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Latest Research on Hemorrhoids
     
Dis Colon Rectum. 2008 Jan 25 [Epub ahead of print]
Doppler-Guided Hemorrhoidal Artery Ligation for the Treatment of Symptomatic Hemorrhoids: Early and Three-Year Follow-up Results in 100 Consecutive Patients.
Faucheron JL, Gangner Y.
Colorectal Unit, Department of Surgery, Hôpital Michallon, B.P. 217, 38043, Grenoble cedex, France, JLFaucheron@chu-grenoble.fr.

PURPOSE: Doppler-guided ligation of the hemorrhoidal arteries was described as an alternative to hemorrhoidectomy. The authors report their experience with this procedure. METHODS: From 2002 to 2004, 100 consecutive patients underwent hemorrhoidal artery ligation procedure for symptomatic hemorrhoids and were reviewed at one month and at three years. RESULTS: There were 54 females. Seventy-eight patients had Grade III hemorrhoids. Eighteen patients had previously been treated for the disease. The mean operative time was 28 minutes. On average, 8.4 ligatures were placed. Seventy-nine patients were discharged the same day. Six patients presented with early complication: isolated pain in one, pain and bleeding in three, isolated bleeding in one, and obstructed defecation in one. Late complications occurred in six patients: anal pain in one, fissure in two, and thrombosis of residual hemorrhoids in three. Twelve patients presented with a recurrence at a mean delay of 12.6 months, which was treated by repeat hemorrhoidal artery ligation (n = 1), hemorrhoidopexy (n = 7), and hemorrhoidectomy (n = 4). CONCLUSIONS: Hemorrhoidal artery ligation procedure is safe, easy to perform, and should be considered as an alternative for the treatment of symptomatic hemorrhoids, even with a recurrence rate of 12 percent, which can be treated by the same technique or another.

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Dis Colon Rectum. 2008 Jan 19 [Epub ahead of print]
Primary and Repeated Stapled Hemorrhoidopexy for Prolapsing Hemorrhoids: Follow-Up to Five Years.
Raahave D, Jepsen LV, Pedersen IK.
Department of Surgery, Colorectal Laboratory, Copenhagen University North Sealand Hospital, 3000, Helsingore, Denmark, dera@noh.regionh.dk.

PURPOSE: Treating hemorrhoids by stapled hemorrhoidopexy has become increasingly common, because the procedure results in less pain and allows the patient to return to work earlier than with open hemorrhoidectomy. However, the durability of stapled hemorrhoidopexy has not been evaluated. This study was designed to assess initial results, analyze complications and failures, and document both the need for repeated procedures and the outcomes of follow-up to five years. METHODS: From 1998 to 2004, 258 patients underwent modified stapled hemorrhoidopexy. The appearance of the anus was scored preoperatively, immediately after the procedure, at three months, and at one to five years postoperatively. The anatomy score ranged from 1 (normal anus) to 7 (worst prolapse). We also evaluated operation time, analgesia, staple line position, postoperative pain score, technical failures, postoperative complications, need for repeated procedures, and patient satisfaction. Statistical analyses
were used to identify correlations and differences, and the variables were analyzed in relation to the final outcome. RESULTS: The patients were observed for a median of 34 (range, 18-78) months. The median postoperative pain score was 4 (Visual Analog Scale 1-10) on the day of stapled hemorrhoidopexy; additional external procedures resulted in significantly higher pain (P < 0.05). Stapled hemorrhoidopexy was repeated in 31 patients (12 percent), and 38 patients (14.7 percent) had subsequent excisions. Technical failures occurred in 18 of 258 patients (7 percent). The median anatomy score decreased from 6 (range, 3-7) preoperatively to 1 (range, 1-6) at last follow-up, irrespective of one or a repeated stapled hemorrhoidopexy, surgical excision, or technical failure. The risk of reintervention was greatest during the first year after a stapled hemorrhoidopexy. Overall, patient satisfaction was high and correlated significantly with the anatomy score (r = 0.46, P < 0.05). CONCLUSIONS: The pain after stapled hemorrhoidopexy was low, recovery was rapid, complications were few, and patient satisfaction was high. A recurrent (or persistent) prolapse was alleviated by a repeated stapled hemorrhoidopexy for cure. However, there was a high risk of reintervention after a stapled hemorrhoidopexy, and this should be further evaluated.

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Tech Coloproctol. 2007 Dec;11(4):333-8; discussion 338-9. Epub 2007 Dec 3.
Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease.
Dal Monte PP, Tagariello C, Sarago M, Giordano P, Shafi A, Cudazzo E, Franzini M.
Casa di Cura Villalba, Via Roncrio 25, Bologna, Italy. pp@ppdalmonte.org

BACKGROUND: Transanal haemorrhoidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorrhoidal plexus. The aim of this study was to assess the long-term efficacy of this treatment. METHODS: The procedure was carried out using a proctoscope with a Doppler probe. The terminal branches were located with Doppler and then sutured. RESULTS: From January 2000 to May 2006, we performed THD in 330 patients (180 men; mean age, 52.4 years), including 138 second-degree, 162 third-degree and 30 fourth-degree haemorrhoids. There were 23 postoperative complications (7 cases of bleeding, 5 thrombosed piles, 4 rectal haematomas, 2 anal fissures, 2 cases of dysuria, 1 of haematuria and 2 needle ruptures). The mean postoperative pain score was 1.32 on a visual analog scale. 219 patients were followed for a mean of 46 months (range, 22-79), including 100 patients with second-degree, 104 with third-degree and 15 with fourth-degree haemorrhoids. The operation completely resolved the symptoms in 132 patients (92.5%) with preoperative bleeding and in 110 patients (92%) with preoperative prolapse. CONCLUSIONS: The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

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Arch Surg. 2007 Dec;142(12):1209-18; discussion 1218.
Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy.
Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP.
Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, 10th Floor QEQM Wing, Praed Street, London W2 1NY, England.

