Hemorrhoid Research: 2002-2006  
     
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005393.
Stapled versus conventional surgery for hemorrhoids.
Jayaraman S, Colquhoun PH, Malthaner RA.
University of Western Ontario, Department of Surgery, 339 Windermere Rd. Rm C8-114, London, Ontario, Canada. sjayaram@uwo.ca

BACKGROUND: Hemorrhoids are one of the most common anorectal disorders. The Milligan-Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized-controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day-case procedures potentially making it more economical OBJECTIVES: To compare the use of circular stapling devices and conventional excisional techniques in patients with symptomatic hemorrhoids. SEARCH STRATEGY: We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to May 2006. SELECTION CRITERIA: All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries were included. DATA COLLECTION AND ANALYSIS: Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model. MAIN RESULTS: Patients undergoing circular stapled hemorrhoidopexy (SH) were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those receiving conventional hemorrhoidectomy (CH) (7 trials, 537 patients, OR 3.85, CI 1.47-10.07, p=0.006). There were 23 recurrences out of 269 patients in the stapled group versus only 4 out of 268 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence(5 trials, 417 patients, OR 3.60, CI 1.24-10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (8 studies, 798 patients, OR 2.96, CI 1.33-6.58, p=0.008). In studies with follow up of greater than one year, the same significant outcome was found (6 studies, 628 patients, OR 2.68, CI 0.98-7.34, p=0.05). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH AUTHORS' CONCLUSIONS: Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also likely to be associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the "gold standard" in the surgical treatment of internal hemorrhoids.

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Dis Colon Rectum. 2006 Sep 25; [Epub ahead of print]
Botulinum Toxin vs. Topical Glyceryl Trinitrate Ointment for Pain Control in Patients Undergoing Hemorrhoidectomy: A Randomized Trial.
Patti R, Luigi AP, Matteo A, Sergio S, Pietro R, Calogero F, Di Gaetano V.
Department of Surgical and Oncologic Science, Division of General Surgery, University of Palermo, Palermo,, Italy.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound healing and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mmHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

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Rev Gastroenterol Mex. 2005 Jul-Sep;70(3):284-90.
[Non-surgical alternative management of hemorrhoidal disease][Article in Spanish]
Charua Guindic L, Chirino Perez AE, Navarrete Cruces T, Osorio Hernandez RM, Avendano Espinosa O.
Unidad de Coloproctologia del Servicio de Gastroenterologia del Hospital General de Mexico. luischarua@hotmail.com

Clinical manifestations of hemorrhoidal disease depend on its location (internal or external) and the presence or not of complications. PURPOSE: To describe the results of the three most common alternatives for non-surgical procedures treating internal hemorrhoids: rubber band ligation, esclerotherapy and infrared photocoagulation. MATERIALS AND METHODS: A retrospective, longitudinal and descriptive study from January 1998 to December 2002 was carried out, including variables like age, gender, clinical manifestations and date of initiation, type of non-surgical alternative treatment, complications, management and stage of the illness. RESULTS: In 9,103 charts reviewed this study included 2,701 patients with hemorrhoidal disease, with an annual incidence of 540.20 patients; 1,388 (51.39%) were male and 1,313 (48.62%) were female; ages between 17 and 78 years, 44.10 as a mean age. Rubber band ligation was used in 516 patients (67.45%), esclerotherapy in 177 (23.13%) and infrared photocoagulation in 72 cases (9.41%). CONCLUSIONS: Rubber band ligation is mainly indicated for internal hemorrhoids II degree, the esclerotherapy is indicated in the suppression of acute hemorrhage, but in the long term, this method has the poorest results. Infrared photocoagulation has its best results in internal hemorrhoids I degree because it causes less pain and complications and patients accept it better.

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Surg Clin North Am. 2006 Aug;86(4):937-67.
New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant.
Singer M, Cintron J.
Department of Surgery (MC958), University of Illinois, Clinical Sciences Building, #518-E, 840 S. Wood Street, Chicago, IL 60612, USA.

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.

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Br J Surg. 2006 Aug;93(8):909-20.
Meta-analysis of flavonoids for the treatment of haemorrhoids.
Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G.
Iberoamerican Cochrane Centre, Clinical Epidemiology and Public Health Department, Hospital Sant Pau, Barcelona, Spain. palonso@santpau.es

BACKGROUND: The aim of the study was to evaluate the impact of flavonoids on those symptoms important to patients with symptomatic haemorrhoids. METHODS: A comprehensive search strategy was used. All published and unpublished randomized controlled trials comparing any type of flavonoid to placebo or no therapy in patients with symptomatic haemorrhoids were included. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies and extracted data. RESULTS: Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality and showed variability in the results with potential publication bias. Meta-analyses using random-effects models suggested that flavonoids decrease the risk of not improving or persisting symptoms by 58 per cent (relative risk (RR) 0.42 (95 per cent confidence interval (c.i.) 0.28 to 0.61)) and showed an apparent reduction in the risk of bleeding (RR 0.33 (95 per cent c.i. 0.19 to 0.57)), persistent pain (RR 0.35 (95 per cent c.i. 0.18 to 0.69)), itching (RR 0.65 (95 per cent c.i. 0.44 to 0.97)) and recurrence (RR 0.53 (95 per cent c.i. 0.41 to 0.69)). CONCLUSION: Limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids.

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Chirurg. 2006 Jul 25; [Epub ahead of print]
[Therapy of haemorrhoidal disease.]
[Article in German]
Herold A.
Enddarm-Zentrum Mannheim, Bismarckplatz 1, 68165 , Mannheim, a.herold@enddarm-zentrum.de.

Haemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is freedom from symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of disease: haemorrhoids 1 are treated conservatively. In addition to high-fibre diet, sclerotherapy is used. Haemorrhoids 2 prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Haemorrhoids 3 that prolapse during defecation have to be digitally reduced, and the majority need surgery. For segmental disorders, haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease, Stapler haemorrhoidopexy is now the procedure of choice. Using a therapeutic regime according to the haemorrhoidal disease classification offers high healing rates and low rates of complications and recurrence.

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J Gastrointest Surg. 2006 May;10(5):627-8.
Stapled hemorrhoidectomy.
Stamos MJ.
Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine School of Medicine, California 92868, USA. mstamos@uci.edu

Stapled hemorrhoidectomy or "hemorrhoidopexy" has gained popularity for the treatment of grade 3-4 hemorrhoids, largely due to decreased pain as compared to traditional surgical hemorrhoidectomy. This decreased pain, along with proven short term efficacy, has been supported by numerous randomized controlled trials. Despite this evidence in support of stapled hemorrhoidectomy, controversy exists due to rare but occasionally life threatening complications, and also due to significant chronic pain experienced by a small but significant subset of patients. Attention to the technical details of the operation will limit these deleterious outcomes, and allow stapled hemorrhoidectomy to maintain it's niche role in the treatment of symptomatic hemorrhoids.

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Br J Surg. 2006 May 31; [Epub ahead of print]
Meta-analysis of flavonoids for the treatment of haemorrhoids.
Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G.
Iberoamerican Cochrane Centre, Clinical Epidemiology and Public Health Department, Hospital Sant Pau, Barcelona, Spain.

BACKGROUND:: The aim of the study was to evaluate the impact of flavonoids on those symptoms important to patients with symptomatic haemorrhoids. METHODS:: A comprehensive search strategy was used. All published and unpublished randomized controlled trials comparing any type of flavonoid to placebo or no therapy in patients with symptomatic haemorrhoids were included. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies and extracted data. RESULTS:: Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality and showed variability in the results with potential publication bias. Meta-analyses using random-effects models suggested that flavonoids decrease the risk of not improving or persisting symptoms by 58 per cent (relative risk (RR) 0.42 (95 per cent confidence interval (c.i.) 0.28 to 0.61)) and showed an apparent reduction in the risk of bleeding (RR 0.33 (95 per cent c.i. 0.19 to 0.57)), persistent pain (RR 0.35 (95 per cent c.i. 0.18 to 0.69)), itching (RR 0.65 (95 per cent c.i. 0.44 to 0.97)) and recurrence (RR 0.53 (95 per cent c.i. 0.41 to 0.69)). CONCLUSION:: Limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Ann R Coll Surg Engl. 2006 May;88(3):275-9.
A prospective audit of early pain and patient satisfaction following out-patient band ligation of haemorrhoids.
Watson NF, Liptrott S, Maxwell-Armstrong CA.
Department of Surgery, Queen's Medical Centre, Nottingham, UK. nicholas.watson@nottingham.ac.uk

INTRODUCTION: Information regarding early morbidity, pain and patient satisfaction following band ligation of haemorrhoids is limited. This is the first report to address these issues specifically.PATIENTS AND METHODS: A total of 183 patients underwent the procedure over a 10-month period. Prospective data were collected using a detailed structured questionnaire regarding symptoms, analgesia requirements and patient satisfaction in the following week.RESULTS: The response rate was 74% (135/183). Pain scores were highest 4 h following the procedure. At 1 week, 75% of patients were pain-free, with 9 (7%) still experiencing moderate-to-severe pain. About 65% required oral analgesia, most frequently on the day of procedure. Rectal bleeding occurred in 86 patients (65%) on the day after banding, persisting in 32 (24%) at 1 week. Vaso-vagal symptoms occurred in 41 patients (30%) and were commonest at the time of banding. Eighty patients (59%) were satisfied with their experience and would undergo the procedure again. Patients requiring oral analgesia and those experiencing bleeding or vaso-vagal symptoms were significantly less likely to be satisfied with the procedure. Only 57% of the patients surveyed would recommend the procedure to a friend.CONCLUSIONS: Data from this large cohort of patients suggest that discomfort and bleeding may persist for a week or more following banding of haemorrhoids. Patients should be aware of this in order to make an informed decision as to whether to undergo the procedure, and surgeons should investigate ways of reducing it. Patient satisfaction may be further improved by more accurate counselling regarding the incidence of specific complications.

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Minerva Chir. 2006 Apr;61(2):119-24.
Second degree haemorrhoids: patient's satisfaction, immediate and long-term results of rubber band ligation treatment.
Benzoni E, Milan E, Cerato F, Narisetti P, Bresadola V, Terrosu G.
Department of Surgery, University of Udine, Udine, Italy.

