A morphometric analysis of pathological alterations in hemorrhoidal disease versus normal controls: a controlled trial

Objective: Until today, the true pathophysiology of hemorrhoidal disease (HD) has not yet been unraveled. More and more evidence guides us towards the hypothesis that reduced connective tissue stability is associated with a higher incidence of hemorrhoids. The present study aimed to compare the quantity and quality of collagen, and vessel morphometrics, in patients with symptomatic HD compared with normal controls. Methods: Twenty-two samples of grade III and grade IV HD tissue from patients undergoing a hemorrhoidectomy between January 2004 and June 2015 were included in the study group. Samples of 15 individuals without symptomatic HD who donated their body to science and died a natural death served as controls. The quantity and quality of anal collagen, and anal vessel morphometrics were objectified. The quality of collagen was subdivided in young (immature) and old (mature) collagen. Results: Patients with HD had an increased percentage of total anal collagen (62.1 ± 13.8 versus 18.7 ± 14.5%; p = 0.0001), a decreased percentage of young collagen (0.00009 ± 0.00008 versus 0.0008 ± 0.0008%; p = 0.001), and a smaller surface area of the anal vessels (795.1 ± 1215.9 micrometre2 versus 1219.0 ± 1976.1; p = 0.003) compared with controls. The percentage of old collagen did not differ between the control and study groups (0.588 ± 0.286% versus 0.389 ± 0.242%; p = 0.06). Conclusion: The outcomes of the present study suggest that alterations in anal collagen composition may play a role in the formation of hemorrhoids. (AU)

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.

Características clínicas de Soiling en pacientes postoperados de enfermedades anales en el Hospital General San Juan de Dios / Clinical settings of patients with postoperative Soiling at San Juan de Dios Hospital

Introducción: El soiling es el escape inconsciente de pequeñas cantidades de materia fecal después de una evacuación normal. Se ha reportado una prevalencia del 7-23% en otros países y se ha observado una alta incidencia después de esfinterotomías y fistulotomías (35-45%). Material y Métodos: Se realizó un estudio observacional que incluyó 80 pacientes con patologías anales que acudieron a la consulta externa del Hospital General San Juan de Dios donde se aplicó un cuestionario de 8 ítems. Resultados: Se evaluaron 80 pacientes, la mayoría son hombres, de la quinta década. La enfermedad anal más frecuente son las hemorroides y el tratamiento quirúrgico más frecuente la hemorroidectomía. La incidencia de soiling definitivo (presencia de manchado a los 6 meses) es del 22.5%. Las variables asociadas fueron el género masculino, el tipo de enfermedad y procedimiento quirúrgico, el enrojecimiento, la picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal. El ser hombre presenta un riesgo 6 veces mayor y el presentar enrojecimiento en la región anal aumenta el riesgo de 27 veces de presentar soiling definitivo. Conclusión: El soiling se presenta en un quinto de los pacientes que son operados de patologías anales en el Hospital General San Juan de Dios. La presencia de eritema, picazón anal, el uso de protector en la región anal, la sensación de materia fecal y la limpieza en región anal son variables estadísticamente asociadas al mismo. (AU)

Introduction: Soiling is the unconscious escape of small amounts of fecal matter after a normal bowel movement. A prevalence of 7-23% was reported in other countries and a high incidence was observed after sphincterotomies and fistulotomies (35-45%). Material and Methods: A observational study that included 80 patients with anal pathologies who attended the outpatient clinic of the San Juan de Dios General Hospital during 2018-2019, where an 8-item questionnaire was applied. Results: Eighty patients were evaluated, the majority are men, in their fifth decade. The most common anal disease is hemorrhoids, and the most common surgical treatment is hemorrhoidectomy. The incidence of definitive soiling (presence of spotting at 6 months) is 22.5%. The variables associated with definitive soiling were male gender, type of disease and surgical procedure, redness, anal itching, use of a protector in the anal region, the sensation of fecal matter, and cleanliness in the anal region. Being male presents a 6 times greater risk of definitive soiling and having redness in the anal region presents a 27 times greater risk of definitive soiling. Conclusion: Soiling occurs in a fifth of the patients operated for anal pathologies at the San Juan de Dios General Hospital. The presence of erythema, anal itching, the use of a protector in the anal region, the sensation of stool, and cleanliness in the anal region are statistically associated variables with soiling. (AU)