OBJECTIVE: To evaluate the short-term outcomes of hemorrhoidectomy performed using the LigaSure vessel sealing device (Valleylab, Boulder, Colorado) or the conventional approach. DATA SOURCES: MEDLINE, EMBASE, Ovid, and Cochrane databases for studies published between 2002 and 2006. STUDY SELECTION: Randomized controlled trials published between 2002 and 2006 comparing short-term outcomes for LigaSure vs conventional hemorrhoidectomy. DATA EXTRACTION: Operative parameters, short-term complications, and postoperative recovery. Trials were assessed using a modified Jadad score. Random-effects meta-analytical techniques were used in the analysis. DATA SYNTHESIS: Nine randomized controlled trials with matched selection criteria reporting on 525 patients, of whom 266 (50.7%) underwent LigaSure and 259 (49.3%) underwent conventional hemorrhoidectomy. Operative time (weighted mean difference [WMD], - 8.67 minutes; 95% confidence interval [CI], - 15.34 to - 2.00 minutes), blood loss
(WMD, - 23.08 mL; 95% CI, - 27.24 to - 18.92 mL), and pain the day after the operation measured by the visual analog scale (WMD, - 2.31; 95% CI, - 3.37 to - 1.26) were significantly reduced following LigaSure hemorrhoidectomy. There was a decrease in time taken to return to work or normal activity (WMD, - 3.49 days; 95% CI, - 7.40 to 0.43), which was of marginal significance (P = .08). Incidence of postoperative hemorrhage was comparable as was incidence of anal stenosis and fecal and flatus incontinence between the 2 groups. CONCLUSIONS: LigaSure hemorrhoidectomy results in a significant reduction in operative time and blood loss, but it may not confer any advantage over the conventional operation in terms of postoperative pain, length of hospital stay, or time taken to return to work or normal activity. The expediency of the device must be weighed against its additional cost. Long-term evaluation of outcomes and morbidity are still needed.

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J Gastrointest Surg. 2007 Dec;11(12):1662-8. Epub 2007 Oct 5.
Stapled hemorrhoidopexy: a prospective study from pathology to clinical outcome.
Sileri P, Stolfi VM, Palmieri G, Mele A, Falchetti A, Di Carlo S, Gaspari AL.
Department of Surgery, University of Rome Tor Vergata, Rome, Italy.

Stapled hemorrhoidopexy is widely accepted to treat hemorrhoids, but serious complications have been reported. In this prospective audit, we correlated clinical outcome with pathological findings. From January 2003 to April 2007, 94 patients underwent hemorrhoidopexy. Macroscopic appearance of the specimen (shape, size, and depth) was recorded. Microscopically, the presence of columnar, transitional, and squamous epithelium, the involvement of circular/longitudinal smooth muscle, and features of mucosal prolapse were assessed. Clinical outcome was evaluated by a validated questionnaire. Postoperative pain, secretion, and bleeding durations were 12.7 +/- 10.6, 5.6 +/- 9.6, and 6.3 +/- 8.4 days. Patient's return to work averaged 16.7 +/- 10.7 days. Fissure, skin tags, and anal strictures were observed in 23.4%. Seven patients experienced pain for a significantly longer period of time. All specimens contained columnar mucosa, but 29.8% contained columnar and transitional epithelium and 12.8% contained columnar, anal transitional, and stratified squamous epithelium. Smooth muscle was observed in 62.7%. Pain was significantly increased if transitional epithelium was present in the specimen. No correlation or differences were observed if smooth muscle was present, although postoperative bleeding was more frequent. Hemorrhoidopexy is safe and effective. The specimen should always be sent for pathology examination. Only columnar epithelium should be present and, although the presence of smooth muscle does not influence the outcome in terms of functional results, its presence may play a role in postoperative bleeding.

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Dis Colon Rectum. 2007 Nov;50(11):1770-5.
Stapled hemorrhoidopexy and milligan morgan hemorrhoidectomy in the cure of fourth-degree hemorrhoids: long-term evaluation and clinical results.
Mattana C, Coco C, Manno A, Verbo A, Rizzo G, Petito L, Sermoneta D.
Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy.