AIM: Rubber band ligation (RBL) is a widely performed and well established treatment for second degree haemorrhoids. The aim of our prospective study was to assess the satisfaction of patients treated by rubber band ligation, as well as the immediate and long-term results of this technique. METHODS: From January 2001 to December 2004, 73 consecutive outpatients with second degree haemorrhoids underwent RBL. From 1 to 3 years from the initial treatment, 73 patients were contacted by phone call to have some news about their health condition and to collect their opinion about the satisfaction of RBL technique. RESULTS: We didn't identify any major complication in our series, sometimes a temporary anal discomfort that could be controlled by low dose of NSAIDs. We report an excellent immediate benefit in 13.7% of cases, a good one in 58.9%. From 1 to 3 years after the initial procedure 82.2% of patients are either symptom free or improved and don't need any medical therapy. CONCLUSIONS: Immediate results are very good in particular for bleeding, anal pain and mucosal prolapse. Immediate and long-term results are invalidated by the concomitance of more symptoms and different results are recorded between sexes. We consider RBL a good ambulatory practice that could either get better or resolve haemorrhoidal disease or delay the invasive surgical treatment for second degree haemorrhoids.

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Eur Rev Med Pharmacol Sci. 2006 Mar-Apr;10(2):79-85.
Clinical applications of radiofrequency in proctology: a review.
Filingeri V, Gravante G, Cassisa D.
Department of Surgery, University of Rome Tor Vergata, Italy. v.filingeri@tiscali.it

The radiofrequency scalpel is an innovative instrument which allows to cut and coagulate tissues in an atraumatic manner, conversely to the electric scalpel. The authors describe the use of radiofrequencies in proctology by making a literature review for every major proctologic disease (hemorrhoids, anal fistulas, anal fissure, sinus pilonidalis, hypertrophied anal papillae). Many techniques have been developed with radiofrequencies in hemorrhoids treatment: coagulation, ablation with plication, Milligan Morgan and Parks hemorrhoidectomy. In the treatment of anal fissures, radiofrequency subcutaneous lateral internal sphincterotomy has been described. For anal fistulas, both radiofrequency fistulotomy and fistulectomy. Finally, radiofrequency sinotomy for sinus pilonidalis and coagulation for hypertrophied anal papillae are present in literature. The analysis of the results obtained with radiofrequency surgery compared with those of the "classic" surgery for proctologic disease shows that in most of them radiosurgery facilitates, accelerates and improves the surgical procedure.

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Tech Coloproctol. 2006 Mar 15; [Epub ahead of print]
PPH03 stapled hemorrhoidopexy: our experience.
Lim YK, Eu KW, Ho KS, Ooi BS, Tang CL.
Department of Colorectal Surgery, Singapore General Hospital, Singapore, gcsekw@sgh.com.sy.

BACKGROUND: Stapled hemorrhoidopexy is an established treatment for hemorrhoidal disease. We evaluated our experience with stapled hemorrhoidopexy using the new Procedure for Prolapse and Hemorrhoids (PPH03) Proximate HCS hemorrhoidal circular stapler (Ethicon Endo-Surgery). METHODS: We retrospectively reviewed clinical data for 238 patients who had undergone stapled hemorrhoidopexy in our department over a 2-month period. Patients were followed-up for a median of 3.5 weeks (range, 1-11 weeks) and were analyzed for complications and resolution of symptoms. RESULTS: The hemorrhoids treated were third- and fourth-degree, as well as second degree (after failure of other therapies). Mean duration of surgery was 12.7 minutes (range, 5-20 minutes) and the majority of patients was treated with an ambulatory procedure. Most patients were discharged within 6 hours after surgery. On follow-up, 3.7% of patiets had minor complaints after surgery. Technically, the new PPH03 stapler device has a quickclose knob, which allows rapid opening and closing. The closed staple height of 0.75 mm increases staple line compression on tissue and key blood vessels, hence minimizing bleeding. Prior to this, stapled hemorrhoidopexy was done using the PPH01 device. CONCLUSIONS: Stapled hemorrhoidopexy using the new PPH03 stapler is a safe, short and effective procedure in the management of hemorrhoids. It can be done in the ambulatory setting and patients have few postoperative complications.

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Tech Coloproctol. 2006 Mar 15; [Epub ahead of print]
Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids.
Kanellos I, Zacharakis E, Kanellos D, Pramateftakis MG, Tsachalis T, Betsis D.
4th Surgical Department, Aristotle University, Thessaloniki, Greece, ik@hol.gr.

BACKGROUND: Stapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long-term results after SH for third-degree haemorrhoids. METHODS: A total of 126 consecutive patients (67 men and 59 women) with third-degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38-84 months). RESULTS: During the postoperative period, 7 patients (5.8%) experienced pain for 5-12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2-8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%). CONCLUSIONS: SH is a safe, low-pain and, in the long-term, effective technique for the treatment of third-degree haemorrhoids.

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Colorectal Dis. 2006 Feb;8(2):130-4.
Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?
Finco C, Sarzo G, Savastano S, Degregori S, Merigliano S.
University of Padova, Department of Medical and Surgical Sciences, 3th General Surgery Clinic, Coloproctological Unit, S. Antonio Hospital, Padova, Italy. cristiano.finco@unipd.it

INTRODUCTION: Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse. MATERIALS AND METHODS: One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease. RESULTS: There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence. CONCLUSION: Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

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Curr Surg. 2006 Jan-Feb;63(1):44-50.
Radiofrequency ablation and plication--a new technique for prolapsing hemorrhoidal disease.
Gupta PJ, Heda PS, Kalaskar S.
Gupta Nursing Home, Nagpur, India. drpjg_ngp@sancharnet.in

BACKGROUND: The author describes a modified procedure of ablation with a radiofrequency device and plication of the hemorrhoidal mass for prolapsing hemorrhoids. The study is aimed at ascertaining if this procedure provides any advantages over the conventional hemorrhoid surgery. MATERIALS AND METHODS: Two different studies are included. The first study describes 600 serial patients with prolapsing hemorrhoids treated with this technique over a period of 18 months. An Ellman radiofrequency generator was used for the ablation of the hemorrhoids. The operative technique and postoperative outcome is reported. The second study compares this technique with standard Milligan-Morgan hemorrhoidectomy in a randomized trial of 100 patients. RESULTS: With this new procedure, the post-defecation pain and pain at rest were within tolerable limits (pain scores 1 to 4 on visual analog scale). Post-defecation bleeding was present in 60% of the patients. Pruritus and perianal thrombosis were complained by few others. No patient encountered any incontinence, prolapse, or stenosis. The comparative study showed definite advantages of this modified technique over Milligan-Morgan hemorrhoidectomy. CONCLUSION: The procedure of radiofrequency ablation and plication of hemorrhoids restricts the hospital stay to only a few hours and provides rapid physical recovery. It does seem to be a better alternative to the conventional surgical procedures in terms of postoperative pain, return to work, and complications.

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Colorectal Dis. 2006 Jan;8(1):56-61.
Day case stapled haemorrhoidopexy for prolapsing haemorrhoids.
Beattie GC, McAdam TK, McIntosh SA, Loudon MA.
Department of Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.

OBJECTIVE: Conventional surgical management of prolapsing haemorrhoids is by excisional haemorrhoidectomy. Postoperative pain has restricted the application of such procedures in the day case setting. These operations remain associated with a period of restricted activity. The use of circular stapling devices as an alternative to the excisional approach in the management of haemorrhoids has been described. This study reports our experience of stapled haemorrhoidopexy as a day case procedure. METHODS: Patients with third or fourth degree haemorrhoids were eligible for the procedure. Patients were considered suitable candidates for day case surgery based on conventional parameters. Symptoms were assessed using a previously validated symptom severity rating score. Stapled haemorrhoidopexy was carried out using a circular stapling device. Pain scores were obtained prior to discharge. Patients were admitted if pain was uncontrolled despite oral analgesia. Symptoms were re-scored at six-week follow-up. RESULTS: Over a 70-month period 168 consecutive stapled haemorrhoidopexies were performed or directly supervised by one consultant colorectal surgeon. One hundred and ten (65%) patients were considered appropriate candidates for day case surgery by conventional criteria. Ninety-six (87.3%) patients successfully underwent stapled haemorrhoidopexy on a day case basis. Fourteen (12.7%) patients required admission on the day of surgery (5 for early postoperative bleeding, 4 for pain necessitating continuing opiate analgesia, two for urinary retention and three for surgery performed late in the day). Six (5%) patients were re-admitted postoperatively; four for pain relief and two because of urinary retention. Of the day case patients, 91 (82.7%) and 56 (50.9%) had been seen for 6 week and 6 month review, respectively, at the time of analysis. Symptom scores were 6 (pre-operatively) vs 0 (postoperatively) (P < 0.01). 76/91 (83.5%) patients reviewed at 6/52 were asymptomatic. CONCLUSION: Stapled haemorrhoidopexy is a safe and effective procedure that can be carried out on selected patients on a day case basis. Complications are of a similar nature to excisional haemorrhoidectomy.

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Colorectal Dis. 2006 Jan;8(1):41-5.
Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids.
Allan A, Samad AJ, Mellon A, Marshall T.
Department of Gastrointestinal Surgery, Good Hope hospital, Birmingham, UK. Arthur.Allen@goodhope.nhs.uk

OBJECTIVE: To compare the outcome of urgent haemorrhoidectomy with conservative treatment for prolapsed thrombosed internal haemorrhoids. METHODS: A prospective randomised study of 50 patients with prolapsed thrombosed internal haemorrhoids was carried out using clinical and ultrasonic outcome measures. Peri-operative bed occupancy and the presence of symptoms at 6 and 24 months were compared. Endoanal ultrasonic scanning was carried out to investigate anal sphincter integrity in those patients willing to be studied. RESULTS: The median length of hospital stay for the group treated conservatively; 2 nights (range 1-9 nights) was significantly shorter than for the group treated by urgent haemorrhoidectomy; 4 nights (range 1-12 nights, P < 0.01). There was no difference between treatment groups in the number of patients with symptoms at six or 24 months. Urgent haemorrhoidectomy was associated with a significantly higher incidence of endosonographically detected anal sphincter damage in 18 patients: 66%vs 0% (P = 0.009). CONCLUSION: Conservative treatment for prolapsed thrombosed internal haemorrhoids is associated with shorter in patient stay and less anal sphincter damage compared with operative treatment.