A new mixed surgical treatment for grades iii and iv hemorrhoids: modified selective hemorrhoidectomy combined with complete anal epithelial retention / Um novo tratamento cirúrgico para hemorroidas mistas graus iii e iv: hemorroidectomia seletiva modificada combinada com retenção epitelial anal completa

ABSTRACT Background: Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life. Aim: To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. Methods: A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences. Results: In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better. Conclusions: In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.

RESUMO Racional: Veias varicosas aparecem acima e abaixo da linha dentada nas hemorroidas mistas, afetando seriamente a função anal e a qualidade de vida. Objetivo: Propor melhoria na terapia de seleção de tecido de reparo do coxim anal combinado com retenção completa epitelial do canal anal em comparação com a operação de Milligan-Morgan. Métodos: Estudo prospectivo randomizado controlado foi desenhado envolvendo 200 pacientes com hemorroidas graus III e IV. Eles foram divididos em grupos de controle e observação. O controle recebeu operação de Milligan-Morgan, e o de observação procedimento de seleção de tecido modificado combinado com operação completa de preservação do canal anal. Todos os pacientes foram acompanhados por seis meses para avaliar as diferenças de tratamento. Resultados: No final, o grupo controle incluiu 82 e o de observação 87. O tempo médio de operação do grupo controle foi significativamente menor do que o de observação, enquanto o volume de sangramento foi significativamente menor no grupo controle. O escore VAS do grupo controle foi 3 (1, 4) e no de observação 4 (2, 5). Não houve diferença significativa na incidência de retenção urinária, sangramento e edema da margem da ferida no pós-operatório de um mês. A incidência de estenose anal digital no grupo observação foi significativamente menor do que no controle; o mesmo ocorreu com as margens anais residuais. O diâmetro do canal anal pós-operatório foi significativamente maior nele do que o grupo controle. A pontuação de incontinência anal de Wexner mostrou que nenhuma incontinência ocorreu em ambos os grupos, e a pontuação do grupo de controle foi significativamente maior do que no de observação. Nos últimos seis meses de acompanhamento, o grupo observação não teve nenhuma recaída e quatro casos foram encontrados entre os controles. A satisfação com o tratamento do grupo observação foi maior. Conclusões: Nas hemorroidas graus III e IV, o tratamento de seleção de tecido modificado combinado com a preservação completa do canal anal teve melhor prognóstico e satisfação do que com o procedimento de Milligan-Morgan, e é um novo método cirúrgico para pacientes com hemorroidas mistas avançadas.

A new approach for hemorrhoid disease: selective dearterialization and mucopexy without doppler guidance / Uma nova opção para o tratamento da doença hemorroidária: desarterialização e mucopexia seletiva sem o ultrassom doppler

ABSTRACT Background: Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly. Aim: To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique. Methods: Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence. Results: Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed. Conclusion: Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.

RESUMO Racional: O tratamento da doença hemorroidária pela técnica de THD (Transanal Hemorrhoidal Dearterialization) é minimamente invasivo e tem se mostrado seguro e eficiente. No entanto, dados sobre a recorrência e complicações (dor e tenesmo) no pós-operatório são muito variáveis. Objetivo: Avaliar se a desarterialização e mucopexia seletiva, sem o uso de Doppler, é suficiente para o controle de sintomas e se a morbidade pós-operatória é menor com esta técnica. Métodos: Vinte pacientes foram tratados com essa técnica e avaliados sobre controle de sintomas, morbidade pós-operatória e recorrência. Resultados: Controle do prolapso e sangramento foi observado em todos pacientes (n=20). Complicações pós-operatórias foram: tenesmo (n=2), trombose hemorroidária externa (n=2), retenção urinária (n=2). Após um seguimento médio de 13 meses, nenhuma recorrência foi detectada. Conclusões: O procedimento de desarterialização e mucopexias seletivas é seguro e eficiente em termos de controle do prolapso e sangramento. Esta técnica resulta em menor morbidade cirúrgica, uma vez que diminui o número de suturas no canal anal, resultando em menos dor e tenesmo pós-operatório. Para este procedimento o uso de ultrassom Doppler é desnecessário, o que diminui custos e o torna mais atrativo do ponto de vista econômico.