PURPOSE: The long-term results after stapled hemorrhoidopexy compared with Milligan-Morgan procedure are discussed. METHODS: The clinical data of 100 patients treated by Milligan-Morgan procedure or stapled hemorrhoidopexy for fourth-degree hemorrhoids have been reviewed. All patients were visited and submitted to a questionnaire to evaluate resumption of symptoms, functional results, and recurrence rate. RESULTS: The mean follow-up was 54 months for stapled hemorrhoidopexy and 92 months for the Milligan-Morgan procedure. Postoperative pain and return to normal activity were worse in the Milligan-Morgan procedure (Visual Analog Scale 8.56 vs. 5.46, P < 0.001; and 2.4 vs. 2 weeks, P value = 0.018). Eight percent of patients who had stapled hemorrhoidopexy complained of spontaneous pain or pain during defecation vs. 0 percent of patients who underwent the Milligan-Morgan procedure. We noted that there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. The relative risk of recurrence for stapled hemorrhoidopexy compared with Milligan-Morgan procedure was 1.18 (95 percent confidence interval 1< relative risk < 1.4). No statistical difference was noted in patients' satisfaction after the procedures. CONCLUSIONS: Long follow-up seems to indicate more favorable results in Milligan-Morgan procedure in terms of resumption of symptoms and risk of recurrence.

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Dig Surg. 2007 Sep 13;24(6):436-440 [Epub ahead of print]
Treatment of Grade 2 and 3 Hemorrhoids with Doppler-Guided Hemorrhoidal Artery Ligation.
Wallis de Vries BM, van der Beek ES, de Wijkerslooth LR, van der Zwet WC, van der Hoeven JA, Eeftinck Schattenkerk M, Eddes EH.
Department of Surgery, Deventer Hospital, Deventer, The Netherlands.

Aim: We evaluated the results of the Doppler-guided hemorrhoidal arterial ligation (DG-HAL) method in the management of symptomatic grade 2 and 3 hemorrhoids. Patients and Methods: Between June 2005 and March 2006, 110 consecutive patients with symptomatic grade 2 and 3 hemorrhoids according to the DG-HAL method were treated. All procedures were performed in daycare under spinal anesthesia. The primary objective was the reduction in hemorrhoidal gradation as determined by proctoscopy; the secondary was patient satisfaction. This was measured by interviewing patients over the telephone. Results: The average age was 47.6 years. 42 patients had grade 2 hemorrhoids, 68 grade 3. An average of 7.3 ligations were placed. Proctoscopy showed that, after 6 weeks, 97 (88%) patients had a significant improvement in their hemorrhoidal gradation. After an average follow-up of 37 weeks, 93 of the 110 (84.5%) patients were satisfied with the postoperative result. Mortality was 0% and morbidity 3%. Conclusion: DG-HAL is a safe and effective treatment in the management of symptomatic grade 2 and 3 hemorrhoids. Copyright (c) 2007 S. Karger AG, Basel.

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Dis Colon Rectum. 2007 Sep;50(9):1445-9.
Combined colonoscopy and three-quadrant hemorrhoidal ligation: 500 consecutive cases.
Davis KG, Pelta AE, Armstrong DN.
Georgia Colon & Rectal Surgical Clinic, Atlanta, GA 30342, USA.

PURPOSE: This study was designed to evaluate the safety and efficacy of combining outpatient colonoscopy with simultaneous three-quadrant hemorrhoidal ligation in patients with symptomatic internal hemorrhoidal disease. METHODS: A four-year analysis of patients undergoing combined colonoscopy and synchronous three-quadrant hemorrhoidal ligation was performed. Indications for the procedure were patients with symptomatic internal hemorrhoids who had failed conservative management and who also required colonoscopy. Conventional colonoscopy was performed under moderate sedation, immediately followed by synchronous three-quadrant hemorrhoidal ligation, using a TriView anoscope and Short-Shot hemorrhoidal ligator. Patients undergoing this procedure were entered in a computer database, and outcomes were tracked. Patients requiring repeat ligation, surgical intervention, or readmission within 30 days were identified and further analyzed. RESULTS: Five hundred patients underwent colonoscopy with simultaneous three-quadrant internal hemorrhoid ligation during the study period. Four hundred sixty-seven patients (93.4 percent) had complete resolution of their symptoms and required no further treatment. Thirty-three patients (6.6 percent) required repeat ligation, and 11 (2.2 percent) required completion surgical hemorrhoidectomy for persistent symptoms. Fifty-two patients (10.4 percent) required incidental biopsy/polypectomy during the colonoscopy. Two incidental colon carcinomas were identified, and ligation was deferred. No patients required admission for bleeding after the procedure. There were no cases of pelvic sepsis, and no patients required emergent surgical intervention. CONCLUSIONS: Combining colonoscopy with three-quadrant hemorrhoidal ligation is a safe and effective method of treating symptomatic internal hemorrhoids. The procedure is convenient for both physician and patient and makes more efficient use of time and resources.