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Ann Chir. 2006 Jan 26; [Epub ahead of print]
[Postoperative pain and long-term results after hemorrhoidal treatment with anopexy.]
[Article in French]
Pigot F, Dao Quang M, Castinel A, Juguet F, Bouchard D, Allaert FA, Bockle J.
Service de proctologie medicochirurgicale, hopital Bagatelle, rue Robespierre, Talence 33400 cedex, France.

Aims. - Anopexy allows treatment of hemorrhoidal symptoms with a less painful postoperative course. This information is important for the patient, but may lead to dissatisfaction if pain level is higher than expected. To evaluate perceived pain and physical limitation levels in relation to patient's expectation. Evaluate long-term functional results. Results. - Sixty-eight consecutive patients (56 males) were prospectively included. Distribution of haemorrhoid grades were 4 grade 2 (6%), 52 grade 3 (76%) and 12 grade 4 (18%). Postoperative pain level was less or equal than expected for 85% of patients, with a better acceptance superior to 45 years. Physical limitation was equally or less important than expected for 89%. At the 32 weeks follow-up hemorrhoidal symptoms were present in 23%, uninfluenced by any patient's or operative characteristics. Incontinence with urgency was reported by 17%. Presence of an alliterated continence was linked to stapled line inferior to 6,5 mm from pectineate line, doughnut height inferior to 22 mm, external hemorrhoids and related to surgeon. Conclusion. - Pragmatic information, although vague, about postoperative pain does not expose to patient's dissatisfaction. Functional results are not influenced by technical variation. Continence alterations are not severe, but frequent when stapled line is too close from pectineate line.

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Dis Colon Rectum. 2006 Jan 31; [Epub ahead of print]
First 100 Cases With Doppler-Guided Hemorrhoidal Artery Ligation.
Greenberg R, Karin E, Avital S, Skornick Y, Werbin N.
Department of Surgery A', Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

PURPOSE: This study was designed to examine the benefits of a Doppler-guided hemorrhoidal artery ligation technique in terms of surgical outcome, functional recovery, and postoperative pain. METHODS: Using local, regional, or general anesthesia, 100 patients with symptomatic Grades II or III hemorrhoids underwent sonographic identification and suture ligation of six to eight terminal branches of the superior rectal artery above the dentate line. Visual Analog Scales were used for postoperative pain scoring. Surgical and functional outcomes were assessed at 6 weeks and 3, 6, and 12 months after surgery. RESULTS: There were 42 (42 percent) males and 58 (58 percent) females (mean age, 42 years; median duration of symptoms, 6.3 years). The mean operative time was 19 minutes. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only five were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative course. The mean pain score decreased from 2.1 at two hours postoperative to 1.3 on the first postoperative day. All patients had a complete functional recovery by the third postoperative day. Ninety-four patients remained asymptomatic after a mean follow-up of six months: four patients required additional surgical excision, and two required rubber band ligations for persistent bleeding. On follow-up, there was no report of incontinence to gas or feces, fecal impaction, or persistent pain. CONCLUSIONS: Our experience indicates that Doppler-guided hemorrhoidal artery ligation is safe and effective and can be performed as an outpatient procedure with local or regional anesthesia and with minimal postoperative pain and early recovery.

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Am J Gastroenterol. 2006 Jan;101(1):181-8.
Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis.
Alonso-Coello P, Mills E, Heels-Ansdell D, Lopez-Yarto M, Zhou Q, Johanson JF, Guyatt G.
Iberoamerican Cochrane Center, Hospital Sant Pau, Barcelona, Spain.

OBJECTIVES: To evaluate the impact of laxatives on a wide range of symptoms in patients with symptomatic hemorrhoids. METHODS: We searched using the following sources: MEDLINE, EMBASE, CINAHL and CENTRAL, BIOSIS, AMED, Papers First and Proceedings; study authors, industry, and experts in the field. We included all published and unpublished parallel group randomized controlled trials comparing any type of laxative to placebo or no therapy in patients with symptomatic hemorrhoids. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies, and extracted data on study population, intervention, prespecified outcomes, and methodology. RESULTS: Seven trials randomized 378 patients to fiber or a nonfiber control. Studies were of moderate quality for most outcomes. Meta-analyses using random effects models suggested that fiber has an apparent beneficial effect. The risk of not improving/persisting symptoms decreased by 47% in the fiber group (RR = 0.53, 95% CI 0.38-0.73) and the risk of bleeding by 50% (RR = 0.50, 95% CI 0.28-0.89). Studies with multiple follow-ups, usually at 6 wk and at 3 months, showed consistent results over time. Results are also compatible with large treatment effects in prolapse, pain, and itching, but even in the pooled analyses confidence intervals were wide and compatible with no effect (RR = 0.79, 95% CI 0.37-1.67; RR = 0.33, 95% CI 0.07-1.65; and RR = 0.71, 95% CI 0.24-2.10, respectively). One study suggested a decrease in recurrence. Results showed a nonsignificant trend toward increases in mild adverse events in the fiber group (RR = 6.0, 95% CI 0.57-64.8). CONCLUSIONS: Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids.

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Bratisl Lek Listy. 2005;106(8-9):274-8.
Radiofrequency coagulation: a new option in early grades of bleeding hemorrhoids.
Gupta PJ.
Gupta Nursing Home, Nagpur, India. drpjg.ngp@sancharnet.in

BACKGROUND: The treatment for hemorrhoids has undergone significant changes on introduction of new techniques in the last few years. Radiofrequency coagulation is a new approach for treating grades I and II of hemorrhoids. In this procedure, the hemorrhoidal tissue is coagulated by means of high-frequency radio wave. The author has described his own experience with this new technique. MATERIALS AND METHODS: The procedure was performed using an Ellman radiofrequency generator. Over a period of 18 months, patients with bleeding hemorrhoids were treated with this technique and a 16-month follow-up was carried out to assess relief in bleeding episodes, complications, and recurrence rate. RESULTS: While 13 % of patients had persistent or recurrent bleeding, 2 % of patients needed readmission for secondary hemorrhage. None had reported with any infective complication. The overall ratio of comfort, and patient's satisfaction due to relief of pain and bleeding were quite satisfactory. CONCLUSION: The treatment of bleeding hemorrhoids by using radiofrequency coagulation is technically simple, therapeutically effective and virtually complication-free. The equipment is portable, easy to handle, durable, and needs little maintenance. Long-term follow-up is necessary to justify the reliance on this method (Ref. 49).

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Dis Colon Rectum. 2005 Dec;48(12):2173-9.
Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection.
Patti R, Almasio PL, Muggeo VM, Buscemi S, Arcara M, Matranga S, Di Vita G.
Department of Surgery 1st Division, University of Palermo, Palermo, Italy.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

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Rom J Gastroenterol. 2005 Dec;14(4):361-6.
Novel approach to advanced hemorrhoidal disease.
Gupta PJ.
Gupta Nursing Home, D/9, Laxminagar, Nagpur - 440022, India. drpjg_ngp@sancharnet.in

BACKGROUND: There have been many attempts to find a less painful surgical method of treating hemorrhoids as against those available in standard surgical procedures. A novel technique of hemorrhoidal ablation by radiofrequency is described, which is followed by suture fixation of the hemorrhoidal mass. MATERIAL AND METHODS: This non-randomized, retrospective study describes the clinical outcome of the procedure performed in 1650 patients over a period of 5 years. An Ellman dual frequency radiofrequency generator was used for ablation of hemorrhoids. RESULTS: The operation time ranged between 6 to 8 minutes. Mean hospital stay was 9 hours. The immediate postoperative complication included retention of urine, wound infection and perianal thrombosis. The mean period of incapacity for work was 10 days. Late complications included development of anal tags, anal papillae and recurrence in 2% patients. There was no incidence of anal stricture or continence disorder. CONCLUSION: The procedure advocated by the author can be opted as an alternative to conventional surgical procedures. This day care procedure is simple to perform, allows the patients to return to normal activities in a short span of time with lesser pain and has fewer postoperative complications.

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Tech Coloproctol. 2005 Dec;9(3):209-15. Epub 2005 Nov 21.
Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience.
Rosa G, Lolli P, Piccinelli D, Vicenzi L, Ballarin A, Bonomo S, Mazzola F.
Department of Surgical and Gastroenterological Sciences, University of Verona, Italy, chirurgiabvr@libero.it.

BACKGROUND: Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks.METHODS: A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia.RESULTS: Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture.CONCLUSIONS: Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

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Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004649.
Laxatives for the treatment of hemorrhoids.
Alonso-Coello P, Guyatt G, Heels-Ansdell D, Johanson J, Lopez-Yarto M, Mills E, Zhou Q, Alonso-Coello P.

BACKGROUND: Symptomatic hemorrhoids are a common medical condition, which increase in prevalence in women during pregnancy and postpartum. Although the evidence appears to be inconclusive, narrative reviews and clinical practice guidelines recommend the use of laxatives (and fiber) for the treatment of hemorrhoids and relief of symptoms. This is due to their safety and low cost. OBJECTIVES: To evaluate the impact of laxatives on a wide range of symptoms in people with symptomatic hemorrhoids. SEARCH STRATEGY: Search strategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), BIOSIS, and AMED (Allied and Alternative Medicine Database), for eligible trials (including conference proceedings). We sought missing and additional information from authors, industry, and experts in the field. SELECTION CRITERIA: We selected all published and unpublished randomised controlled trials that compared any type of laxative to placebo or no therapy in any patient population. DATA COLLECTION AND ANALYSIS: Two authors independently screened studies for inclusion and retrieved all potentially relevant studies. Data were extracted from studies that met our selection criteria on study population, intervention used, pre-specified outcomes, and methodology. We extracted methodological information for the assessment of internal validity: existence and method of generation of the randomization schedule, and method of allocation concealment; blinding of caregivers and outcomes assessors; numbers of and reasons for participants lost to follow up; and use of validated outcome measures. MAIN RESULTS: Seven randomised trials enrolling a total of 378 participants to fiber or a non-fiber control were identified. Meta-analyses using random-effects models showed that laxatives in the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber group (risk reduction (RR) 0.47, 95% CI 0.32 to 0.68). These results are compatible with large treatment effects regarding prolapse, pain, itching, although the pooled analyses showed a tendency toward no-effect for these parametres. The effect on bleeding showed a significant difference in favour of the fiber (RR 0.50, 95% CI 0.28 to 0.89). Studies including data on multiple follow ups (usually after six weeks and three months) showed consistent results over time. However, we have to stress two possible limitations of this review: the risk of publication bias, and only moderate study quality. AUTHORS' CONCLUSIONS: The use of fiber shows a consistent beneficial effect for relieving overall symptoms and bleeding in the treatment of symptomatic hemorrhoids.

