023 using computers.Clinical randomized controlled trials(RCTs)of RPH combined with MMH and MMH alone in the treatment of mixed hemorrhoids were selected and analyzed,and meta-analysis was conducted using RevMan5.3 software.Results:A total of 30 RCTs were included,involving 4 609 patients.Results of Meta-analysis showed that there were statistically significant differences in surgical efficacy(RR=1.05,95% CI:1.02-1.08,P= 0.003),postoperative margin edema(RR=0.36,95% CI:0.27-0.49,P＜0.01),postoperative anal pain(RR=0.35,95% CI:0.23-0.53,P＜0.01),postoperative rectal bleeding(RR=0.35,95% CI:0.17-0.72,P=0.004),postoperative anal stenosis(RR=0.26,95% CI:0.11-0.59,P=0.001)and postoperative urinary retention(RR=0.77,95% CI:0.63-0.93,P=0.007)between RPH combined with MMH group and MMH group.Conclusion:Compared with MMH alone,RPH combined with MMH in the treatment of mixed hemorrhoids can reduce the incidence of postoperative side effects,such as postoperative margin edema,anal pain,rectal bleeding,anal stenosis,and urinary retention,with a relatively higher efficiency.

Postoperative analgesic efficacy of nefopam after anorectal surgery: a retrospective observational study

Objective: To examine the effectiveness of nefopam on postoperative pain control after anorectal surgeries. Methods: We retrospectively reviewed the electronic medical records of patients who underwent anorectal surgeries from January 2019 to March 2022 at two medical centers. The data were divided into nefopam and conventional groups. The primary outcome was the number of patients who requested additional opioids in the 24-h postoperative period. The secondary outcomes were numeric rating pain scores (NRPS) within a 24-h postoperative period and analgesic drugs-related side effects. Results: Eighty-seven patients in the conventional group and 60 in the nefopam group were recruited. The nefopam group reported less additional opioid consumption than the conventional group in all dimensions of analysis, including overall, adjusted to anesthetic techniques and types of surgery. However, these did not reach statistical significance (P = 0.093). Only patients in the nefopam group who underwent hemorrhoidectomy under TIVA or spinal anesthesia significantly required fewer additional opioids (P = 0.016, 60% mean difference). Similarly, the 24-h postoperative morphine consumption was lower in the nefopam group (mean difference = -3.4, 95%CI: 0.72,6.08). Furthermore, significantly lower NRPS were reported in the nefopam group during the 12-18 h postoperative period (P = 0.009). On the other hand, analgesic drugs related side effects were similar in both groups. Conclusions: The administration of nefopam after major anorectal surgery is beneficially evident in reducing postoperative opioid requirements. (AU)

Evaluación comparativa de la efectividad en el manejo del dolor posthemorroidectomia con tres estrategias farmacológicas diferentes

Introducción: La hemorroidectomía produce un intenso dolor postoperatorio recomendándose la analgesia multimodal para su manejo, manteniéndose como problema no resuelto. El objetivo fue evaluar la efectividad analgésica de tres combinaciones farmacológicas para el dolor post-hemorroidectomía. Materiales y Método: Estudio clínico prospectivo, aleatorizado, realizado en Clínica INDISA, entre diciembre 2019 y diciembre 2021, incluyendo pacientes con indicación de hemorroidectomía electiva. Se excluyeron hemorroidectomías asociadas a otro procedimiento quirúrgico, embarazadas/lactancia, reacciones adversas a medicamentos (RAM) a los fármacos en estudio, enfermedades hepáticas, renales o alteraciones/discapacidades mentales. Grupo I (control): Ketorolaco, Tramadol, Paracetamol. Grupo II: Grupo I y Nifedipino 0,2% tópico. Grupo III: Buprenorfina en parche 10 mcg/hora, Paracetamol y Ketorolaco. Asociado a régimen rico en fibra, polietilenglicol, baños de asiento y omeprazol. Se utilizó estadística descriptiva y analítica usando Chi-cuadrado, ANOVA-Bonferroni, Test de Kruskal Wallis, Wilcoxon y Fisher. Software R, utilizando un alfa del 5%. Resultados: De 117 pacientes, se enrolaron 39 = Grupo I, 41 = Grupo II y 37 = Grupo III. No hubo diferencias en la efectividad analgésica (p = 0,45). Para las RAM se observó que los pacientes con Buprenorfina tuvieron más náuseas (p = 0,08), vómitos (p = 0,04), dermatitis (p < 0,001) y prurito (p = 0,006). Discusión y Conclusiones: No hubo diferencias significativas para la efectividad analgésica post-hemorroidectomía al comparar los grupos de estudio. El uso de nifedipino tópico se recomienda como complemento a la terapia multimodal al mejorar los resultados sin aumentar las RAM. El uso de buprenorfina presentó más RAM sin mejores resultados como analgésico. El principal determinante para el alivio del dolor fue el tiempo transcurrido desde la cirugía.