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Dis Colon Rectum. 2007 Sep;50(9):1297-305.
Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery.
Jayaraman S, Colquhoun PH, Malthaner RA.
Department of Surgery, University of Western Ontario, London, Ontario, Canada. shivaj76@yahoo.ca

PURPOSE: The purpose of this systematic review was to compare the long-term results of stapled hemorrhoidopexy with conventional excisional hemorrhoidectomy in patients with internal hemorrhoids. METHODS: A systematic review of all randomized, controlled trials comparing stapled hemorrhoidopexy and conventional hemorrhoidectomy with long-term results was performed by using the Cochrane methodology. The minimum follow-up was six months. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications, and pain. RESULTS: Twelve trials were included. Follow-up varied from six months to four years. Conventional hemorrhoidectomy was more effective in preventing long-term recurrence of hemorrhoids (odds ratio (OR), 3.85; 95 percent confidence interval (CI), 1.47-10.07; P < 0.006). Conventional hemorrhoidectomy also prevents hemorrhoids in studies with follow-up of one year or more (OR, 3.6; 95 percent CI, 1.24-10.49; P < 0.02). Conventional hemorrhoidectomy is superior in preventing the symptom of prolapse (OR, 2.96; 95 percent CI, 1.33-6.58; P < 0.008). Conventional hemorrhoidectomy also is more effective at preventing prolapse in studies with follow-up of one year or more (OR, 2.68; 95 percent CI, 0.98-7.34; P < 0.05). Nonsignificant trends in favor of conventional hemorrhoidectomy were seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, the presence of perianal skin tags, and the need for further surgery. Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and symptoms of anal obstruction/stenosis. CONCLUSIONS: Conventional hemorrhoidectomy is superior to stapled hemorrhoidopexy for prevention of postoperative recurrence of internal hemorrhoids. Fewer patients who received conventional hemorrhoidectomy complained of hemorrhoidal prolapse in long-term follow-up compared with stapled hemorrhoidopexy.

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Minerva Chir. 2007 Aug;62(4):235-40.
Foam sclerotherapy with Fibrovein (STD) for the treatment of hemorrhoids, using a flexible endoscope.
Benin P, D'Amico C.
Department of General Surgery, Piove di Sacco Hospital, Piove di Sacco, Padova, Italy p.benin@tiscali.it.

AIM: This case study was designed to evaluate foam sclerotherapy of hemorrhoidal disease using a flexible endoscope. METHODS: We treated 250 patients of grade II-IV hemorrhoids with Sotradecol foam. To obtain sclerosing foam, we used a special foam kit, which produced a stable and standardized sclerosing foam. The quantity of foam injected into the hemorrhoids was 1 to 2 cc with a total of 6 cc for each session. Variables to assess efficacy of treatment were: pain, bleeding and prolapse. RESULTS: Generally, bleeding and hemorrhoidal prolapse were resolved with at most two sclerotherapy sessions. However, pain usually had disappeared after the first session. No complications such as mucosal erosions at the foam injection site, formation of abscesses, bacteraemia, or fistulas occurred. CONCLUSION: The advantages of sclerosing foam are its adhesiveness and compactness, its greater volume, its increased spasm generation, and the greater sclerosing power. Sclero-therapy with foam makes it possible to reach optimal results with small amounts of sclerosing agent and fewer risks of complications.

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Br J Surg. 2007 Aug;94(8):937-42.
Randomized clinical trial of LigaSure and conventional diathermy haemorrhoidectomy.
Muzi MG, Milito G, Nigro C, Cadeddu F, Andreoli F, Amabile D, Farinon AM.
Department of Surgery, Tor Vergata University Hospital, Rome, Italy. marcog.muzi@ptvonline.it

BACKGROUND: The aim of this randomized prospective trial was to compare LigaSure and conventional diathermy haemorrhoidectomy. METHODS: Two hundred and eighty-four patients with grade III or IV haemorrhoids were randomized to LigaSure or diathermy (Milligan-Morgan) haemorrhoidectomy as a day-case procedure. Operating time, postoperative pain score, hospital stay, postoperative complications, wound healing time and time to return to normal activities were assessed. Thirty-four patients were lost to follow-up. RESULTS: The mean operating time for LigaSure haemorrhoidectomy was significantly shorter than that for diathermy (P = 0.011). Patients treated with LigaSure had significantly less postoperative pain (measured on a visual analogue scale; P = 0.010), a shorter wound healing time (defined as time to absence of swelling; P = 0.012) and less time off work (P = 0.010) than patients who had diathermy. Neither postoperative complications nor mean hospital stay (day-case surgery) were significantly different. CONCLUSION: LigaSure haemorrhoidectomy demonstrates simplicity, reproducibility, a low complication rate, fast wound healing, a quick return to work and reduced postoperative pain. Copyright (c) 2007 British Journal of Surgery Society Ltd.

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Am Surg. 2007 Jul;73(7):733-6.
Stapled hemorrhoidopexy: outcome assessment.
Goldstein SD, Meslin KP, Mazza T, Isenberg GA, Fitzgerald J, Richards A, Delong B, Sollenberger L.
Division of Colon and Rectal Surgery, Department of Surgery, Thomas Jefferson University, 1100 Walnut Street, Suite 702, Philadelphia, PA 19107, USA. scott.goldstein@jefferson.edu

Since its introduction as a new procedure for the surgical management of hemorrhoidal disease in 1993, stapled hemorrhoidopexy has become increasingly popular. This has been mostly the result of the reported reduction in postoperative pain. This study was designed to review retrospectively 152 patients combined from a 3-year period in a three-surgeon private colorectal practice and a 1-year period from an academic colon and rectal surgery training program. All patients had either grade II or III hemorrhoidal prolapse. There were 78 male (mean age, 52 years) and 74 female patients (mean age, 54 years). A total of 133 patients (87.5%) were treated on an ambulatory basis, with 131 patients (86%) given monitored sedation with local anesthesia. Postoperative complications were seen in 49 patients (32%); 33 were for bleeding, with four requiring operative control. Subsequent associated anorectal procedures were performed on 14 patients (9.2%). Of the original 152 patients, 78 participated in a postoperative survey. Of these patients, 67.9 per cent stated that their postoperative pain was less than expected. Seventy-one patients (91%) stated significant improvement or complete resolution of their symptoms, and 73.1 per cent returned to normal activity in less than 2 weeks. Eighty-nine per cent of patients surveyed stated they would recommend hemorrhoidopexy to others.