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Asian J Surg. 2005 Oct;28(4):241-5.
Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids.
Ramzisham AR, Sagap I, Nadeson S, Ali IM, Hasni MJ.
Department of Surgery, Hospital Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia. ramzisham@hotmail.com

OBJECTIVE: This prospective randomized clinical trial was undertaken to compare the use of a single-operator vacuum suction ligator and the traditional forceps ligator in terms of pain perception following the procedure, intra-procedure bleeding and other complications. METHODS: One hundred consecutive patients with second- and third-degree haemorrhoids presenting between July 2002 and September 2003 were randomized into suction and forceps groups for rubber band ligations. They were equally distributed in both groups, with a mean age of 48.7 years (range, 15-83 years). The immediate, 24-hour, 7-day and 14-day pain scores after the procedure were evaluated using a visual analogue scale. Intra-procedure bleeding and other complications at follow-up were evaluated. RESULTS: Pain perception was worse in the forceps group immediately after ligation, with a mean score of 6.08 compared with 3.08 in the suction group (p < 0.001). Pain score remained high among the forceps patients at 24 hours post-banding, with a mean score of 4.00 compared with 1.92 in the suction group (p < 0.001). There was no significant difference in terms of immediate and 24-hour pain perceptions whether two or three haemorrhoids were banded per session (p = 0.904 and p = 0.058). The amount of analgesia consumed after banding correlated well with the severity of pain reported, being higher among the forceps group with a mean of 4.48 tablets (p = 0.003). Intra-procedure bleeding occurred in 25 patients in the forceps group compared with five in the suction group (p < 0.001). There were no severe complications such as perianal sepsis, urinary retention, sphincter dysfunction or bleeding during the trial. CONCLUSION: Suction band ligation is superior to forceps ligation for the treatment of second- and third-degree haemorrhoids in terms of pain tolerance, amount of analgesia consumed and intra-procedure bleeding.

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Dis Colon Rectum. 2005 Oct;48(10):1913-6.
A randomized, prospective, double-blind, placebo-controlled trial of the effect of a calcium channel blocker ointment on pain after hemorrhoidectomy.
Silverman R, Bendick PJ, Wasvary HJ.
Division of Colon & Rectal Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA.

PURPOSE: Spasm of the internal sphincter plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery. We have evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. METHODS: After hemorrhoidectomy, 18 patients were randomly assigned to receive 2 percent diltiazem ointment (n = 9) or a placebo ointment (n = 9). Ointments were applied to the perianal region three times daily for seven days. Patients were prescribed hydrocodone bitartrate (Vicodin) to take as needed. The type and number of prescribed or nonprescribed medications taken during the postoperative period were recorded. Patients maintained a log to measure postoperative pain daily and perceived benefit of the ointment, using a Visual Analog Scale ranging from 0 to 10. Any postoperative morbidity noted during the follow-up period was recorded. RESULTS: Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week. Postoperative pain scores in the placebo group averaged 8.8 +/- 1.2 early and diminished to 5.2 +/- 1.7 at the end of one week, compared to the diltiazem group of 5.2 +/- 2.4 early and 2.3 +/- 1.2 at the end of one week (P < 0.001, both time periods). Perceived benefit in the placebo group averaged 2.7 +/- 1.2 vs. 5.6 +/- 1.4 in the diltiazem group (P < 0.001). Total and daily narcotic use was higher in the placebo group, but this was not statistically significant (P = 0.13). No differences in the frequency of use of nonsteroidal anti-inflammatory drugs and acetaminophen were seen between the two groups, and there were no differences in morbidity between the two groups. CONCLUSIONS: Perianal application of 2 percent diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity. Patients using a placebo ointment tend to take more prescription narcotics for pain relief postoperatively, with a similar usage of nonsteroidal anti-inflammatory drugs and acetaminophen, although differences were not significant.

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Rev Med Liege. 2005 Sep;60(9):695-9.
[Ambulatory treatment of hemorrhoids]
[Article in French]
Lombard R.
Service de Chirurgie, Clinique Saint Joseph, Liege.

DGHAL (Doppler Guided Hemorrhoid Arterial Ligation) represents a new approach to the treatment of internal hemorrhoids; it entails exact and selective ligation of the arteries supplying the piles (hemorrhoids). The intervention can be performed on ambulatory patients under local anaesthesia. An anoscope is used which incorporates a Doppler head. The superior hemorrhoidal arteries are identified under guidance of the arterial Doppler sound and ligated through a window located just above the Doppler head. The intervention lasts some 30 minutes. Local discomfort can ensue for a few days following surgery. At one month, the time required for the internal haemorrhoids to fade away, the patient is seen again; an external hemorrhoid or residual skintag can then be considered for treatment under local anaesthesia if needed. As of November 2001 until today, more than 350 patients have been treated, and we report here on 150 of them. Long term data (6 months to 2 years) have been collected which includes 85 to 90% patient satisfaction.

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Dis Colon Rectum. 2005 Sep 30; [Epub ahead of print]
Doppler-Guided Hemorrhoidal Artery Ligation: An Alternative to Hemorrhoidectomy.
Felice G, Privitera A, Ellul E, Klaumann M.
Department of General Surgery, St. Luke's Hospital, Gwardamangia, Malta, privitera@hotmail.com.

PURPOSE: Postoperative pain is the main adverse effect of formal hemorrhoidectomy. A new technique based on Doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy. The authors report a preliminary experience with this procedure. METHODS: The Doppler-guided hemorrhoidal artery ligation technique uses a special proctoscope bearing a Doppler transducer that allows identification and suture ligation of the hemorrhoidal arteries. Sixty-eight consecutive patients (mean age, 48 years; range, 21-74 years) with Grade 3 hemorrhoids were treated. RESULTS: Intraoperative discomfort was measured by a visual analog scale (1-10) and resulted in a mean score of 2.3 (range, 1.3-2.8). Only 38 percent of patients required postoperative analgesia. Patients were examined at 1 week, 1 month, and 3 months and every 6 months thereafter. The mean follow-up was 11 (range, 3-18) months. Bleeding resolved in 91 percent of patients, pain in 73 percent, and prolapse in 94 percent. Complications were recorded in five patients and included persistent pain for more than two days in two patients (3 percent), swelling and thrombosis of one of the hemorrhoids in two patients (3 percent), and a secondary hemorrhage in one patient (1.5 percent). CONCLUSION: Doppler-guided ligation of the hemorrhoidal artery is a safe and effective alternative to hemorrhoidectomy and is associated with minimal discomfort and low risk of complications.

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Arq Gastroenterol. 2005 Jul-Sep;42(3):191-4. Epub 2005 Sep 22.
Stapled hemorrhoidectomy: present status.
Lacerda-Filho A, Silva RG.
Department of Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, MG, Brazil. alacerda@ufmg.br

AIM: To evaluate cost-effectiveness of stapled hemorrhoidectomy comparing its results with conventional technique. SOURCE OF DATA: We retrospectively analyzed the MEDLINE data basis from 2000 to 2004 studying randomized clinical trials which compared pain intensity, recovery period, return to work and occurrence of anal incontinence, in addition to postoperative complications and costs evaluation between stapled and conventional hemorrhoidectomy during different periods of follow-up. CONCLUSIONS: Stapled hemorrhoidectomy provides lesser postoperative pain and earlier return to work than conventional hemorrhoidectomy. However, its efficacy could not be determined, since rigorous prospective and randomized clinical trials with long-term follow-up periods and large size samples are not available at this time.

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Digestion. 2005;72(2-3):181-8. Epub 2005 Sep 20.
Hemorrhoidal ablation and fixation: an alternative procedure for prolapsing hemorrhoids.
Gupta PJ.
Fine Morning Hospital and Research Center, Gupta Nursing Home, Nagpur, India. drpjg_ngp@sancharnet.in

BACKGROUND: Many new techniques have been evolved to curb the problem of post-operative pain after hemorrhoidectomy. Stapler hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation are the two methods gaining popularity amongst proctologists. The author proposes another technique called radiofrequency ablation and fixation of hemorrhoids to add to this list. PATIENTS AND METHODS: The surgical technique and clinical follow-up of 410 patients operated by this technique are presented. An Ellman radiofrequency generator was used for hemorrhoidal ablation at the output power intensity of 80. Post-defecation pain and pain at rest were assessed using a visual analogue scale. Patient satisfaction score was calculated at the mean follow-up of 60 months (range 48-72). The results in terms of mean hospital stay, post-operative pain, post-operative complications, and period of incapacity for work were compared with the published data of results of stapled hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation. RESULTS: Pain score at first evacuation was 6. The post-defecation pain score in the first week was 4 (range 3-6) and it was 3 (range 2-5) in the second week. The mean pain score at rest in the first week was 2 (range 1-4) and 1 (range 0-2) in the second post-operative week. In the long-term follow-up at a mean of 60 months, this procedure was found in most of the cases to control prolapse, discharge, and bleeding, with no stenosis or incontinence. The recurrence rate was less than 2%. The patient satisfaction score was high. CONCLUSION: The results of this technique of radiofrequency ablation and fixation of hemorrhoids hold positive promises in terms of less post-operative pain, early discharge from the hospital and faster return to work. The results are comparable to stapled hemorrhoidopexy and are better than Doppler-guided hemorrhoidal artery ligation in terms of effectiveness and symptomatic relief on a long-term basis. Copyright (c) 2005 S. Karger AG, Basel.

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Digestion. 2005 Sep 20;72(2-3):181-188 [Epub ahead of print]
Hemorrhoidal Ablation and Fixation: An Alternative Procedure for Prolapsing Hemorrhoids.
Gupta PJ.
Fine Morning Hospital and Research Center, Gupta Nursing Home, Nagpur, India.