Consensus of Chinese experts on treatment of prolapsed hemorrhoids with transanal stapler / 中华胃肠外科杂志

Prolapsed hemorrhoids is a common clinical disease, and severe symptoms can significantly affect work and life. The transanal stapler has the advantages of simple operation and less trauma in treating prolapsed hemorrhoids. Its clinical efficacy is closely related to the selection of indications, the standardization of surgical operations, and the prevention and treatment of complications. In current clinical practice, there is no consensus on the treatment of prolapsed hemorrhoids with transanal stapler. Hence a discussion was held by the Professional Committee of Colorectal Diseases of Chinese Society of Integrated Chinese and Western Medicine, concerning the indications, contraindications, operating specifications and perioperative management of prolapsed hemorrhoids. A consensus was consequently formed, aiming to provide a guideline for the clinical practice.

Transanal haemorrhoidal dearterialization with mucopexy (thd-m) for treatment of hemorrhoids: is it applicable in all grades? brazilian multicenter study / A técnica de desarterialização hemorroidária transanal associada à mucopexia (thd-m) é aplicável em todos os graus? estudo multicêntrico brasileiro

ABSTRACT 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.

RESUMO Racional: A desarterialização hemorroidária transanal associada à mucopexia (THD-M) tem sido indicada como alternativa à hemorroidectomia convencional para o tratamento da doença hemorroidária nos seus variados graus. No entanto, ainda hoje existe controvérsia com relação a sua eficácia para os graus mais avançados. Objetivo: Avaliar a eficácia da técnica THD-M para tratamento doença hemorroidária e comparar os resultados imediatos e tardios nos diferentes graus. Método: Entre julho de 2010 e setembro de 2015, 705 pacientes consecutivos com hemorroidas sintomáticas de graus II, III e IV foram submetidos ao tratamento cirúrgico pelo método THD-M e acompanhados por um período médio de 21 meses (12-48). As operações foram realizadas por seis cirurgiões com experiência em cirurgia colorretal, em três estados brasileiros. Resultados: Complicações intraoperatórias foram observadas em 1,1% dos casos, incluindo quatro casos de hematoma, dois de laceração da mucosa e dois de sangramento. Todos foram controlados com sutura hemostática. As complicações pós-operatórias mais comuns foram: tenesmo transitório (21,4%); dor (7,2%); prolapso mucoso ou hemorroidário (6,4%); plicoma residual (5,6%); impactação fecal (3,2%); trombose hemorroidária (2,8%); sangramento (2,1%); fissura anal (0,7%) e abscesso anal (0,3%). Não houve casos de complicações severas ou mortalidade perioperatória. A recorrência do prolapso e sangramento foi maior na doença hemorroidária grau IV do que nos graus III e II (26.54% e 7.96% vs. 2.31% e 0.92% vs. 2.5% e 1.25%; p<0,001), respectivamente. Conclusão: O método THD-M é seguro e efetivo no tratamento da doença hemorroidária nos graus II e III com baixo índice de complicações. No entanto, para a doença hemorroidária de grau IV essa técnica está relacionada com maior índice de recorrência e complicações tardias, não devendo ser considerada opção eficiente neste estágio de doença.