Introduction: Hemorrhoidectomy produces intense postoperative pain, recommending multimodal analgesia for its management, remaining as an unresolved problem. The aim of this study was to evaluate the analgesic effectiveness of three pharmacological combinations for post-hemorrhoidectomy pain. Material and Method: A prospective, randomized clinical study, conducted at the INDISA Clinic, between December 2019 and December 2021, including patients with an indication for elective hemorrhoidectomy. Hemorrhoidectomies associated with another surgical procedure, pregnant/lactating women, adverse drug reactions (ADRs) to the study drugs, liver and kidney diseases, or mental disorders/disabilities were excluded. Group I (control): Ketorolac, Tramadol, Paracetamol. Group II: Group I and Nifedipine 0.2% topical. Group III: Buprenorphine patch 10 mcg/hour, Paracetamol and Ketorolac. Associated with a diet rich in fiber, polyethylene glycol, sitz baths, and omeprazole. Descriptive and analytical statistics were used using Chi-square, ANOVA-Bonferroni, Kruskal Wallis, Wilcoxon and Fisher test. Software R, using an alpha of 5%. Of 117 patients, 39 = Group I, 41 = Group II and 37 = Group III were enrolled. Results: There were no differences in analgesic effectiveness (p = 0.45). For the ADRs, it was observed that the patients with Buprenorphine had more nausea (p = 0.08), vomiting (p = 0.04), dermatitis (p < 0.001) and itching (p = 0.006). Discussion and Conclusion: There were no significant differences for post-hemorrhoidectomy analgesic effectiveness when comparing the study groups. The use of topical nifedipine is recommended as a complement to multimodal therapy as it improves results without increasing adverse drugs reaction (ADR).The use of buprenorphine presented more ADR without better results as an analgesic.The main determinant for pain relief was the time elapsed since surgery.

Effectiveness and safety of ultra-low-dose spinal anesthesia versus perineal blocks in hemorroidectomy and anal fistula surgery: a randomized controlled trial

Abstract Background: Ultra-low-dose Spinal Anesthesia (SA) is the practice of employing minimal doses of intrathecal agents so that only the roots that supply a specific area are anesthetized. The aim of this study was to compare the effectiveness and safety of ultra-low-dose spinal anesthesia with that of Perineal Blocks (PB). Methods: A two-arm, parallel, double-blind randomized controlled trial comparing two anesthetic techniques (SA and PB) for hemorrhoidectomy and anal fistula surgery was performed. The primary outcomes were postoperative pain, complementation and/or conversion of anesthesia, and hemodynamic changes. Results: Fifty-nine patients were included in the final analysis. The mean pain values were similar in the first 48 h in both groups (p > 0.05). The individuals allocated to the SA group did not need anesthetic complementation; however, those in the PB group required it considerably (SA group, 0% vs. PB group, 25%; p = 0.005). Hemodynamic changes were more pronounced after PB: during all surgical times, the PB group showed lower MAP values and higher HR values (p < 0.05). Postoperative urinary retention rates were similar between both groups (SA group 0% vs. PB group 3.1%, p = 0.354). Conclusion: SA and PB are similarly effective in pain control during the first 48 h after hemorrhoidec-tomy and anal fistula surgery. Although surgical time was shorter among patients in the PB group, the SA technique may be preferable as it avoids the need for additional anesthesia. Furthermore, the group that received perineal blocks was under sedation with a considerable dose of propofol.

Effect of Neibu Huangqi Decoction combined with Kangfuxin Liquid on wound healing after hemorrhoid fistula / 国际中医中药杂志

Objective:To investigate the effects of Neibu Huangqi Decoction combined with Kangfuxin Liquid on wound healing after hemorrhoid fistula.Methods:Randomized controlled trial. A total of 90 patients with hemorrhoid fistula surgery in Tangshan Hospital of Traditional Chinese Medicine from January 2020 to June 2021 were selected as the observation objects and divided into 2 groups by random number table method, with 45 cases in each group. The control group was treated with Kangfuxin Liquid after surgery, and the observation group was treated with Neibu Huangqi Decoction. Both groups were treated continuously for 14 days. Wound symptom score was performed before and after treatment. The levels of TNF-α, IL-6 and IL-8 were determined by ELISA. The wound healing time was observed and the wound healing rate was calculated. Adverse reactions were recorded and clinical efficacy was evaluated.Results:The total effective rate was 93.33% (42/45) in the observation group and 66.67% (30/45) in the control group, with statistical significance ( χ2=9.89, P=0.002). After treatment, the scores of pain [(0.63±0.14) vs. (0.97±0.27), t=7.50], exudation [(0.67±0.12) vs. (1.09±0.31), t=8.48], edema [(0.78±0.17) vs.(1.25±0.36), t=7.92], pruritus [(0.78±0.20) vs. (1.32±0.33), t=9.39] were lower than those in the control group ( P<0.01); serum TNF-α [(33.46±2.86) μg/L vs. (45.78±3.92) μg/L, t=25.39], IL-6 [(41.86±5.84) μg/L vs. (56.12±6.75) μg/L, t=15.98], IL-8 [(27.40±3.58) ng/L vs. (36.16±3.84) ng/L, t=16.69] were lower than those in the control group ( P<0.01). The wound healing time of the observation group was shorter than that of the control group ( t=8.60, P<0.01), and the wound healing rate was higher than that of the control group ( t=24.65, P<0.01). During treatment, the incidence of adverse reactions was 11.11% (5/45) in the observation group and 6.67% (3/45) in the control group, without statistical significance ( χ2=0.14, P=0.711). Conclusion:Neibu Huangqi Decoction combined with Kangfuxin Liquid can promote wound healing, reduce inflammatory cytokines, relieve pain and exudation, improve clinical efficacy, and have few adverse reactions.