Background: Many new techniques have been evolved to curb the problem of post-operative pain after hemorrhoidectomy. Stapler hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation are the two methods gaining popularity amongst proctologists. The author proposes another technique called radiofrequency ablation and fixation of hemorrhoids to add to this list. Patients and Methods: The surgical technique and clinical follow-up of 410 patients operated by this technique are presented. An Ellman radiofrequency generator was used for hemorrhoidal ablation at the output power intensity of 80. Post-defecation pain and pain at rest were assessed using a visual analogue scale. Patient satisfaction score was calculated at the mean follow-up of 60 months (range 48-72). The results in terms of mean hospital stay, post-operative pain, post-operative complications, and period of incapacity for work were compared with the published data of results of stapled hemorrhoidopexy and Doppler-guided hemorrhoidal artery ligation. Results: Pain score at first evacuation was 6. The post-defecation pain score in the first week was 4 (range 3-6) and it was 3 (range 2-5) in the second week. The mean pain score at rest in the first week was 2 (range 1-4) and 1 (range 0-2) in the second post-operative week. In the long-term follow-up at a mean of 60 months, this procedure was found in most of the cases to control prolapse, discharge, and bleeding, with no stenosis or incontinence. The recurrence rate was less than 2%. The patient satisfaction score was high. Conclusion: The results of this technique of radiofrequency ablation and fixation of hemorrhoids hold positive promises in terms of less post-operative pain, early discharge from the hospital and faster return to work. The results are comparable to stapled hemorrhoidopexy and are better than Doppler-guided hemorrhoidal artery ligation in terms of effectiveness and symptomatic relief on a long-term basis. Copyright (c) 2005 S. Karger AG, Basel.

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Dis Colon Rectum. 2005 Aug;48(8):1517-22.
Prospective, randomized study: proximate PPH stapler vs. LigaSure for hemorrhoidal surgery.
Kraemer M, Parulava T, Roblick M, Duschka L, Muller-Lobeck H.
Department of General Surgery/Coloproctology, St. Barbara-Klinik, Hamm-Heessen, Germany. mkraemer@barbaraklinik.de

PURPOSE: It has been shown that for hemorrhoidal surgery both LigaSure and stapler cause less pain than diathermy or scissor dissection. This study has attempted to establish which of the less painful alternatives proves best in an unselected series of patients with hemorrhoidal disease. METHODS: Fifty patients were randomized to undergo stapling hemorrhoidopexy or LigaSure hemorrhoidectomy. Parameters investigated were pain (primary parameter), patient satisfaction with treatment, and recovery of personal activity. Other factors investigated were operative result, ease of handling, analgesic requirements, and postoperative course. RESULTS: Both methods were found to be equivalent in all major aspects analyzed. Postoperative pain scores (P = 0.99), patient satisfaction (P = 1), and self-assessment of activity (P = 0.99) were almost identical in both groups of patients. Significant differences were found in none of the numerous factors investigated. CONCLUSION: Both methods can be used safely and without major disadvantage for the patient regardless of stage and extent of hemorrhoidal disease.

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Dis Colon Rectum. 2005 Aug;48(8):1523-7.
Ferguson hemorrhoidectomy: long-term results and patient satisfaction after Ferguson's hemorrhoidectomy.
Guenin MO, Rosenthal R, Kern B, Peterli R, von Flue M, Ackermann C.
Department of Surgery, St. Claraspital, Basel, Switzerland. marc.guenin@claraspital.ch

PURPOSE: Perioperative morbidity and long-term results after hemorrhoidectomy (Ferguson's technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy. METHODS: All records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients. RESULTS: Five-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22-96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1-7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases. CONCLUSION: Ferguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

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Wien Klin Wochenschr. 2005 Aug;117(15-16):558-60.
[Flavonoids to reduce bleeding and pain after stapled hemorrhoidopexy: a randomized controlled trial.]
[Article in German]
Mlakar B, Kosorok P.
Medical centre IATROS, Ljubljana, Slovenia, mlakarbostjan@yahoo.com.

INTRODUCTION: Control of postoperative symptoms is of paramount importance in ambulatory surgery. This trial was conducted to evaluate whether a micronized purified flavonoid fraction (MPFF) (Detralex((R))) reduces postoperative bleeding, pain and consumption of analgesics after ambulatory stapled hemorrhoidopexy, as reported in trials after classic hemorrhoidectomy. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of this drug have been reported in several studies. METHODS: Sixty-three patients with third-degree hemorrhoids had ambulatory stapled hemorrhoidopexy under spinal anesthesia in the period of one year. The patients were randomized, with 30 receiving Detralex 500 mg (2 tablets 3 times daily for 5 days after the operation) and 33 forming the control group. The patients were asked to daily self-assess the presence of blood on defecation, degree of pain and consumption of analgesics for the first week after the operation. RESULTS: There was no significant difference between the two groups in duration of presence of blood, degree of pain or analgesics requirement. No major complications, such as bleeding requiring transfusion or hospitalization, sepsis, anal stenosis or urgent defecation, were noted in the follow-up period. There were no side effects from Detralex treatment. DISCUSSION: In our study we could not demonstrate any positive effect of prescribing flavonoids after stapler hemorrhoidopexy. This procedure may not be sufficiently aggressive and is associated with too few postoperative complications to show any protective influence of flavonoids.

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Chir Ital. 2005 Jul-Aug;57(4):439-47.
[Long stapled haemorrhoidectomy versus Milligan-Morgan procedure: short- and long-term results of a randomised, controlled, prospective trial]
[Article in Italian]
Ascanelli S, Gregorio C, Tonini G, Baccarini M, Azzena G.
Sezione di Clinica Chirurgica, Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche, Universita degli Studi di Ferrara.

The aim of this study was to assess the short- and long-term results of treatment for haemorrhoids by prospectively comparing two techniques, namely, stapled rectal prolapse mucosectomy according to Longo and open hemorrhoidectomy. One hundred consecutive patients were randomised to stapled (50 patients) or manual hemorrhoidectomy (50 patients). We analysed postoperative pain, preoperative and postoperative anorectal function, intraoperative and postoperative complications, time needed to return to work and to normal social activities, and costs. Long-term follow data were obtained by means of an outpatient visit. The operative time of the stapled technique was less than that of open haemorrhoidectomy (22 vs 35 minutes). Two cases of early postoperative bleeding occurred after the stapled technique. The mean pain score on a visual scale was significantly less in patients undergoing the stapled technique. In addition, the time needed to return to work and to normal social activities was significantly less after the stapled technique, which, however, proved to be a more expensive procedure. Stapled mucosectomy of the prolapsed rectal mucosa is a safe, rapid, and relatively painless technique, which has a low incidence of complications. It can be performed in a day surgery unit. Patient satisfaction, early return to normal activities and good long-term results counterbalance the high cost of the procedure.

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Drugs. 2005;65(11):1481-91.
Drug treatment of haemorrhoids.
Misra MC, Imlitemsu.
Department of Surgery, All India Institute of Medical Sciences, New Delhi, India. kkcorporation@mac.com

Drug treatment for various anorectal conditions has been known since ancient times. Today, modern as well as traditional drugs are being increasingly used in all grades of symptomatic haemorrhoids. These drugs (oral and local) are used as a part of conservative management or as an adjuvant to invasive outpatient procedures. Flavonoids, in the new formulation of micronised purified flavonoid fraction (MPFF) or as part of the ancient traditional medicine derivative of the Ginkgo tree, are used for relief of acute symptoms (for control of bleeding and re-bleeding in all grades of haemorrhoids). MPFF has been recommended for control of acute bleeding in patients waiting for a definitive outpatient treatment. Similarly, better known drugs such as calcium dobisilate (used in diabetic retinopathy and chronic venous insufficiency), nitrates and nifedipine have also been effective and well tolerated in the medical treatment of haemorrhoids. However, drug treatment is not aimed at curing haemorrhoids. The prime objective of drug therapy is to control the acute phase (bleeding) so that definitive therapy (banding, injection sclerotherapy, infrared photocoagulation, cryotherapy or surgery) can be scheduled at a convenient time.

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Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005034.
Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids.
Shanmugam V, Thaha M, Rabindranath K, Campbell K, Steele R, Loudon M.
General / Colorectal surgery, Aberdeen Royal Infirmary / Aberdeen University, Ward 50, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Grampian, UK, AB25 2ZN.

BACKGROUND: Traditional treatment methods for haemorrhoids fall into two broad groups: less invasive techniques including rubber band ligation (RBL), which tend to produce minimal pain, and the more radical techniques like excisional haemorrhoidectomy (EH), which are inherently more painful. For decades, innovations in the field of haemorrhoidal treatment have centred on modifying the traditional methods to achieve a minimally invasive, less painful procedure and yet with a more sustainable result. The availability of newer techniques has reopened debate on the roles of traditional treatment options for haemorrhoids. OBJECTIVES: To review the efficacy and safety of the two most popular conventional methods of haemorrhoidal treatment, rubber band ligation and excisional haemorrhoidectomy. SEARCH STRATEGY: We searched all the major electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL). SELECTION CRITERIA: Randomised controlled trials comparing rubber band ligation with excisional haemorrhoidectomy for symptomatic haemorrhoids in adult human patients were included. DATA COLLECTION AND ANALYSIS: We extracted data on to previously designed data extraction sheet. Dichtomous data were presented as relative risk and 95% confidence intervals, and continuous outcomes as weighted mean difference and 95% confidence intervals. MAIN RESULTS: Three trials (of poor methodological quality) met the inclusion criteria. Complete remission of haemorrhoidal symptom was better with EH (three studies, 202 patients, RR 1.68, 95% CI 1.00 to 2.83). There was significant heterogeneity between the studies (I2 = 90.5%; P = 0.0001). Similar analysis based on the grading of haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04 to 1.45; P = 0.01). However, no significant difference was noticed in grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94 to 1.21; P = 0.32) Fewer patients required re-treatment after EH (three trials, RR 0.20 CI 0.09 to 0.40; P < 0.00001). Patients undergoing EH were at significantly higher risk of postoperative pain (three trials, fixed effect; 212 patients, RR 1.94, 95% CI 1.62 to 2.33, P < 0.00001). The overall delayed complication rate showed significant difference (P = 0.03) (three trials, 204 patients, RR 6.32, CI 1.15 to 34.89) between the two interventions. AUTHORS' CONCLUSIONS: The present systematic review confirms the long-term efficacy of EH, at least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the expense of increased pain, higher complications and more time off work. However, despite these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment modalities seems to be similar following both the techniques implying patient's preference for complete long-term cure of symptoms and possibly less concern for minor complications. So, RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results but with out the side effects of EH while reserving EH for grade III haemorrhoids or recurrence after RBL. More robust study is required to make definitive conclusions.

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Cochrane Database Syst Rev. 2005 Jul 20;(3):CD004077.
Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium.
Quijano C, Abalos E.
Centro Rosarino de Estudios Perinatales, Pueyrredon 985, Rosario, ARGENTINA, 2000.