Macroligaduras hemorroidales. Tratamiento ideal del prolapso hemorroidario. Seguimiento a 5 años / Hemorrhoidal macro rubber band ligations. Ideal treatment of hemorrhoidal prolapse. Follow-up at 5 years

Introducción: Entre los tratamientos alternativos de las hemorroides se destaca por ser costo-eficientes las ligaduras elásticas convencionales. Las macroligaduras elásticas se hayan en difusión por similares resultados que las bandas elasticas convencionales. La literatura es aun escasa. El objetivo fue analizar los resultados, morbilidad y recidiva a corto y mediano plazo de hemorroides tratadas con macroligaduras. Diseño: Estudio observacional analítico prospectivo. Pacientes: 188 pacientes (110 varones y 78 mujeres). Periodo: 2011-2014. Lugar: Institución privada universitaria. Métodos: Inclusión: pacientes tratados con hemorroides internas sintomáticas. Exclusión: enfermedad anoperineal asociada, tratamiento previo, inmunocompromiso o anticoagulación. Se registraron resultados, complicaciones y recidiva. La técnica empleada fue la descripta por Reis Neto. El Seguimiento fue a 10, 30 días y 6 y 12 meses y 5 años. Resultados: Todos fueron tratados con internación de corta estadía. La edad fue 49,5 años (23-76). Los síntomas fueron prolapso 96, sangrado 44 y ambos 48. Se realizó sólo una sesión en 178 casos (94,6%). Se trataron 2 paquetes en 122 y 3 en 66. El dolor moderado fue en 5 casos y prolongado en 2. El sangrado leve y tenesmo se presentó en la mayoría de los pacientes, pero desapareció en la primera semana. Se registró sangrado inmediato moderado en 5% sin sangrado severo inmediato. Otras complicaciones inmediatas: 2 trombosis y 3 congestión/edema local. En 1 paciente ocurrió un sangrado que requirió de internación sin necesidad de cirugía en forma alejada. Sólo en 3 casos se realizó resección local de plicomas previos. En 139 casos se realizó como único procedimiento. La recidiva fue 6 casos. (2 al primer año y 4 a los 5 años), 5 se trataron con nueva macroligadura y 1 con cirugía. No se registró ninguna complicacion severa, infecciosa o única relacionada al procedimiento. El seguimiento a 1 año fue del 100% y a 5 años del 96%. Discusión y conclusiones: El tratamiento con macroligaduras para el prolapso hemorroidario presentó con baja morbilidad sin complicaciones severas. Los resultados son reproducibles entre diferentes autores. Son el tratamiento ideal para las hemorroides grado III con poco componente externo. (AU)

Introduction: Alternative therapies for internal hemorrhoid plexus are several procedures with specific indications for each grade of hemorrhoid. Due to some major advantages, rubber band ligation has become probably in the most popular between colorectal surgeons. The high-macro rubber band ligation appears to be as the first choice but literature is few. Objective: To analyze results, morbidity and recurrence of internal hemorrhoid disease treated with high-macro rubber band ligation. Design: Observational non-randomized prospective analysis. Patients: 188 patients (110 male). Period: 2011-2014. Setting: Private Institution. Methods: Patients with symptomatic internal hemorrhoid disease (grade II-III-IV). Results, Immediate and late complications and 5 years recurrence were registered. Technique used was the original description by Reis Neto. Patients with immunosuppression, additional perianal disease, previous treatment and anticoagulation were excluded. Results: There was only one session in 178 cases. Two banding were placed in 122 and 3 in 66. Symptoms were prolapse in 96, bleeding in 44 and both in 48. 139 patients were treated as only procedure. Tenesmus and light hemorrhage occurred in most cases. Moderate or late pain was registered in 7 cases, and immediate moderate bleeding in 5%. There was no severe immediate bleeding. Immediate morbidity was 2 thrombosis and 3 anal congestion. There was one moderate late bleeding at day 28 and required admission. Recurrence occurred in six cases, 5 were ligated again and 1 was treated by conventional surgery. There was none severed or unique complication or infection associated. Discussion and conclusion: Macrorubber band presented low morbidity and there are no severe complications at 5 years follow-up. Recurrence of prolapse is low and could be treated by a new session with equal morbidity. Results are equivalent and reproducible by different authors. This procedure might be the ideal treatment for hemorrhoid prolapse. (AU)

Postoperative results of 407 patients submitted to Doppler-guided transanal hemorrhoidal dearterialization / Resultados pós-operatórios de 407 doentes submetidos à desarterialização hemorroidária guiada pelo Doppler