Caracterización de las técnicas quirúrgicas para el tratamiento de la enfermedad hemorroidal

Introducción: En el tramo distal del conducto anal es normal la presencia de unas estructuras a modo de cojines, constituidas por tejido vascular, denominadas plexos hemorroidales. Objetivo: Comparar las técnicas quirúrgicas abiertas y cerrada en la enfermedad hemorroidal en la provincia Camagüey, en el periodo comprendido desde enero de 2021 a enero de 2023. Métodos: Se realizó un estudio observacional, analítico de corte transversal. El universo lo conformaron 135 pacientes que acudieron a consulta con el diagnóstico de enfermedad hemorroidal. Se le realizó un muestreo aleatorio simple, donde se tomaron 15 pacientes de cada uno de los grupos para conformar una muestra total de 45, cada grupo fue tratado con una técnica quirúrgica diferente. Resultados: En relación al sexo predominó el femenino, el tiempo quirúrgico fue dado a los 30 minutos en las técnicas abiertas. El dolor postoperatorio como complicación inmediata fue significativo con la utilización de la técnica abierta Whitehead clásico, no existieron complicaciones mediatas en el estudio; mientras que en las tardías la estenosis anal fue la que más se manifestó. Conclusiones: Existió predomino del sexo femenino, el tiempo de quirúrgico de mayor frecuencia fue de 30 minutos en los pacientes operados con la técnica abiertas, en la mayor parte de los pacientes se constató dolor excesivo como complicación inmediata con las técnicas de Milligan-Morgan y Whitehead clásico abiertas no así con la cerrada de Ferguson. La estenosis anal fue la complicación quirúrgica tardía más frecuente asociada a la técnica de Whitehead clásico.

Introduction: In the distal section of the anal canal, the presence of "cushion"-like structures, mainly made up of vascular tissue, called hemorrhoid plexuses. Objective: To compare the open and closed surgical techniques in hemorrhoid disease in Camagüey province, in the period from January 2021 to January 2023. Methods: An observational, analytical, cross-sectional study was carried out. The universe was made up of 135 patients who attended the consultation with the diagnosis of hemorrhoid disease. A simple random sampling was carried out, where 15 patients from each of the groups were taken to form a total sample of 45 patients, each group was treated with a surgical technique. Results: In relation to sex, the female sex predominated, the surgical time was given at 30 minutes in the open techniques. Postoperative pain as an immediate complication was significant with the use of the classic Whitehead open technique; there were no mediate complications in this study; while in the late ones, anal stenosis was the one that manifested itself the most. Conclusions: There was a predominance of the female sex, the most frequent surgical time was 30 minutes in patients operated with the open technique, in most patients excessive pain was found as an immediate complication with the Milligan-Morgan and classic Whitehead open techniques, but not so with the closed technique of Ferguson. Anal stenosis was the most frequent late surgical complication associated with the classic Whitehead technique.

Complications after Stapled Hemorrhoidectomy: A Single Center Experience

Background: A circumferential strip of mucosa about 1.5 to 2 centimetres above the dentate line is removed in stapled hemorrhoidectomy, a new technique for haemorrhoids treatments. Objective: The aim of the study was to evaluate complications after stapled hemorrhoidectomy.Methods:A total of 101 patients between the age group 20 to 70 years were diagnosed with grade 3 and grade 4 haemorrhoids. Patients are included in stapled haemorrhoidectomy. The questionnaire focused on stapled hemorrhoidectomy procedures performed in the period July 2018 to June 2020. Descriptive analysis was done based on the student抯 T-test using SPSS 24 software version. The level of significance was set at 5% (p < 0.05).Results:In the 2-years timeframe, out of 101 patients in the Immediate (within 1 week) complications of stapled hemorrhoidectomy, 84.16% were in None, 5.94% were severe pain, 3.96% were bleeding, 1.98% were Thrombosis, 0.99% were urinary retention, 1.98% were Anastomotic dehiscence 0.99% were Fissure, 0.99% were perineal intramural hematoma and 0.99% were submucosal abscess. Out of 90.09% were in none, 1.98% were Recurrent hemorrhoids, 0.99% were Severe pain, Stenosis, Fissure, Skin tag, Thrombosis, Staples problems, Intramural abscess and Intussusception.Conclusion:Although stapled hemorrhoidectomy appears to be promising, we believe that a multicenter randomized controlled trial with a long-term follow-up comparing stapled hemorrhoidectomy and banding is required before the treatment can be recommended. The majority of difficulties can be avoided by following the rectal wall anatomy during the surgery.