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Colorectal Dis. 2007 Jul;9(6):532-5.
Day case haemorrhoidectomy.
Miles AJ, Dunkley AJ.
Department of General Surgery, Royal Hampshire County Hospital, Winchester, Hampshire, UK. andrewmiles@doctors.org.uk

OBJECTIVE: Day case haemorrhoidectomy in a District General Hospital. We have investigated the uptake and outcome of day case haemorrhoidectomy in a small district general hospital. METHOD: Case note review with completion of standard proforma for all patients undergoing haemorrhoidectomy as day case (same day admission and discharge) or inpatient over a 4-year period. RESULTS: Sixty patients underwent day case closed haemorrhoidectomy, 2 day case stapled haemorrhoidectomy and 1 day case open haemorrhoidectomy, whilst 18 patients were treated as in-patients. One patient required re-admission within 31 days for reactionary haemorrhage after day case surgery. None suffered acute urinary retention. Concomitant medical disease or emergency admission were the only reasons for exclusion from day case haemorrhoidectomy. Of the 18 patients treated as in-patients haemorrhoidectomy two had unplanned readmission. CONCLUSION: Closed haemorrhoidectomy with same day discharge should be offered to all patients that require surgical treatment of haemorrhoids and do not have other contra-indications to day case surgery.

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Minerva Chir. 2007 Jun;62(3):151-159.
The gold standard in the treatment of haemorrhoidal disease. Milligan-Mor-gan haemorrhoidectomy vs Longo mucoprolapsectomy: comparing techniques.
Candela G, Varriale S, Di Libero L, Manetta F, Maschio A, Giordano M, Pizza A, Sciascia V, Napolitano S, Santini L.
VII Divisione di Chirurgia Generale, Facoltà di Medicina e Chirurgia, Seconda Università degli Studi di Napoli, Napoli.

AIM: Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease. METHODS: From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation. RESULTS: The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences. CONCLUSION: The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.

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Colorectal Dis. 2007 Jun;9(5):457-63.
Rectogesic (glyceryl trinitrate 0.2%) ointment relieves symptoms of haemorrhoids associated with high resting anal canal pressures.
Tjandra JJ, Tan JJ, Lim JF, Murray-Green C, Kennedy ML, Lubowski DZ.
Department of Colorectal Surgery, Epworth Colorectal Center and The Royal Melbourne Hospital, Melbourne, Australia. tjandra@connexus.net.au

OBJECTIVE: Some haemorrhoids are associated with high resting anal canal pressures. The aim of this study was to assess if Rectogesic, a topical glyceryl trinitrate 0.2% ointment was effective in relieving symptoms of early grade haemorrhoids associated with high resting anal canal pressures. METHOD: This was a prospective, two-centre, open label study of 58 patients with persistent haemorrhoidal symptoms. Patients with first or second degree haemorrhoids and a maximum resting anal canal pressure > 70 mmHg were included. Rectogesic was applied three times a day for 14 days. Anorectal manometry was performed 30 min after the first application of Rectogesic. A 28-day diary was completed during 14 days of therapy and for 14 days after cessation of treatment. This recorded the incidence of rectal bleeding, and visual analogue scales for anal pain, throbbing, pruritis, irritation and difficulty in bowel movement. RESULTS: Maximum resting anal canal pressures were reduced after application of Rectogesic (115.0 +/- 40.4 mmHg vs 94.7 +/- 34.1 mmHg, P < 0.001). In the study period and at 14 days after cessation of Rectogesic, there was significant reduction in rectal bleeding (P = 0.0002), and significant improvement of anal pain (P = 0.0024), throbbing (P = 0.0355), pruritis (P = 0.0043), irritation (P = 0.0000) and difficulty in bowel movement (P = 0.001). The main adverse event was headache in 43.1% of patients. CONCLUSION: Rectogesic is a safe and feasible treatment for patients with early grade haemorrhoids associated with high resting anal canal pressures.

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Br J Surg. 2007 May 22; [Epub ahead of print]
Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy.
Ganio E, Altomare DF, Milito G, Gabrielli F, Canuti S.
Department of Emergency and Organ Transplantation, Section of General Surgery and Liver Transplantation, University of Bari, Policlinico, Piazza G. Cesare 11, 70124 Bari, Italy.

INTRODUCTION:: Stapled haemorrhoidopexy is less painful than Milligan-Morgan haemorrhoidectomy, allowing an earlier return to working activities, but its long-term efficacy is not fully established. This study reports the long-term follow-up of a randomized clinical trial comparing the two techniques in 100 patients affected by third- and fourth-degree haemorrhoids. METHODS:: All patients were contacted and invited to attend the clinic to assess long-term functional outcome. The degree of continence and satisfaction were assessed by questionnaire. Anal manometry and anoscopy were performed. RESULTS:: Eighty patients were available after a median follow-up of 87 months. No statistically significant differences were found between the two groups in terms of incontinence, stenosis, pain, bleeding, residual skin tags or recurrent prolapse. A tendency towards a higher recurrence rate was reported in patients with fourth-degree haemorrhoids, irrespective of the technique used. No significant changes in anal manometric values were found after surgery in either group. CONCLUSION:: Both techniques are effective in the long term. Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Colorectal Dis. 2007 May;9(4):352-6.
A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids.
Slawik S, Kenefick N, Greenslade GL, Dixon AR.
Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, UK.