ABSTRACT Introduction: The treatment of hemorrhoidal disease by conventional technique is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. A technique of hemorrhoidal dearterialization associated with rectal mucopexy is a minimal invasive surgical option that has been used to treat the hemorrhoidal disease and reduce its inconveniences. Objective: To analyze the seven-year results of hemorrhoidal dearterialization associated with rectal mucopexy in the treatment of hemorrhoidal disease. Methods: This study analyzed 407 patients with hemorrhoids grade II, III and IV, who underwent the technique of hemorrhoidal dearterialization in the Luzia de Pinho Melo Hospital, during the period between December 2010 and December 2017. Twenty-seven patients (6.6%) had hemorrhoidal disease of the grade II, 240 (59.0%) grade III, and 117 (28.8%) grade IV. In 23 patients (5.7%), the grade was not found. All patients were operated by the same surgeon under spinal anesthesia. The 407 patients underwent dearterialization, with a varying ligation of one to six arterial branches followed by rectal mucopexy by uninterrupted suture. Eighty-two (20.14%) required removal of concomitant perianal piles or external hemorrhoids and/or fibrosed. In the postoperative follow-up the following parameters were evaluated: pain, tenesmus, bleeding, prolapse, thrombosis, and recurrence. Results: The tenesmus was postoperative complaint reported by 93.6% of patients. Forty-three (10.5%) presented intense tenesmus and 44 (22%), moderate to intense pain. Four (0.98%) patients presented more intense bleeding in postoperative follow up; none of the patients required blood transfusions. The prolapse occurred in 18 (4.42%) patients, thrombosis in 11 (2.7%), and there were 19 (4.67%) recurrences that were reoperated in this period. Conclusion: The hemorrhoidal dearterialization technique presents good results, with light and easy-to-resolve complications and little postoperative pain.

RESUMO Introdução: O tratamento da doença hemorroidária pelas técnicas convencionais cursa com significante redução da qualidade de vida do doente, principalmente relacionada à dor pós-operatória e ao considerável tempo de afastamento do trabalho. A técnica de desarterialização hemorroidária associada à mucopexia retal é uma opção cirúrgica pouco invasiva, a qual é utilizada com o objetivo de tratar a doença hemorroidária e reduzir seus inconvenientes. Objetivo: Analisar os resultados encontrados após sete anos de seguimento em doentes submetidos à técnica da desarterialização hemorroidária associada à mucopexia para o tratamento da doença hemorroidária. Método: Foram estudados 407 portadores de doença hemorroidária de graus II, III e IV, submetidos à técnica da desarterialização hemorroidária no Hospital das Clínicas Luzia de Pinho Melo de Mogi das Cruzes, durante o período de Dezembro de 2010 a Dezembro de 2017. Vinte e sete doentes (6,6%) apresentavam doença hemorroidária de grau II, 240 (59,0%) do grau III e 117 (28,8%) do grau IV. Em 23 doentes (5,7%) não foram encontradas a classificação nos prontuários. Todos os doentes foram operados pelo mesmo cirurgião e sob anestesia raquidiana. Os 407 doentes foram submetidos à desarterialização, variando de um até seis ramos arteriais seguidos de mucopexia por sutura contínua. Oitenta e dois (20,14%) necessitaram ressecções associadas por plicomas ou hemorroidas externas. No pós-operatório foram avaliados os seguintes parâmetros: dor, tenesmo, sangramento, prolapso, trombose e recidiva. Resultados: O tenesmo foi a queixa pós-operatória referida por 93,36% dos doentes. Quarenta e três (10,5%) apresentaram tenesmo intenso e 44 (22%) de moderado a intenso. Quatro (0,98%) doentes apresentaram sangramento de maior intensidade no pós-operatório e em 1 (0,5%) houve necessidade de hemostasia cirúrgica, em nenhum deles houve necessidade de reposição sanguínea. O prolapso ocorreu em 18 (4,42%) doentes, trombose em 11 (2,7%) e houve 19 (4,67%) recidivas reoperados durante o período. Conclusão: A desarterialização hemorroidária apresenta bons resultados, complicações leves e de fácil resolução e pouca dor pós-operatória.