Is it possible to optimize stapled hemorrhoidopexy outcomes by enlarging operative criteria indications? results of a tailored procedure with associated resection in a comparative personal series / é possível otimizar os resultados da hemorroidopexia grampeada pela ampliação dos critérios de indicação operatória? resultados de um procedimento personalizado com ressecção associada em uma série comparativa pessoal

ABSTRACT BACKGROUND: Since its introduction, stapled hemorrhoidopexy has been increasingly indicated in the management of hemorrhoidal disease. AIM: Our primary end point was to evaluate the incidence of recurrent disease requiring another surgical intervention. On a secondary analysis, we also compared pain, complications, and patient's satisfaction after a tailored surgery. METHODS: We retrospectively reviewed 196 patients (103 males and 93 females) with a median age of 47.9 years (range, 17-78) who were undergoing stapled hemorrhoidopexy alone (STG; n=65) or combined surgery (CSG; n=131, stapled hemorrhoidopexy associated with resection). RESULTS: Complications were detected in 11 (5.6%) patients (4.6% for STG vs. 6.1% for CSG; p=0.95). At the same time, symptoms recurrence (13.8% vs. 8.4%; p=034), reoperation rate for complications (3.1% vs. 3.0%; p=1.0), and reoperation rate for recurrence (6.1% vs. 4.6%; p=1.0) were not different among groups. Grade IV patients were more commonly managed with simultaneous stapling and resection (63% vs. 49.5%), but none of them presented symptoms recurrence nor need reoperation due to recurrence. Median pain score during the first week was higher in CSG patients (0.8 vs. 1.7). After a follow-up of 24.9 months, satisfaction scores were similar (8.6; p=0.8). CONCLUSION: Recurrent symptoms were observed in 10% of patients, requiring surgery in approximately half of them. Even though the association of techniques may raise pain scores, a tailored approach based on amplified indication criteria and combined techniques seems to be an effective and safe alternative, with decreased relapse rates in patients suffering from more advanced hemorrhoidal disease. Satisfaction scores after hemorrhoidopexy are high.

RESUMO RACIONAL: Desde sua introdução, a hemorroidopexia por grampeamento tem sido cada vez mais indicada no manuseio da doença hemorroidária. OBJETIVOS: Nosso objetivo primário foi avaliar a incidência de doença recidivada que requeira tratamento cirúrgico. Numa análise secundária, também comparamos dor, complicações e satisfação do paciente após uma operação ajustada a cada caso. MÉTODOS: Foram revistos retrospectivamente 196 pacientes (103 homens e 93 mulheres) com idade média de 47,9 anos (17-78) submetidos a hemorroidopexia mecânica isoladamente (STG; n=65) ou cirurgia combinada (CSG; n=131, hemorroidopexia por grampeamento com ressecção). RESULTADOS: Complicações foram detectadas 11 (5,6%) pacientes (4,6% para STG vs. 6,1% para CSG; p=0,95). Ao mesmo tempo, recidiva de sintomas (13,8% vs. 8,4%; p=034), reoperações por complicações (3,1% vs. 3,0%; p=1,0) ou por recidiva (6,1 vs. 4,6%; p=1,0) não foram diferentes entre os dois grupos. Pacientes com grau IV foram mais comumente manuseados com grampeamento e ressecção simultâneos (63% vs. 49,5%), mas nenhum deles apresentou recidiva ou necessitou reoperação. O escore médio de dor na primeira semana foi maior no grupo CSG (0,8 vs. 1,7). Após seguimento de 24,9 meses, os índices de satisfação foram similares (8,6; p=0,8). CONCLUSÕES: Sintomas de recidiva foram observados em 10%, requerendo cirurgia em aproximadamente metade dos doentes. Embora a associação de técnicas aumente os escores de dor, um procedimento sob medida baseado em critérios ampliados de indicação e técnicas combinadas parece ser uma alternativa efetiva e segura, com menor recidiva em pacientes portadores de doença hemorroidária mais avançada. Os escores de satisfação após hemorroidopexia são altos.

Stapled hemorrhoidopexy: results, late complications, and degree of satisfaction after 16 years of follow-up / Hemorroidopexia mecânica: resultados, complicações tardias e grau de satisfação após 16 anos de seguimento

ABSTRACT - BACKGROUND: Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids, but concerns about complications and recurrences after prolonged follow-up are still under debate. AIMS: The aim of this study was to evaluate the very long-term results of the stapled hemorrhoidopexy technique. METHODS: Stapled hemorrhoidopexy was performed on 155 patients between 2000 and 2003, and the early results have already been published. In this study, we evaluated the same patients after a very long follow-up. Data were collected with regard to late complications, rate and timing of recurrences, and patients' degree of satisfaction. RESULTS: From a total of 155 patients, 98 patients were evaluated: 59 (60.2%) were interviewed by telephone and 39 (39.8%) were evaluated by outpatient consultation. The mean follow-up was 193 months (range: 184-231), 52 were female, 52 were grade III hemorrhoids, and 46 were grade IV. Recurrence was higher in grade IV (26.1%) than in grade III (7.7%) (p=0.014). Recurrence after prolonged follow-up was seen in 16 patients (16.3%) and 11 (11.2%) required reoperations. The complications were skin tags (3.1%), anal sub-stenosis (2.1%), and fecal incontinence (2.1%). After a prolonged follow-up, 82.5% of patients were either very satisfied or satisfied with the surgery. CONCLUSIONS: Stapled hemorrhoidopexy is a safe and effective treatment for hemorrhoidal disease grades III and IV. Recurrence is higher for grade IV hemorrhoids and may occur up to 9 years of follow-up. Reoperations were infrequent and there is a high patient's degree of satisfaction associated with this technique.