BACKGROUND: Haemorrhoids (piles) are swollen veins at or near the anus, normally asymptomatic. They do not constitute a disease, unless they become symptomatic. Pregnancy and the puerperium predispose to symptomatic haemorrhoids, being the most common ano-rectal disease at these stages. Symptoms are usually mild and transient and include intermittent bleeding from the anus and pain. Depending on the degree of pain, quality of life could be affected, varying from mild discomfort to real difficulty in dealing with the activities of everyday life. Treatment during pregnancy is mainly directed to the relief of symptoms, especially pain control. The so-called conservative management includes dietary modifications, stimulants or depressants of the bowel transit, local treatment, and phlebotonics (drugs that cause decreased capillary fragility, improving the microcirculation in venous insufficiency). For many women, symptoms will resolve spontaneously soon after birth, and so any corrective treatment is usually deferred to some time after birth. Thus, the objective of this review is to evaluate the efficacy of conservative management of piles during pregnancy and the puerperium. OBJECTIVES: To determine the possible benefits, risks and side-effects of the conservative management of symptomatic haemorrhoids during pregnancy and the puerperium. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 June 2004). SELECTION CRITERIA: Randomised-controlled trials comparing any of the conservative treatments for symptomatic haemorrhoids during pregnancy and the puerperium (such as dietary modifications, stimulant/depressant of the bowel transit, local treatments, drugs that improve the microcirculation in venous insufficiency) with a placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently performed a methodological assessment for deciding which studies to include/exclude from the review and extracted data. MAIN RESULTS: From 10 potentially eligible studies, two were included in this review (150 women). Both compared oral rutosides against placebo. Rutosides seem to be effective in reducing the signs identified by the healthcare provider, and symptoms and signs reported by women, of haemorrhoidal disease. For the outcome no response to treatment: relative risk 0.07, 95% confidence interval 0.03 to 0.20. Regarding perinatal outcomes, one fetal death and one congenital malformation (possible not related to exposure) were reported in the control and treatment group respectively. AUTHORS' CONCLUSIONS: Although the treatment with oral hydroxyethylrutosides looks promising for symptom relief in first and second degree haemorrhoids, its use cannot be recommended until new evidence reassures women and their clinicians about their safety. The most commonly used approaches, such as dietary modifications and local treatments, were not properly evaluated during pregnancy and the puerperium.

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Zhonghua Wei Chang Wai Ke Za Zhi. 2005 Jul;8(4):325-7.
[Effect of diode laser coagulation treatment on grade III internal hemorrhoids.]
[Article in Chinese]
Wang D, Zhong KL, Chen JL, Wang XX, Pan K, Xia LG, Chen XC, Yang XD.
Department of Gastroenterology,The Second Affiliated Hospital,Medical School of Jinan University,Shenzhen Peoples Hospital,Shenzhen 518020,China. wangdong_szph@hotmail.com.

OBJECTIVE: To evaluate the curative effects of diode laser coagulation on grade III( internal hemorrhoids. METHODS:aForm March 2004 to December 2004,86 patients with grade III( internal hemorrhoids were divided into two groups,received laser coagulation (laser group,n=46) or received hemorrhoidectomy (control group,n=40). Complications,symptom relief,pain scores and satisfaction scores were compared between the two groups six months after operation. RESULTS:aPain scores were lower in laser group than that of the control group on the first day and seventh day after operation. Small amount of bleeding occurred in the laser group (12 cases) and control group (35 cases), however, non of them required special hemostasis. Laser coagulation and closed hemorrhoidectomy were equally effective in controlling symptomatic prolapse. There was no difference in terms of continence scores and patients satisfaction between the two groups (P> 0.05). CONCLUSIONS:aDiode laser coagulation can be considered as a safe and effective procedure for the treatment of grade III( hemorrhoids.

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Clin Ther. 2005 Jun;27(6):746-54.
Prospective, randomized, controlled, observer-blinded trial of combined infrared photocoagulation and micronized purified flavonoid fraction versus each alone for the treatment of hemorrhoidal disease.
Dimitroulopoulos D, Tsamakidis K, Xinopoulos D, Karaitianos I, Fotopoulou A, Paraskevas E.
Gastroenterology Unit, Saint Savvas Hospital, Athens, Greece. dimdim@otenet.gr

BACKGROUND: Infrared photocoagulation (IRP) is commonly used in the treatment of hemorrhoids, but rectal bleeding can persist after this procedure. Adjuvant therapy may thus be considered for more definitive control of symptoms, particularly bleeding. OBJECTIVE: The goal of this study was to compare the efficacy of a treatment combining IRP and oral micronized purified flavonoid fraction (MPFF) versus each treatment used alone on bleeding cessation in patients with grades I, II, and III acute internal hemorrhoids. METHODS: This was a prospective, randomized, controlled, single-blind study. Consecutive outpatients were randomly assigned to a treatment combining MPFF and IRP or to each treatment separately. For each patient, bleeding status was reported at day 0 (day of inclusion) and compared with that at day 5 after treatment by observers blinded to treatment assignment. Follow-up visits were planned at days 7, 30, 60, and 90 of therapy, including monitoring of treatment-related side effects and self-reporting by patients of any problem related to hemorrhoidal disease. RESULTS: A total of 351 patients (180 women, 171 men) were enrolled in the study. Their mean age was 49.2 years (range, 29-71 years). Hemorrhoids were grade I in 33.6% (118 patients), grade II in 48.7% (171 patients), and grade III in 17.7% (62 patients) of the study population. Patients were randomly assigned to each of the 3 treatment groups (117 patients in each), with no significant difference between groups in the age, sex, or distribution of grade of hemorrhoids. The percentage of patients with no bleeding after 5 days of treatment was higher in the combined treatment group (74.8%) compared with MPFF alone (59.6%; P = 0.023) or with IRP alone (55.6%; P = 0.004). MPFF alone was as effective as IRP alone at stopping bleeding. Patients with grades I and II hemorrhoids responded significantly better (82.5% and 61.7%, respectively) to either treatment than those with grade III hemorrhoids (22.9%; P < 0.001). Of the 216 patients who were followed up for 90 days, 3 had a gastrointestinal adverse event, and 19 had a relapse of bleeding. CONCLUSION: Five days of treatment combining MPFF with IRP significantly reduced bleeding status in these study patients with grades I and II acute internal hemorrhoids compared with each treatment used alone.

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J Surg Res. 2005 Jun 1;126(1):66-72.
Radiofrequency ablation and plication: a non-resectional therapy for advanced hemorrhoids.
Gupta PJ.
Gupta Nursing Home, Laxminagar, Nagpur, India.

BACKGROUND: Radio frequency ablation followed by plication of the hemorrhoidal mass for patients who would otherwise require hemorrhoidectomy is being practiced at our hospital since last 5 years. This procedure accomplishes hemorrhoidal symptom relief with far less post-operative pain and other complications as compared to various other types of hemorrhoidectomies. MATERIALS AND METHODS: A retrospective study of 1000 patients having grade III or grade IV hemorrhoids treated with the above technique over a period of 30 months is reported. A Ellman radiofrequency generator was used for ablation of the hemorrhoids. Follow-up record of these patients is presented. The post-operative outcome and procedure related complications are compared with conventional hemorrhoidectomy procedures. RESULTS: With this procedure, the post-defecation pain score reported was between 1 and 4 (VAS) in the first week, which subsided thereafter. There were 42% patients who had post-defecation bleeding in the first 10 days. There were 82% patients able to resume duties on the 6th post-operative day. Of these, 5% of the patients had post-operative urinary retention needing catheterization for a single time, and 18 patients required readmission for secondary bleeding. None of the patients complained of fecal incontinence, sepsis, or anal stenosis. In the subsequent follow-up at a mean of 19 months, 4% of the patients had residual skin tags, 3% of them had symptomatic anal papillae, and 2% developed recurrence of hemorrhoids. CONCLUSION: The combined procedure described above could be a feasible alternative for surgical treatment of hemorrhoids being quick and easy to perform. With this procedure, the hospital stay is short, post-operative pain is less, return to work is faster, and recurrence rate is low.

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Dis Colon Rectum. 2005 May 31; [Epub ahead of print]
Ferguson Hemorrhoidectomy: Long-Term Results and Patient Satisfaction After Ferguson's Hemorrhoidectomy.
Guenin MO, Rosenthal R, Kern B, Peterli R, von Flue M, Ackermann C.
Department of Surgery, St. Claraspital, Basel, Switzerland, marc.guenin@claraspital.ch.

PURPOSE: Perioperative morbidity and long-term results after hemorrhoidectomy (Ferguson's technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy. METHODS: All records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients. RESULTS: Five-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22-96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1-7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases. CONCLUSION: Ferguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

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Int J Colorectal Dis. 2005 Apr 21; [Epub ahead of print]
Sclerosing therapy of internal hemorrhoids with a novel sclerosing agent Comparison with ligation and excision.
Takano M, Iwadare J, Ohba H, Takamura H, Masuda Y, Matsuo K, Kanai T, Ieda H, Hattori Y, Kurata S, Koganezawa S, Hamano K, Tsuchiya S.
Coloproctology Center, Takano Hospital, 4-2-88 Obiyama, Kumamoto, 862-0924, Japan, m-takano@ku.magma.ne.jp.

BACKGROUND AND AIMS: Patients with prolapsing internal hemorrhoids were treated with a novel sclerosing agent (OC-108), and the results were compared with surgery of ligation and excision. PATIENTS AND METHODS: This study included 20 years or older patients with prolapsing internal hemorrhoids who visited ten medical institutions in Japan from October 2000 to October 2002. Investigation on surgery was also performed. RESULTS: Comparing OC-108 and surgery in patients with third- and fourth-degree internal hemorrhoids according to the Goligher's classification, for which surgery has been generally indicated, at 28 days after treatment, the disappearance rate of prolapse was similar between OC-108 and surgery, 94% (75/80 patients) and 99% (84/85 patients), respectively. The 1-year recurrence rate was 16% (12/73 patients) in the OC-108 group, and this value was satisfactory because of its less invasive nature while it was more or less higher compared with 2% (2/81 patients) in the surgery group. The incidences of pain and bleeding were lower in the OC-108 group. CONCLUSIONS: OC-108 is a useful alternative treatment for hemorrhoids.