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.

Hemorroidopexia. Nuestra experiencia. Análisis descriptivo de las complicaciones de la técnica de hemorroideopexia con sutura mecánica y el grado de satisfacción / Hemorroidopexy Our experience. Descriptive analysis of the complications of the hemorrhoidepexy technique with mechanical suture and the degree of satisfaction

Introducción: La hemorroidopexia con sutura mecánica, es una técnica eficaz para los prolapsos hemorroidales grado III y IV. Objetivo: Describir nuestra experiencia con dicho método. Material y métodos: Se realizó un análisis descriptivo, retrospectivo sobre una base de datos cargada en forma prospectiva. Se analizaron pacientes con hemorroides grado III y IV, en quienes se realizó hemorroidopexia con PPH- 03, desde enero del 2010 hasta diciembre de 2017. Se evaluaron las variables demográficas, las complicaciones y el grado de satisfacción. Se realizó seguimiento postoperatorio semanal, a los 15 días, al mes, a los 6 meses y finalmente un control telefónico. Resultados: Se estudiaron 452 pacientes. La edad media fue de 46 años (rango: 20-75), siendo el 63% (n=291) del sexo masculino. El 84% (n=387) presentaban hemorroides grado III. El índice de complicación fue del 25% (n=115) durante el periodo de seguimiento, en el postoperatorio inmediato, 60 (52%) pacientes presentaron un evento considerado como complicación, y 55 (48%) pacientes presentaron complicaciones mediatas y tardías. Las complicaciones más frecuentes fueron: dolor en 37 (8%) de los pacientes, seguida por proctorragía en 18 casos (4%) y trombosis hemorroidal externa en 15 pacientes (3,3%). (AU)

Background: Hemorrhoidopexy with mechanical suture is an effective technique for hemorrhoidal prolapses grade III and IV. Objective: Describe our experience with this method. Material and methods: A descriptive, retrospective analysis was performed on a prospectively loaded database. Patients with grade III and IV hemorrhoids were analyzed, in whom hemorrhoidopexy was performed with PPH-03, from January 2010 to December 2017. Demographic variables, complications and degree of satisfaction were evaluated. Weekly postoperative follow-up was performed at 15 days, at month, at 6 months and finally a telephone control. Results: 452 patients were studied. The average age was 46 years (range,: 20 - 75), being 63% (n = 291) of the male sex. 84% (n = 387) had grade III hemorrhoids. The complication rate was 25% (n = 115) during the follow-up period, in the immediate postoperative period, 60 (52%). The most frequent complications were: pain in 37 (8%) patients, follow-up by proctorrhagia in 18 cases (4%) and hemorrhoidal thrombosis external in 15 patients (3.3%). (AU)

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.

Effect of electroacupuncture preconditioning with different frequencies on anal pain after milligan-morgan hemorrhoidectomy / 中国针灸

OBJECTIVE@#To compare the effect of electroacupuncture preconditioning with different frequencies on anal pain after milligan-morgan hemorrhoidectomy.@*METHODS@#A total of 120 patients with mixed hemorrhoids were randomly divided into an electroacupuncture group A (dilatational wave, 2 Hz/100 Hz in frequency), an electroacupuncture group B (continuous wave, 2 Hz in frequency) and an electroacupuncture group C (continuous wave, 100 Hz in frequency), 40 cases in each group. Electroacupuncture at Xialiao (BL 34) and Chengshan (BL 57) was applied with tolerant intensity for 30 min before operation in all groups. The number of additional anesthetic drugs in the 3 groups, the visual anal pain score (VAS) and limb activity score at 4, 12, and 24 h after operation, the maximum VAS score within 24 h after surgery and oral dose of aminophenol dihydrocodeine were compared.@*RESULTS@#The number of additional anesthetic drugs in the electroacupuncture group A, the electroacupuncture group B and the electroacupuncture group C were 4, 5, 4 respectively, and there was not statistically significant (>0.05). There was no significant difference in the anal pain VAS score and limb activity score at 4 h after operation among the 3 groups (>0.05), at the 12 h after operation, the VAS scores and limb activity scores in the electroacupunctures group A and B were lower than those in the electroacupuncture group C (<0.05), at 24 h after operation, the VAS score and limb activity score in the electroacupuncture group A were lower than those in the electroacupuncture group B and C (<0.05), the maximum VAS score within 24 h and oral dose of aminophenol dihydrocodeine within 24 h after operation in the electroacupuncture group A were lower than those in the electroacupuncture group B and C (<0.05).@*CONCLUSION@#Different frequency electroacupuncture preconditioning has the effect of alleviating anal pain after milligan-morgan hemorrhoidectomy. The analgesic effect of electroacupuncture with different frequencies is different. The electroacupuncture analgesic effect of 2 Hz /100 Hz dilatational wave is better than 2 Hz and 100 Hz continuous waves.