RESUMO - RACIONAL: A hemorroidopexia mecênica tem sido amplamente utilizada para o tratamento de hemorroidas, mas as preocupações com complicações e recorrências após seguimento prolongado ainda estão em debate. OBJETIVOS: Nosso objetivo foi avaliar os resultados a muito longo prazo com a técnica hemorroidopexia mecênica. MÉTODOS: O hemorroidopexia mecênica foi realizada em 155 pacientes entre 2000 e 2003, e os primeiros resultados já foram publicados. No presente estudo, avaliamos os mesmos pacientes após um seguimento muito longo. Os dados foram coletados em relação às complicações tardias, taxa e tempo de recorrência e grau de satisfação do paciente. RESULTADOS: De um total de 155 pacientes, 98 pacientes foram avaliados: 59 (60,2%) foram entrevistados por telefone e 39 (39,8%) foram avaliados por consulta ambulatorial. O seguimento médio foi de 193 meses (variação: 184-231), 52 eram do sexo feminino, 52 eram hemorroidas grau III e 46 eram grau IV. A recorrência foi maior no grau IV (26,1%) do que no grau III (7,7%) (p=0,014). A recorrência após seguimento prolongado foi observada em 16 pacientes (16,3%) e 11 (11,2%) necessitaram de reoperações. As complicações foram: plicomas (3,1%), subestenose anal (2,1%) e incontinência fecal (2,1%). Após seguimento prolongado, 82,5% dos pacientes ficaram muito satisfeitos ou satisfeitos com a cirurgia. CONCLUSÕES: O hemorroidopexia mecênica é um tratamento seguro e eficaz para a doença hemorroidária graus III e IV. A recorrência é maior para hemorroidas grau IV e pode ocorrer até 9 anos de seguimento. As reoperações foram infrequentes e há um alto grau de satisfação do paciente associado a esta técnica.

recurrent hemorrhoids-efficacy, utility and initial experience with the use of stapled hemorrhoidopexy in recurrent hemorrhoids

Overview: Hemorrhoidal disease (HD) is a common surgical disorder. The treatment modalities can be surgical or nonsurgical. Every surgical option has its own indications and limitations. Postsurgical symptomatic recurrence rates are low and vary between different techniques. The ideal way to deal with recurrent HD is not clear. Material and Methods: The present prospective case series enrolled a total of 87 patients (54male/33 female). Thirteen out of 87 patients (15%) had history of previous intervention for HD. Amodification of the standard technique was adopted for patients with recurrent HD. A mean follow-up of 22 months was achieved. Results: Stapled hemorrhoidectomy (SD)was performedin13patientswho had historyof previous surgical intervention for HD. There were no adverse events related to the technique. Patients with recurrent HD had severe pain scores with SH as compared to patients who underwent SH at the first time. There were no wound related complications. Conclusion: Stapled hemorrhoidectomy can be performed easily and offers good results in patients with recurrent HD. (AU)

Selective hemorrhoidal dearterialization with high mucopexy in the surgical treatment of hemorrhoidal disease

The doppler-guided transanal hemorrhoidal dearterialization technique associated with mucopexy is a noninvasive surgical option used to treat hemorrhoidal disease (HD). Objective: To compare and analyze the results using a variation of the doppler-guided transanal hemorrhoidal dearterialization technique with the technique of selective hemorrhoidal dearterialization with high mucopexy in the treatment of HD. Method: A total of 292 patients who underwent surgical treatment for grade II, III and IV HD from March 2012 to December 2017 were studied. From this total, 110 (37.6%) patients underwent a conventional doppler-guided transanal hemorrhoidal dearterialization with mucopexy (CD), and 182 (62.3%) underwent selective hemorrhoidal dearterialization with highmucopexy (SHeLF). In the group of patients undergoing CD, 4 patients (3.64%) had grade II HD, 82 (74.55%) grade III, and 24 (21.82%) grade IV. In the group submitted to SHeLF, 18 (9.89%) patients had grade II HD, 86 (47.25%) had grade III, and 65 (35.71%) had grade IV. The same surgeon operated all patients under spinal anesthesia. In patients undergoing CD, six arterial branches have been dearterialized, while in patients undergoing SHeLF, the hemorrhoidary nipples submitted to a dearterialization were selected (from 1 to 5) by intraoperative evaluation followed by high rectal mucopexy. In the postoperative period, the following parameters were evaluated: pain, tenesmus, bleeding, and recurrence. Moderate results to severe pain was a postoperative complaint reported by 13 (11.82%) patients undergoing CD, and by 19 (10.44%) undergoing SHeLF. Intense tenesmus was reported by 26 (23.64%) patients undergoing CD and by 7 (3.85%) undergoing SHeLF. Three patients (2.73%) undergoing CD and 1 (0.55%) undergoing SHeLF evolved with postoperative bleeding. One patient (0.55%) in the group undergoing CD required surgical review of hemostasis. Six patients (5.45%) who underwent CD and 8 (4.39%) who underwent SHeLF were reoperated due to disease recurrence. Conclusion: Comparing statistics, patients undergoing the SHeLF technique have less postoperative pain, tenesmus and postoperative bleeding when compared with CD. (AU)