OBJECTIVE: We have audited our 5 years experience of circumferential-stapled haemorrhoidopexy (PPH). METHOD: A prospectively collected electronic data base of our 5-year experience to September 2005 has been examined. RESULTS: A total of 357 consecutive patients (220 - 62% women, median age 46 years; range 28-92) with symptomatic third- and fourth-degree haemorrhoids (ratio 222:135) have undergone a stapled haemorrhoidopexy/rectal mucosectomy. One hundred and thirty-two (37%) had failed previous banding; 42 (12%) had undergone a Milligan-Morgan haemorrhoidectomy in the past. All but one was performed under general anaesthetic. Mean duration of surgery was 15 min (range 11-40); 299 (84%) were planned day cases (three patients were admitted overnight for pain relief (2) and retention of urine) and 57 were planned successful overnight stays. Reactive postoperative bleeding requiring a blood transfusion occurred in three patients (0.8%): one returned to theatre (0.2%). Three patients (0.8%) had a secondary haemorrhage requiring a hospital visit, one was admitted overnight. Four patients complaining of severe pain were managed in the community. Transient urgency was reported in 92 patients (26%); 58 (63%) were men, faecal impaction 4 (1.1%), minor staple line stenosis requiring dilatation 5 (1.4%), peri-anal sepsis from an associated untreated chronic anal fissure 1 (0.2%). Normal work was resumed between 3 and 31 days (median 7). Five patients re-presented with recurrent symptoms between 14 & 18 months: further treatment comprised a repeat PPH in three (one was very painful), banding 1 and reassurance alone. A further patient re-presented with minor soiling which responded to physiotherapy. CONCLUSION: Stapled haemorrhoidopexy/rectal mucosectomy is a safe, effective and predictable treatment of third- and fourth- degree haemorrhoids and in the majority of patients can be carried out on a day case basis.

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Chir Ital. 2007 Mar-Apr;59(2):231-5.
[Transfixed stitches technique versus open haemorrhoidectomy. Results of a randomised trial]
[Article in Italian]
Gaj F, Trecca A, Crispino P.
Dipartimento di Chirurgia Generale e Trapianti d'Organo, Istituto "Paride Stefanini", Università degli Studi "La Sapienza", Roma.

Nowadays different surgical techniques are available for the treatment of haemorrhoids even if a general, international consensus is still lacking. The authors, through a personal interpretation of haemorrhoids based on the PATE 2000 Sorrento classification, report on a comparative trial of haemorrhoidectomy by the transfixed stitches technique versus an open surgical technique (Milligan-Morgan). Particular attention was devoted in this prospective randomised trial to analysing the early postoperative side effects (bleeding, urinary retention), the time taken to return to active life and wound healing. Patients with grade III-IV haemorrhoids were enrolled in our study and divided into two groups: one treated by the transfixed stitches technique and the other by the Milligan-Morgan procedure. The main outcome measures such as analgesic use during the first week, early side effects, wound healing and the time taken to return to active life were evaluated. Patients were followed for 6 months after surgery. A total of 160 patients were enrolled, 80 in each group. The pain score after surgery was significantly lower in the transfixed stitches group than in the Milligan-Morgan group (p < 0.01). 30% of the transfixed stitches patients took analgesics in comparison with 90% of the Milligan-Morgan patients (p < 0.01). Postoperative pain after the start of bowel movements in the transfixed stitches group was lower than in the Milligan-Morgan group. Wound healing was immediate in the transfixed stitches patients and was obtained after one month in the open surgery group. Haemorrhoidectomy by the transfixed stitches technique is more advantageous in comparison with the Milligan-Morgan procedure because of its lesser discomfort for the patient, earlier wound healing, milder side effects, shorter surgical time and earlier return to active life.

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Chir Ital. 2007 Mar-Apr;59(2):225-9.
Bleeding after stapled haemorrhoidopexy using the PPH 03 stapler device. Experience and results in 100 consecutive patients.
Angelone G, Giardiello C, Prota C.
General and Miniinvasive Surgery Unit, "S. Maria della Pieti" Hospital, Casoria, Napoli.

Bleeding after stapled haemorrhoidopexy using the PPH 01 device is a relatively frequent major complication. Using the new PPH 03 instrument may enable to achieve better control. From June 2004 to July 2005, 100 patients with 2nd and 3rd degree haemorrhoids and mucosal rectal prolapse were treated at our institution. In all of the cases the PPH 03 instrument was used and the operations were performed by two surgeons with expertise in stapled haemorrhoidopexy. During structural interviews, the patients assessed their symptoms before and after surgery, and surgical outcome was assessed at 1 and 2 weeks. Major bleeding (loss of Hb > 5 points) occurred in 2 patients in the first 10 cases and re-operation was necessary. Minor bleeding (loss of Hb < 3 points) occurred in 2 patients. We had 2 bleeds in the early postoperative period (2%) and 2 cases of late bleeding (2%). Stapled haemorrhoidopexy is an effective treatment for haemorrhoids and is a significantly less painful operation. Any postoperative bleeding that may occur is easy to resolve and its incidence depends on the careful haemostatic control at the staple line. The new PPH 03 stapler device seems to be more effective than the PPH 01 device for control of the staple line suture. We would suggest that colorectal surgeons who are familiar with the technique and aware of possible complications should perform stapled haemorrhoidopexy using the PPH 03 stapler.