Transanal Hemorrhoidal Dearterialization With Doppler Arterial Identification Versus Classic Hemorrhoidectomy: A Retrospective Analysis of 270 Patients

PURPOSE: Despite the minimally invasive nature of transanal hemorrhoidal dearterialization (THD) with Doppler arterial identification procedures, hemorrhoidectomy is still considered the gold standard procedure for hemorrhoidal disease. However, the classical techniques of hemorrhoidectomy have a high rate of postoperative complications. The main purpose of this study is to demonstrate the efficacy and complications of these techniques used for grades II and III hemorrhoids. METHODS: A retrospective (case-control) study was carried out from January 2009 to May 2014, and all patients undergoing surgical procedures for hemorrhoidal disease in two French clinics were considered. Application of inclusion and exclusion criteria identified 270 eligible patients (163 undergoing Doppler THD and 107 treated with Milligan Morgan hemorrhoidectomy). Statistical analysis was calculated considering immediate postoperative complications, functional results, chronic complications, and recurrences. RESULTS: Analysis of primary outcomes showed a significant difference between the 2 groups concerning postoperative pain, which had a lower rate in THD (P = 0.0001) and in postoperative bleeding (P = 0.02) than hemorrhoidectomy. However, long-term follow-up at three years showed a superior rate of recurrence in the THD group (P = 0.009). CONCLUSION: The THD technique is a safe and effective procedure for grades II and III hemorrhoids, has lower rates of post-operative pain and bleeding, and allows faster hospital discharge; however, it also shows a higher rate of recurrence at three years of follow-up.

Bilateral Rotational S Flap Technique for Preventing Restenosis in Patients With Severe Circular Anal Stenosis: A Review of 2 Cases

Anal stenosis is a late hemorrhoidectomy complication. Sphincterotomy and various anoplasty techniques are used for treatment severe anal stenosis, such as the C flap, House flap, U flap, and rotational S flap, but no procedure is ideal for every patient. We review 2 cases of severe circular anal stenosis. Their complaints included narrow caliber of the stool and feeling unsatisfied defecation. Excision of scar tissue using the circular technique was followed by reconstruction using the bilateral rotational S flap procedure. At the 1-year follow-up, the patient had complaints about neither defecation nor pain, and no longer needed laxative agents. In conclusion, the bilateral rotational S flap technique should be considered as a viable treatment because it can also prevent the occurrence of restenosis, especially given the consideration of adequate blood supply.

Hidradenoma Papilliferum of the Anus: A Report of 2 Cases and Review of the Literature

Hidradenoma papilliferum is a rare benign cystic tumor that originates from apocrine glands or anogenital mammary glands. Here, we describe 2 cases of hidradenoma papilliferum of the anus. Two female patients aged 39 and 35 presented with perianal masses with hemorrhoids. The patients underwent hemorrhoidectomy and excision of the lesion. Histopathology confirmed the masses as hidradenoma papilliferum. The postoperative course was uneventful for both patients, and there were no recurrences after 18 and 12 months of follow-up, respectively. Proctologists should consider hidradenoma papilliferum in their differential diagnosis of benign anal tumors. Surgical excision is necessary for diagnosis and treatment of hidradenoma papilliferum.