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ANZ J Surg. 2005 Apr;75(4):184-6.
Ambulatory circular stapled haemorrhoidectomy under local anaesthesia versus circular stapled haemorrhoidectomy under regional anaesthesia.
Ong CH, Chee Boon Foo E, Keng V.
Department of Surgery, Alexandra Hospital, Singapore.

BACKGROUND: The usage of circular stapled haemorrhoidectomy (CSH) has increased dramatically in recent years. Hitherto this has been performed using regional or general anaesthesia. The present study assesses the feasibility of performing CSH under local anaesthesia on an ambulatory basis and its acceptance by patients. METHODS: Sixty patients with symptomatic third or fourth degree haemorrhoids were randomized into two groups. Group A patients had CSH under regional anaesthesia (i.e spinal anaesthesia) and were discharged the next day and group B patients had CSH under local anaesthesia and were discharged on the same admission day. Both groups were assessed by visual analogue pain score. In addition, group B patients were asked questions regarding their satisfaction with the procedure. RESULTS: No significant differences in pain score and analgesic requirement were found between the two groups of patients. All patients in group B except for one, reported that they were satisfied to highly satisfied with their procedure. CONCLUSIONS: Circular stapled haemorrhoidectomy can be performed safely under local anaesthesia in an ambulatory care setting. The potential cost savings that may accrue would offset the cost of the stapler.

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Dis Colon Rectum. 2005 Apr;48(4):809-15.
Stapled hemorrhoidopexy vs. diathermy excision for fourth-degree hemorrhoids: a randomized, clinical trial and review of the literature.
Ortiz H, Marzo J, Armendariz P, De Miguel M.
Unit of Coloproctology, Department of Surgery, Hospital Virgen del Camino, Pamplona, Navarra, Spain.

PURPOSE: The aim of this prospective study was to compare the results of stapled hemorrhoidopexy with those of conventional diathermy excision for controlling symptoms in patients with fourth-degree hemorrhoids. METHODS: Thirty-one patients with symptomatic, prolapsed irreducible piles were randomized to either stapled hemorrhoidopexy (n = 15) or diathermy excision (n = 16). The primary outcome measure was the control of hemorrhoidal symptoms one year after operation. RESULTS: The two procedures were comparable in terms of pain relief and disappearance of bleeding. Recurrent prolapse starting from the fourth month after operation was confirmed in 8 of 15 patients in the stapled group and in none in the diathermy excision group: two-tailed Fisher's exact test P = 0.002, RR 0.33, 95 percent confidence interval 0.19-0.59). Five of these patients responded well to a later conventional diathermy hemorrhoidectomy. Persistence of itching was reported in six patients in the stapled group and in one of the diathermy excision group (P = 0.03). On the other hand, six patients in the stapled group and none in the diathermy excision group experienced tenesmus (P = 0.007). CONCLUSIONS: Stapled hemorrhoidopexy was not effective as a definitive cure for the symptoms of prolapse and itching in patients with fourth-degree hemorrhoids. Moreover, stapled hemorrhoidopexy induced the appearance of a new symptom, tenesmus, in 40 percent of the patients. Therefore conventional diathermy hemorrhoidectomy should continue to be recommended in patients with symptomatic, prolapsed, irreducible piles.

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Rom J Gastroenterol. 2005 Mar;14(1):37-41.
Ambulatory hemorrhoid therapy with radiofrequency coagulation. Clinical practice paper.
Gupta PJ.
Gupta Nursing Home, D/9 Laxminagar, Nagpur-44022, India. drpjg_ngp@sancharnet.in

BACKGROUND: Despite availability of numerous surgical and non-surgical options for the treatment of hemorrhoids like sclerotherapy, rubber band ligation, cryosurgery, infrared photocoagulation, bipolar diathermy, and electro coagulation, none of these therapies has been acclaimed as the ultimate. Coagulation of hemorrhoids using a radio-frequency device is a new therapy to be added to the list. PATIENTS AND METHODS: In the present retrospective study, the early and long -term effects of radiofrequency coagulation on patients presenting with hemorrhoids is described. An Ellman radiofrequency generator was used for this procedure. In a separate, randomized, and blinded study, a comparative evaluation was carried out between radiofrequency coagulation and rubber band ligation in terms of their effectiveness and patient comfort. RESULTS: Two hundred and forty patients with Grade I and II hemorrhoids were treated by radiofrequency coagulation technique and were followed up for a period of 16 months. While 33 patients reported persistence or recurrence of bleeding, only few complained of pain or discomfort. The comparative study showed that though rubber band ligation is an effective procedure, its pain quotient is greater than the radiofrequency coagulation. CONCLUSION: This study shows that radiofrequency coagulation is an easy and effective alternative to conventional techniques employed in the treatment of bleeding hemorrhoids. It is easy to perform, is less painful, and has a low rate of complications. However, further results based on a longer follow-up of larger number of patients and its comparison with other conventional treatment techniques are called for.

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Dis Colon Rectum. 2005 Mar 24; [Epub ahead of print]
Stapled Hemorrhoidopexy vs. Harmonic Scalpeltrade mark Hemorrhoidectomy: A Randomized Trial.
Chung CC, Cheung HY, Chan ES, Kwok SY, Li MK.
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China, kwok_shek_yuen@hotmail.com.

PURPOSE: A randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpeltrade mark was used. METHODS: Patients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpeltrade mark hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions. RESULTS: Over a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpeltrade mark (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpeltrade mark hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001). CONCLUSION: Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

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Chir Ital. 2005 Jan-Feb;57(1):77-85.
[Efficacy of topical use of 0.2% glyceryl trinitrate in reducing post-haemorrhoidectomy pain and improving wound healing]
[Article in Italian]
Patti R, Arcara M, Padronaggio D, Bonventre S, Angileri M, Salerno R, Romano P, Buscemi S, Di Vita G.
Cattedra di Chirurgia Generale, Dipartimento di Discipline Chirurgiche ed Oncologiche, Universita degli Studi di Palermo.

The aim of the study was to evaluate whether topical application of 0.2% glyceryl trinitrate ointment could reduce post-haemorrhoidectomy healing time and pain both at rest and during defecation. Thirty patients with grade III and IV haemorrhoids were included in the study and divided into two groups. All patients underwent Milligan-Morgan haemorrhoidectomy, and anorectal manometry was performed before surgery and after 5 and 30 days. In one group a placebo ointment was applied to the perianal wounds, while in the other group a 0.2% glyceryl trinitrate ointment was used. Maximum resting pressure was reduced in the glyceryl trinitrate group and increased in the placebo group after 5 days. Postoperative pain both at rest and during defecation, and the time to healing and return to normal activity were significantly reduced in the glyceryl trinitrate group, whilst analgesic consumption was similar. An elevated incidence of headache was observed In the glyceryl trinitrate group. Topical application of glyceryl trinitrate was effective in reducing postoperative pain and healing time, but the substantial incidence of side effects may limit its extensive use.

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World J Surg. 2005 Mar 22; [Epub ahead of print]
Usefulness of Lateral Internal Sphincterotomy in Reducing Postoperative Pain after Open Hemorrhoidectomy.
Kanellos I, Zacharakis E, Christoforidis E, Angelopoulos S, Kanellos D, Pramateftakis MG, Betsis D.
Fourth Surgical Department, Aristotle University of Thessaloniki, 'G. Papanikolaou' General Regional Hospital, 57010, Exohi, Thessaloniki, Greece, ik@hol.gr.

The aim of the present study was to evaluate the effect of lateral internal sphincterotomy on pain after open hemorrhoidectomy. From 1998 to 2003, seventy-eight (78) patients with fourth-degree hemorrhoids were included in this prospective randomized trial. The patients were randomized into two equal groups of 39 patients. Patients from group I underwent Milligan-Morgan hemorrhoidectomy. Patients from group II, quite apart from Milligan-Morgan hemorrhoidectomy, underwent lateral internal sphincterotomy up to the dentate line, in the left hemorrhoidectomy wound. One surgeon from the Department, who did not know to which group the patients belonged, evaluated the postoperative course in all the patients. After the first bowel movement, there were three (7.7%) patients who did not experience any pain in the internal sphincterotomy group, while in the non-internal sphincterotomy group all patients experienced mild or moderate pain. There were also more patients who experienced excruciating pain in the non-internal sphincterotomy group than in the internal sphincterotomy group (25 vs. 18); these differences were statistically significant (p = 0.034). There was no significant difference in the Wexner Incontinence Scale between the groups (p = 0.228). The addition of lateral internal sphincterotomy to open hemorrhoidectomy seems to have a positive effect on reducing postoperative pain in a few patients, without affecting the postoperative complications rate.

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Am J Surg. 2005 Jan;189(1):56-60.
Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy.
Bikhchandani J, Agarwal PN, Kant R, Malik VK.
Department of Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, AG-I/9C, Vikaspuri, New Delhi 110018, India. jai_9c@rediffmail.com

BACKGROUND: The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy. METHODS: After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction. RESULTS: The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group (P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) (P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2-19 months). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.

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Dis Colon Rectum. 2005 Jan;48(1):108-13.
Open vs. closed hemorrhoidectomy.
You SY, Kim SH, Chung CS, Lee DK.
Department of Colon and Rectal Surgery, Hang Clinic Gangnam, Seoul, Korea. seongyou@hotmail.com

PURPOSE: This prospective, randomized, clinical trial compared the outcome of surgical hemorrhoidectomy by open and closed techniques in terms of postoperative pain, wound healing, and morbidity. METHODS: All consecutive patients with Grade III internal hemorrhoids with prominent external components or Grade IV hemorrhoids were randomly allocated to one of two groups. The entire wound was left open in the open group and completely closed using 5-0 chromic sutures in the closed group. Postoperative pain was assessed by a linear analog scale. Additional consumption of oxycodone hydrochloride on the day of surgery and at defecation during the first week was recorded. Patients were followed up 1, 2, and 3 weeks after the procedure. RESULTS: There were 40 patients in each group. Pain score at recovery from the anesthesia was significantly lower in the closed group (P < 0.05). Altogether, 15 percent of patients in the closed group required additional oxycodone hydrochloride for pain compared to 45 percent in the open group (P < 0.01). The pain score at the first bowel movement was significantly lower in the closed group (P < 0.01). Wound healing was significantly faster in the closed group: 75 percent of patients in the closed group had healed at 3 weeks after the procedure compared to 18 percent in the open group (P < 0.001). CONCLUSIONS: The closed technique is more advantageous with respect to less pain during the early postoperative period and faster wound healing.