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Tech Coloproctol. 2007 Mar;11(1):1-6. Epub 2007 Feb 16.
Stapled transanal rectal mucosectomy ten years after.
Pescatori M, Aigner F.
Coloproctology Unit, Villa Flaminia Hospital, Via Bodio 58, Rome, Italy. ucpclub@virgilio.it

Stapled mucosectomy (SM) was first proposed for the management of patients with rectal internal mucosal prolapse and obstructed defecation, but gained popularity worldwide for the treatment of hemorrhoids. The present review highlights the advantages and disadvantages of the operation. SM tends to decrease postoperative pain and shortens convalescence after hemorrhoid surgery, but may be followed by severe complications, e.g. rectal obliteration and pelvic sepsis requiring a diverting stoma, more frequently than after standard hemorrhoidectomy. Moreover it carries a higher recurrence rate in the treatment of fourth-degree piles. A recent Cochrane metaanalysis demonstrated that SM is less effective than standard hemorrhoidectomy since it carries a higher recurrence rate (OR=3.6) and reintervention rate (OR=2.3). When used for rectal mucosal prolapse and obstructed defecation, SM is reported to have variable results. A better outcome is likely to be achieved in patients without anismus and psychoneurosis operated on by specialists trained with this technique.

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Urologe A. 2007 Feb 9; [Epub ahead of print]
[Haemorrhoidal suffering.]
[Article in German]
Puhse G, Raulf F.
Klinik und Poliklinik fur Urologie, Universitatsklinikum Munster, Albert-Schweitzer-Strasse 33, 48149, Munster, Deutschland, puehse@uni-muenster.de.

Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Conservative treatment consists of dietary and lifestyle modifications. Standard interventional procedures in outpatient treatment are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows shorter convalescence but may have a higher recurrence rate and needs further long-term evaluation.

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Dis Colon Rectum. 2007 Feb;50(2):204-12.
Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms.
Fueglistaler P, Guenin MO, Montali I, Kern B, Peterli R, von Flue M, Ackermann C.
Surgical Department, St. Claraspital, Basel, Switzerland.

PURPOSE: Stapled hemorrhoidopexy has been demonstrated to be advantageous in the short term compared with the traditional techniques. We aimed to evaluate long-term results after stapled hemorrhoidopexy and to assess patient satisfaction in association with postoperative hemorrhoidal symptoms. METHODS: This prospective study included 216 patients with Grade 2 or 3 hemorrhoids, who had stapled hemorrhoidopexy using the circular stapled technique. The results were evaluated by a standardized questionnaire at least 12 months after the operation. The primary end point was patient satisfaction; secondary end points included specific hemorrhoidal symptoms. RESULTS: Followup data were obtained for 193 of 216 patients (89 percent) with a median follow-up of 28 (range, 12-53) months, most of whom (89 percent) were satisfied or very satisfied with the surgery. The main preoperative symptom was no longer present postoperatively in 66 percent of patients, was relieved in 28 percent, and had worsened in 2 percent. Postoperative complaints included symptoms of hemorrhoidal prolapse (24 percent of patients), anal bleeding (20 percent), anal pain (25 percent) fecal soiling/leakage (31 percent), fecal urgency (40 percent), and local discomfort (38 percent). Bivariate analysis showed significant associations between each of these symptoms and patient satisfaction. Nine patients (5 percent) were reoperated on during the follow-up period. CONCLUSIONS: Long-term patient satisfaction was high in most of patients after stapled hemorrhoidopexy for second-degree and third-degree hemorrhoids. However, an unsatisfactory outcome was significantly related to postoperative hemorrhoidal symptoms such as prolapse, fecal soiling/leakage, and new onset of fecal urgency.

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World J Gastroenterol. 2007 Jan 28;13(4):585-7.
Elastic band ligation of hemorrhoids: Flexible gastroscope or rigid proctoscope?
Cazemier M, Felt-Bersma RJ, Cuesta MA, Mulder CJ.
Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, VU Medical Center, PO Box 7057, Amsterdam 1007 MB, The Netherlands. marcel.cazemier@wanadoo.nl.