Impact of Ambulatory Surgery for Hemorrhoidal Disease on Clinical Outcomes and Institutional Costs / Impacto da cirurgia ambulatória para patologia hemorroidária nos resultados clínicos e custos

Abstract Objective Transanal hemorrhoidal artery ligation with mucopexy (ligation anopexy [LA]) and open hemorrhoidectomy (OH) can both be performed under local anesthesia. The aim of the present study was to analyze the impact and the cost-effectiveness of performing these techniques in an ambulatory setting of an Italian academic center on the postoperative outcome. Methods A series of 122 consecutive patients with grades II and III hemorrhoidal disease undergoing ambulatory surgical treatment of hemorrhoids in 2015 to 2018 (group A) was comparedwith 122 patients operated at the same institution in the same period (group H) in a hospital setting. The primary outcome was the number of days required to return to work/daily activities. Secondary outcomes included postoperative pain and complications, costeffectiveness, patient satisfaction, and recurrence at 12 months. In group A, all the procedures were performed under local anesthesia with early discharge. In group H, the procedureswere performed under general or loco-regional anesthesia with hospital admission. Results The mean number of days required to return to work/daily activities was 8.4 ± 4.8 days in group A, compared with 12.5 ± 3 days in group H (p<0.001). The visual analog scale (VAS) pain score at 1 week, 2 and 3 weeks, and 1 month after surgery was lower for patients undergoing LA in the ambulatory setting (p<0.01). We observedmore postoperative complications in hospitalized (12.5%) than in ambulatory patients (7.5%) (p<0.001). The total mean direct costs per patient were significantly lower in the ambulatory setting versus the hospital stay group (351.3 versus 1,746 euros). Conclusion Implementing ambulatory surgery for hemorrhoids is feasible, safe, and cost-effective.

Resumo Objetivo A ligação transanal da artéria hemorroidária com mucopexia e a hemorroidectomia aberta (HA) podem ser realizadas em anestesia local. O objetivo do presente estudo foi analisar o impacto no resultado pós-operatório e a relação custo-eficácia da realização destas técnicas em ambiente ambulatorial de um centro acadêmico italiano no desfecho pós-operatório. Métodos Uma série de 122 pacientes consecutivos com patologia hemorroidária de graus II e III submetidos a cirurgia de hemorroidas em regime ambulatório de 2015 a 2018 (grupo A) foi comparada com 122 pacientes operados na mesma instituição no mesmo período (grupo H) por hospitalização. O desfecho primário foi o número de dias necessários para regressar ao trabalho/atividades diárias. Os desfechos secundários incluíram dor e complicações pós-operatórias, custo-eficácia, satisfação do paciente, e recidiva aos 12 meses. No grupo A, todos os procedimentos foram realizados em anestesia local. No grupo H, os procedimentos foram realizados em anestesia geral ou loco-regional. Resultados A espera média para o regresso ao trabalho foi de 8,4 ± 4,8 dias no grupo A em comparação com 12,5 ± 3 dias no grupo H (p<0,001). A pontuação na escala visual analógica (EVA) da dor 1 semana, 2 e 3 semanas, e 1 mês após a cirurgia foi mais baixa para os pacientes submetidos a cirurgia de ligadura com anopexia em ambiente ambulatorial (p<0,01). Observamosmais complicações pós-operatórias empacientes hospitalizados (12,5%) do que em pacientes ambulatórios (7,5%) (p<0,001). Os custos diretosmédios totais por paciente foram mais baixos em ambiente ambulatório do que no grupo de hospitalização (351,3 contra 1.746 euros). Conclusão A implementação da cirurgia ambulatória para hemorroidas é possível, segura e rentável.

Assessment of the Success Rates of Stapled Hemorrhoidopexy Intervention for Grade III and IV Hemorrhoids among Adult Patients of North India: An Observational Hospital-based Study

Introduction: Hemorrhoid disease therapy is effectively been treated with conventional excisional hemorrhoidectomy. Stapledhemorrhoidopexy (SH) revolutionized the traditional surgical approach by the introduction of the theory of dealing with the rectalmucosal prolapse by resecting a mucosal cylinder above the dentate line by means of mechanical stapling. It is a non-excisionalapproach for the surgical treatment of hemorrhoid disease.Materials and Methods: Ethical clearance was obtained from the institution. A total of 100 adult patients with Grade III/IVhemorrhoids indicated for surgery were recruited for the study purpose. Data collected were post-operative pain in the form ofVAS scale, immediate complications, duration, or length of stay in the hospital along with the time to resume work again. SPSS17.0 was used to carry out the analysis. All P < 0.05 were considered to be statistically significant.Results: The mean age of the study group was 45 ± 14.93 years. The mean length of hospital stays, postoperatively for 21%subjects, was mere 1 day; however, it was 2 days for the rest of population studied. The only complication was with 2% of thestudy population having excessive intraoperative bleeding. The mean time to return to work was 8 days. About 77% of thepatients resumed their work within 8 days of surgery.Conclusion: Within the given limitations of the study, we can conclude that SH is a successful procedure for Grade-III/IVhemorrhoids in terms of immediate post-operative complications, pain as well as the duration of hospital stay

Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial / 中西医结合学报

BACKGROUND@#Hemorrhoids are one of the most common conditions that lead to surgery, and until now surgical hemorrhoidectomy has been the major effective treatment. Post-operative pain from hemorrhoidectomy has been experienced by thousands of patients and remains a major inconvenience of the operation.@*OBJECTIVE@#This study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain.@*DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS@#This was a single-center, patient-assessor-blinded and randomized controlled trial with 154 patients receiving Milligan hemorrhoidectomy surgery. Eligible patients were randomly assigned to either a treatment group or a control group at a ratio of 1:1. The treatment group received the pestle needle therapy, with manual stimulation at Yaoshu (DU2), Mingmen (DU4), Changqiang (DU1), Chengshan (BL57), Erbai (EX-UE2) and the perianal points (1, 3, 5, 7, 9, and 11o'clock around the lesion); while the control group received a sham treatment with very light pressure. Three sessions of treatment were performed at 30 min, 4 h and 12 h after the surgery, and each lasted for 15 min.@*MAIN OUTCOME MEASURES@#The primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery. The secondary outcomes included the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery, the analgesic dose, the time and the VAS score of the patients' first defecation after surgery, as well as the Hamilton Rating Scale for Anxiety (HAMA) evaluated before discharge.@*RESULTS@#The mean pain score of the treatment group was significantly lower than that of the control group (3.10 ± 1.27 vs 4.82 ± 1.29; P < 0.001) at 12 h after surgery. Compared with the control group, patients in the treatment group needed a smaller dose of analgesic within the first 24 hours after surgery (P = 0.002); and their HAMA scores before discharge were lower (4.07 ± 2.40 vs 5.10 ± 2.45, P = 0.009). Compared to the treatment group, patients in the control group had a greater time to the first defecation after surgery ([52.34 ± 15.72] h vs [27.08 ± 13.68] h; P < 0.001), but there was no difference in their VAS scores at the first defecation (P = 0.092).@*CONCLUSION@#The pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.

Manejo de la trombosis hemorroidal externa en la unidad de emergencia / Management of external hemorrhoid thrombosis in the accident and emergency unit

La trombosis hemorroidal externa es la principal complicación aguda de la enfermedad hemorroidal externa. Esta, constituye una de las urgencias proctológicas más frecuentes, llevando a los pacientes a consultar en la unidad de emergencia por proctalgia. Su manejo en fase aguda aún es discutido, pero se menciona el tratamiento quirúrgico con hemorroidectomía o trombectomía y el manejo conservador como opciones válidas. La hemorroidectomía se describe como la mejor opción terapéutica dentro de las primeras 48 - 72 horas, puesto que favorece un alivio sintomático más precoz, menor recurrencia y periodos de remisión más largos. El manejo conservador consta de diferentes intervenciones orientadas a disminuir el dolor, y se puede ofrecer a pacientes que no aceptan la opción quirúrgica, que consulten con más de 72 horas de evolución, o cuyo dolor va en regresión, puesto que los síntomas pueden remitir espontáneamente en 7 a 10 días. La elección del tratamiento debe considerar tanto las preferencias del paciente como la realidad local de la unidad de emergencia donde consulta. El objetivo de esta revisión es realizar un análisis de la evidencia disponible en cuanto al manejo de la trombosis hemorroidal externa en la unidad de emergencia.

External hemorrhoid thrombosis is the principal complication of external hemorrhoids. It is one of the most frequent proctological emergencies, patients coming to Accident and Emergency (A&E) with proctalgia. Although there is still no agreement on its treatment in the acute phase, surgical treatment with hemorrhoidectomy or thrombectomy or conservative management are all valid options. In the first 48 ­ 72 hours hemorrhoidectomy is said to be the best therapeutic option as it achieves the most rapid symptomatic relief, less recurrence and longest remission periods. Conservative management comprises different interventions which aim to diminish the pain and can be offered to patients not wishing surgery, who consult more than 72 hours after the symptoms start or whose pain is now diminishing, given that the symptoms may remit spontaneously over 7 to 10 days. The choice of treatment should take into consideration the patient's preferences as well as the local conditions in the A&E unit. The objective of this review is to analyze the available evidence on management of external hemorrhoidal thrombosis in A&E.