Lessons from the first 70 patients operated by doppler-guided haemorrhoidal artery ligation with mucopexy in a French team specialising in surgical proctology / Lições dos primeiros 70 pacientes operados por ligadura de artéria hemorroidária guiada por doppler com mucopexia por uma equipe francesa especializada em proctologia cirúrgica

ABSTRACT Background: Doppler-guided haemorrhoidal artery ligation with mucopexy is a minimal-invasive surgical technique. It is both effective and less painful than conventional haemorrhoidectomy. Methods: We gathered records on all patients operated on between November 2012 and June 2014. Pre- and postoperative scores were calculated during consultation and then by phone. Unsuccessful surgical treatment was defined by persistent haemorrhoid symptoms within three months following the procedure and relapse defined by recurrent symptoms after the third postoperative month. Results: During the period analysed, 70 patients underwent consecutive surgical procedures for haemorrhoid prolapse (52%), bleeding (29%), or both (17%). Hospitalisation was outpatient or overnight for 87% of patients. There were no complications in 92.7% of cases. The average period away from work was 11 days (± 6.5). The time between the procedure and last postoperative consultation, followed by telephone contact, was respectively 2.7 months (± 5.8) and 16.5 months (± 4.9). At the time of the postoperative telephone call, the Thaha et al. score decreased by 5.6 (p < 0.001), while the quality of life score decreased by 2 (p < 0.001). The Wexner score remained the same or improved for all patients except one. Treatment was unsuccessful for 6/67 patients (9%) and 10/61 patients (16.4%) experienced a subsequent recurrence in haemorrhoid symptoms. Only those over 51 years old were statistically associated with more frequent recurrences (p = 0.044). Conclusion: Doppler-guided haemorrhoidal artery ligation with mucopexy is an effective technique in the medium-term. Good tolerance in makes this treatment an attractive alternative to conventional haemorrhoidectomy.

RESUMO Experiência: A ligação de artéria hemorroidária com mucopexia orientada por Doppler é técnica cirúrgica minimamente invasiva. Esse procedimento é efetivo e menos doloroso do que a hemorroidectomia convencional. Métodos: Reunimos os prontuários de todos os pacientes operados entre novembro de 2012 e junho de 2014. Foram calculados escores pré-operatórios e pós-operatórios durante as consultas e, em seguida, por telefone. Tratamento cirúrgico malsucedido foi definido como a persistência dos sintomas de hemorroidas dentro de três meses após o procedimento, e recidiva foi definida por sintomas recorrentes depois do terceiro mês do pós-operatório. Resultados: Durante o período analisado, 70 pacientes passaram por procedimentos cirúrgicos consecutivos para prolapso de hemorroida (52%), sangramento (29%), ou ambos (17%). Para 87% dos pacientes, a hospitalização foi ambulatorial ou de pernoite. Não ocorreram complicações em 92,7% dos casos. O período médio de absenteísmo foi de 11 ± 6,5 dias. Os tempos transcorridos entre o procedimento e a última consulta no pós-operatório, seguida pelo contato telefônico, foram de respectivamente 2,7 ± 5,8 meses e 16,5 ± 4,9 meses. Por ocasião do contato telefônico no pós-operatório, o escore de Thaha et al. diminuiu em 5,6 pontos (p < 0,001), enquanto o escore de qualidade de vida diminuiu em 2 pontos (p < 0,001). O escore de Wexner permaneceu igual ou melhorou para todos os pacientes, exceto um. O tratamento não obteve sucesso para 6/67 pacientes (9%); e 10/61 pacientes (16,4%) sofreram uma subsequente recorrência nos sintomas hemorroidários. Apenas aqueles participantes com mais de 51 anos demonstraram associação estatística com recorrências mais frequentes (p = 0,044). Conclusão: A ligação de artéria hemorroidária com mucopexia orientada por Doppler é técnica efetiva no meio termo. A boa tolerância faz com que esse tratamento seja uma alternativa efetiva à hemorroidectomia convencional.