AIM: To compare rigid proctoscope and flexible endoscope for elastic band ligation of internal hemorrhoids. METHODS: Patients between 18 and 80 years old, with chronic complaints (blood loss, pain, itching or prolapse) of internal hemorrhoids of grade 1-3, were randomized to elastic band ligation by rigid proctoscope or flexible endoscope (preloaded with 7 bands). Patients were re-treated every 6 wk until the cessation of complaints. Evaluation by three-dimensional anal endosonography was performed. RESULTS: Forty-one patients were included (median age 52.0, range 27-79 years, 20 men). Nineteen patients were treated with a rigid proctoscope and twenty two with a flexible endoscope. Twenty-nine patients had grade 1 hemorrhoids, 9 patients had grade 2 hemorrhoids and 3 patients had grade 3 hemorrhoids. All patients needed a minimum of 1 treatment and a maximum of 3 treatments. A median of 4.0 bands was used in the rigid proctoscope group and a median of 6.0 bands was used in the flexible endoscope group (P < 0.05). Pain after ligation tended to be more frequent in patients treated with the flexible endoscope (first treatment: 3 vs 10 patients, P < 0.05). Three-dimensional endosonography showed no sphincter defects or alterations in submucosal thickness. CONCLUSION: Both techniques are easy to perform, well tolerated and have a good and fast effect. It is easier to perform more ligations with the flexible endoscope. Additional advantages of the flexible scope are the maneuverability and photographic documentation. However, treatment with the flexible endoscope might be more painful and is more expensive.

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Tech Coloproctol. 2006 Dec;10(4):312-7. Epub 2006 Nov 27.
Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial.
Marques CF, Nahas SC, Nahas CS, Sobrado CW Jr, Habr-Gama A, Kiss DR.
Colorectal Unit, Department of Gastroenterology, School of Medicine University of Sao Paulo, Sao Paulo, Brazil.

BACKGROUND: Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of "heat". Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH). METHODS: Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient's satisfaction. RESULTS: A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC. CONCLUSIONS: Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period.

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Chir Ital. 2006 Nov-Dec;58(6):753-60.
Stapled hemorrhoidopexy. Complications and 2-year follow-up.
Angelone G, Giardiello C, Prota C.
General and Minimally Invasive Surgery Unit, S. Maria della Pieta Hospital, Casoria, Naples, Italy.

Stapled hemorrhoidopexy (SH) presents a number of complications which differ from those of traditional haemorrhoidectomy (Milligan-Morgan, diathermy haemorrhoidectomy). The follow-up shows better symptom control than other surgical techniques. Four hundred and forty-nine patients with haemorrhoids of all degrees and mucosal rectal prolapse were treated at our institution over a five-year period (1999-2004). Patients were assessed by structural interview to assess their symptoms before and after surgery, and surgical and functional outcome was assessed at 1, 3, 6, 12 and 24 months. A visual analog scale was used for postoperative pain scoring. Patient's satisfaction is the best response to all criticism. Bleeding in the early postoperative period occurred in 3.9% of all patients and in 7 cases (1.5%) reoperation was necessary. Urge to defecate, although present in 14% of patients, disappears in a few weeks. Severe pain, when present, may depend on technical failure or learning curve. Complete or incomplete recurrence occurred in 10 cases (2.2%). We had one case of rectovaginal fistula in a young woman. In 3 cases we underestimated the extent of the mucosal prolapse and the patients were reoperated on by stapled transanal rectal resection after one (2 patients) and two years. Stapled hemorrhoidopexy is a significantly less painful operation and offers significant advantages in terms of hospital stay and symptom control in the long term, making for a significantly earlier return to work. The complications are similar to those of other techniques and are easily resolved. The unusual complications described (rectal perforation, pelvic sepsis, rectovaginal fistulas) might suggest that the operation should be performed by experienced colorectal surgeons who are familiar with the technique and aware of the possible complications.

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Int J Colorectal Dis. 2006 Nov 22; [Epub ahead of print]
Simple harmonic scalpel hemorrhoidectomy utilizing local anesthesia combined with intravenous sedation: a safe and rapid alternative to conventional hemorrhoidectomy.
Haveran LA, Sturrock PR, Sun MY, McDade J, Singla S, Paterson CA, Counihan TC.
Section of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA, USA.

BACKGROUND: Harmonic Scalpel(R) hemorrhoidectomy (HSH) is an established surgical therapy for the treatment of symptomatic grade III and IV hemorrhoids. Hemorrhoid surgery is still being performed as an inpatient procedure with general or regional anesthesia in many centers today. There was a trend toward performing hemorrhoid surgery as an ambulatory procedure using local anesthesia supplemented with intravenous sedation. The aim of the current study was to evaluate the safety and efficacy of HSH performed with combination local anesthesia and intravenous sedation in an ambulatory surgical center. MATERIALS AND METHODS: A retrospective review was performed on the clinical charts of all patients undergoing HSH in an ambulatory surgical center from 2001 to 2005. All hemorrhoidectomies were attempted under propofol/ketamine intravenous sedation and local anesthesia in the prone position. A simple, open technique without routine suture was used. RESULTS: During the study period, 180 patients (70 females) underwent HSM. Mean procedure and total operating room time were 12 and 28 min, respectively. One patient (0.6%) was converted to general endotracheal anesthesia. Ten patients (5.6%) required post anesthesia care unit (PACU) observation. All patients were discharged home after the procedure. Postoperative complications occurred in 19 patients (10.6%). There were no reoperations and the total readmission rate was 3.7%. CONCLUSION: HSH performed with a combination of intravenous sedation and local anesthesia is safe and effective in the ambulatory surgery setting. The combined technique was associated with a rate of complications comparable to published series utilizing conventional hemorrhoidectomy techniques. Added benefits include shorter hospital stay and a potential for cost savings.
 

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