Evidence-based review of methods used to reduce pain after excisional hemorrhoidectomy / Revisão baseada em evidências de métodos utilizados para reduzir a dor após hemorrroidectomia excisional

ABSTRACT Background: Excisional hemorrhoidectomy is one of the most commonly performed anorectal procedures. Despite the satisfactory outcomes of excisional hemorrhoidectomy, the pain perceived by the patients following the procedure can be a distressing sequel. This review aimed to search the current literature for the existing evidence on how to avoid or minimize the severity of post-hemorrhoidectomy pain. Methods: An organized literature search was performed using electronic databases including PubMed/Medline and Google Scholar service for the articles that evaluated different methods for pain relief after excisional hemorrhoidectomy. Then, the studies were summarized in a narrative way illustrating the hypothesis and the outcomes of each study. The methods devised to reduce pain after excisional hemorrhoidectomy were classified into three main categories: technical tips; systemic and topical agents; and surgical methods. The efficacy of each method was highlighted along the level of evidence supporting it. Results: Stronger evidence (level Ia) supported LigaSure hemorrhoidectomy and the use of glyceryl trinitrate ointment to be associated with significant pain relief after excisional hemorrhoidectomy whereas the remaining methods were supported by lower level of evidence (level Ib). Conclusion: The use of LigaSure in performing excisional hemorrhoidectomy and the application of topical glyceryl trinitrate ointment contributed to remarkable relief of postoperative pain after excisional hemorrhoidectomy according to the highest level of evidence. Perhaps a multimodality strategy that combines systemic and topical agents can be the optimal method for control of pain after excisional hemorrhoidectomy, yet further prospective trials are required to draw such conclusion.

RESUMO Introdução: A hemorroidectomia excisional (HE) é um dos procedimentos anorretais mais comumente realizados. Apesar dos resultados satisfatórios da hemorroidectomia excisional, a dor percebida pelos pacientes após o procedimento pode ser uma sequela angustiante. Esta revisão teve como objetivo buscar na literatura atual as evidências existentes sobre como evitar ou minimizar a gravidade da dor pós-hemorroidectomia. Métodos: Uma busca organizada da literatura foi realizada usando bancos de dados eletrônicos, incluindo PubMed/Medline e Google Scholar, para os artigos que avaliaram diferentes métodos para o alívio da dor após hemorroidectomia excisional. Em seguida, os estudos foram resumidos de forma narrativa, ilustrando a hipótese e os resultados de cada estudo. Os métodos desenvolvidos para reduzir a dor após a hemorroidectomia excisional foram classificados em três categorias principais: dicas técnicas; agentes sísticos e ticos; e métodos cirúrgicos. A eficácia de cada método foi destacada ao longo do nível de evidência que a suporta. Resultados: Evidências mais fortes (nível Ia) apoiaram a hemorroidectomia de LigaSure e o uso de pomada de trinitrato de glicerila para ser associado com alívio significativo da dor após hemorroidectomia excisional, enquanto os métodos restantes foram apoiados por menor nível de evidência (nível Ib). Conclusão: O uso de LigaSure na realização de hemorroidectomia excisional e a aplicação de pomada tópica de gliceril trinitrato contribuíram para o notável alívio da dor pós-operatória após hemorroidectomia excisional, de acordo com o maior nível de evidência. Talvez uma estratégia multimodal que combine agentes sistêmicos e tópicos possa ser o método ideal para o controle da dor após hemorroidectomia excisional, mas ainda são necessários mais estudos prospectivos para chegar a essa conclusão.

Meralgia paresthetica following hemorrhoidectomy in the jack-knife position: A case report

Meralgia paresthetica (MP) is a neuropathic pain caused by the entrapment of the lateral femoral cutaneous nerve (LFCN). There have been reports of MP following various surgeries; however, it has not yet been reported after hemorrhoid surgery. We report a case of bilateral MP after hemorrhoid surgery in a jack-knife position. The patient presented with pain, tightness, and a tingling sensation in the anterolateral aspect of both thighs. Ultrasonography-guided LFCN block was used for diagnosis and treatment, along with conservative management for 20 days with oral medication. One month later, the patient's symptoms had resolved completely. MP due to the jack-knife position may occur postoperatively in patients with predisposing risk factors such as obesity and diabetes mellitus, despite adequate padding and a shorter operating time.

Effect of electroacupuncture preconditioning combined with induced urination on urinary retention after milligan-morgan hemorrhoidectomy / 中国针灸

OBJECTIVE@#To investigate the effect of electroacupuncture preconditioning combined with induced urination on urinary retention after milligan-morgan hemorrhoidectomy.@*METHODS@#Eighty patients with mixed hemorrhoids were randomly divided into an electroacupuncture group and a routine group, 40 cases in each group. Anesthesia at Yaoshu (GV 2) was given in the two groups. In the electroacupuncture group, electroacupuncture at Zhongji (CV 3)，Guanyuan (CV 4)，Pangguangshu (BL 28) and Sanyinjiao (SP 6) was applied with tolerant intensity for 30 min before operation, 2 Hz/100 Hz in frequency. After operation, induced urination was given, namely hot compress of bladder area and sound of hearing water. In the routine group，induced urination was given after operation. The score of the first urination waiting time, the distension of lower abdomen on the evening of the postoperative, the first time urinary volume and incidence of urinary retention were compared between the two groups.@*RESULTS@#The scores of the first urination waiting time after operation and distension of lower abdomen in the evening of the postoperative in the electroacupuncture group were lower than those in the routine group, the first time urinary volume was more than that in the routine group, and the incidence of urinary retention was lower than that in the routine group (5.0% (2/40) vs 22.5% (9/40), all <0.05).@*CONCLUSION@#Electroacupuncture preconditioning combined with induced urination can effectively prevent the incidence of urinary retention after milligan-morgan hemorrhoidectomy.