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Surgeon. 2004 Dec;2(6):335-8, 361.
Daflon for haemorrhoids: a prospective, multi-centre observational study.
Meshikhes AW.
Department of Surgery, Dammam Central Hospital, Dammam, Eastern Province, Saudi Arabia. meshikhes@doctor.com

BACKGROUND: Daflon, a phlebotropic agent, is of proven efficacy in the treatment of various venous disorders. Although it has been tried in the treatment of haemorrhoids, its efficacy in alleviating various haemorrhoidal symptoms has not been assessed properly. The aim of this study was to confirm the efficacy of Daflon in the treatment of haemorrhoidal symptoms. METHODS: Two hundred and sixty eight patients presenting with haemorrhoidal symptoms were recruited. This was a multicentre non-randomised observational study with no placebo arm. After establishing the extent of their symptoms and determining the position, size and degree of haemorrhoids by proctoscopy, all patients were started on Daflon, four tablets per day, in two divided doses for four weeks. Patients were seen weekly during the study period and carefully questioned as regard to symptoms, and a proctoscopy was carried out. RESULTS: There was a statistically significant improvement (p<0.001) in all haemorrhoidal symptoms (pain, heaviness, bleeding, pruritus and anal discharge) and in the proctoscopic appearance of the 'piles,' comparing baseline visit findings with the last visit four weeks after treatment with Daflon. CONCLUSIONS: Daflon has been shown to be effective in alleviating (variable degree) haemorrhoidal symptoms and improving the proctoscopic appearance of haemorrhoids. Therefore, it should be considered initially for patients presenting with haemorrhoidal symptoms. However, prospective randomised trials and longer follow-up are needed to confirm the findings of this study and delineate more precisely the role of Daflon in the management of haemorrhoidal disease

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Surg Innov. 2004 Dec;11(4):241-52.
Novel technology and innovations in colorectal surgery: the circular stapler for treatment of hemorrhoids and fibrin glue for treatment of perianal fistulae.
Person B, Wexner SD.
The Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.

The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called "stapled hemorrhoidectomy" has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.

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Acta Chir Iugosl. 2004;51(2):77-9.
Should we treat hemorrhoids according to the stage.
Pfeifer J.
Medical University Graz, Austria.

Hemorrhoidal disease is a very common and widespread disease, and it is estimated that about one subject out of three may suffer from this pathology. Hemorrhoids generally cause symptoms when enlarged, inflamed, thrombosed, or prolapsed. Internal hemorrhoids arise above the dentate line (in comparison to external hemorrhoids perianal phlebothrombosis) and are covered by transitional or columnar epithelium. Scleotherapy is one of the oldest therapy forms mainly for bleeding hemorrhoids. The so called Barron ligature is an office procedure in which a small rubber band is placed at the base of the internal hemorrhoid with a special applicator.

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Tech Coloproctol. 2004 Nov;8(3):163-8.
A comparative study between radiofrequency ablation with plication and Milligan-Morgan hemorrhoidectomy for grade III hemorrhoids.
Gupta PJ.
Fine Morning Hospital and Research Center, Gupta Nursing Home, Laxminagar, Nagpur, India. drpjg@yahoo.co.in

BACKGROUND: Milligan-Morgan (MM) hemorrhoidectomy is the most favored treatment for prolapsed hemorrhoids. However, it may be associated with severe postoperative pain, long periods of convalescence and other complications. In alternative, I use a procedure of radiofrequency ablation and plication (RAP) of hemorrhoids. The present study compared the two procedures in terms of surgical parameters, postoperative pain and complications. PATIENTS AND METHODS: A total of 60 patients with grade III hemorrhoids were randomized to undergo radiofrequency ablation and plication (31 patients) or MM hemorrhoidectomy (29 patients). The patients were followed up to 2 years. RESULTS: Duration of surgery was significantly longer in the MM group as was postoperative hospitalization (p<0.05). Post-defecation pain and pain at rest were much less in the RAP group (p<0.05). Wound healing period (17 vs. 38 days) and time to return to work (7 vs. 17 days) were the other significant findings favoring RAP procedure. Early complications occurred more frequently in MM group, but late complications like external skin tags (4 vs. 2 patients) were more common in RAP group. One asymptomatic recurrence was noted in RAP group. CONCLUSIONS: Radiofrequency ablation and plication of hemorrhoids is associated with significantly less postoperative pain, shorter hospital stay and earlier return to normal activity. It can be considered as an alternative to the Milligan-Morgan hemorrhoidectomy.

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Dis Colon Rectum. 2004 Nov;47(11):1837-45.
Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials.
Nisar PJ, Acheson AG, Neal KR, Scholefield JH.
Section of Surgery, University Hospital, Queen's Medical Centre, Nottingham, United Kingdom. pasha.nisar@nottingham.ac.uk

PURPOSE: This study was designed to determine whether conventional hemorrhoidectomy or stapled hemorrhoidopexy is superior for the management of hemorrhoids. METHODS: A systematic review of all randomized trials comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched using the terms "hemorrhoid*" or "haemorrhoid*" and "stapl*." A list of clinical outcomes was extracted. Meta-analysis was calculated if possible. RESULTS: Fifteen trials recruiting 1,077 patients were included. Follow-up ranged from 6 weeks to 37 months. Qualitative analysis showed that stapled hemorrhoidopexy is less painful compared with hemorrhoidectomy. Stapled hemorrhoidopexy has a shorter inpatient stay (weighted mean difference, -1.02 days; 95 percent confidence interval, -1.47 to -0.57; P = 0.0001), operative time (weighted mean difference, -12.82 minutes; 95 percent confidence interval, -22.61 to -3.04; P = 0.01), and return to normal activity (standardized mean difference, -4.03 days; 95 percent confidence interval, -6.95 to -1.10; P = 0.007). Studies in a day-case setting do not prove that stapled hemorrhoidopexy is more feasible than conventional hemorrhoidectomy. Stapled hemorrhoidopexy has a higher recurrence rate (odds ratio, 3.64; 95 percent confidence interval, 1.40-9.47; P = 0.008) at a minimum follow-up of six months. CONCLUSIONS: Although stapled hemorrhoidopexy is widely used, the data available on long-term outcomes is limited. The variability in case selection and reported end points are difficulties in interpreting results. Stapled hemorrhoidopexy has unique potential complications and is a less effective cure compared with hemorrhoidectomy. With this understanding, it may be offered to patients seeking a less painful alternative to conventional surgery. Hemorrhoidectomy remains the "gold standard" of treatment.

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Surg Endosc. 2004 Dec 2; [Epub ahead of print]
Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles.
Basdanis G, Papadopoulos VN, Michalopoulos A, Apostolidis S, Harlaftis N.
1st Propedeutic Surgical Clinic, Aristotle's University of Thessaloniki, A.H.E.P.A. Hospital, T. Ikouomidi 21, 551 31, Kalamaria, Thessaloniki, Greece.

BACKGROUND. The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure.METHODS. Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients.RESULTS. Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique.CONCLUSIONS. Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.

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N Z Med J. 2004 Oct 08;117(1203):U1104.
Stapled haemorrhoidectomy—no pain, no gain?
Hill A.
South Auckland Clinical School, Middlemore Hospital, University of Auckland, Otahuhu, Auckland, New Zealand. AHill@middlemore.co.nz

Stapled anopexy/haemorrhoidectomy (SH) was introduced in 1993 and first described by Longo in 1998. In New Zealand, more than 700 stapled haemorrhoidectomies have been performed. The procedure is one of the most studied of all recent new surgical technologies, and the literature is surveyed in this paper to assess the procedure's safety and efficacy. From review of the current literature is seems appropriate to conclude that SH is a safe procedure. It is probably not the answer for all haemorrhoids, especially those that are extremely large or are associated with a very significant external component. The procedure certainly has a sound theoretical basis and is likely here to stay. Patients like it because it is less painful than conventional techniques but they need to be counselled that its durability is not known.

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Chir Ital. 2004 Sep-Oct;56(5):699-703.
[Transfixed stitches for the treatment of haemorrhoids]
[Article in Italian]
Gaj F, Trecca A, Garbarino M, Flati G.
Dipartimento di Chirurgia Generale e Trapianti d'Organo, Istituto Paride Stefanini, Azienda Policlinico Umberto I, Universita degli Studi di Roma La Sapienza.

Nowadays the proctologist has the opportunity to perform various different surgical techniques for the treatment of hemorrhoids. Circumferential mucosectomy with a stapler, diathermic hemorrhoidectomy with high frequency devices, and the HLA doppler II system have significantly modified the classical indications for the treatment of the disease. There is, however, still no general consensus as to the indications for the use of each of these techniques in clinical practice, giving rise to confusion among specialists and an inappropriate use of health care resources. For these reasons the authors propose a new technique for the treatment of haemorrhoids based upon a new classification system, named PATE 2000 Sorrento. The transfixed correction of haemorrhoids makes it possible to treat third degree internal piles in association with the Milligan-Morgan procedure for fourth degree piles in a simple, definitive and safe session. This technique seems to offer a valid alternative to stapled hemorrhoidectomy, on the one hand, and classical open or closed hemorrhoidectomy combined with rubber band ligation, on the other. The authors describe the technical feasibility of their technique and underline the good clinical results obtained in their initial experience with 20 consecutive patients.

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Chir Ital. 2004 Sep-Oct;56(5):693-7.
[Doppler-guided transanal haemorrhoidal dearterialisation]
[Article in Italian]
Tagariello C, Dal Monte PP, Sarago M.
UO Chirurgia Generale, Case di Cura M. F. Toniolo, Villa Erbosa, Bologna.

The usual surgical treatment for haemorrhoids consists in excision of the piles and ligation of the hemorrhoidal plexus, with considerable postoperative pain. A new, less invasive technique has been introduced, called transanal haemorrhoidal dearterialisation. This technique consists in Doppler-guided ligation of the distal branches of the superior rectal arteries (3 to 6) 2-3 cm above the pectinate line. Arterial ligation causes reduction of blood flow to, and decongestion of, the haemorrhoidal plexus. From January 2000 to September 2003, we performed transanal haemorrhoidal dearterialisation in 138 patients. Patients experienced no pain in the immediate postoperative period. The follow-up revealed good outcomes. The transanal haemorrhoidal dearterialisation procedure can be considered a safe, effective, painless and quick method of curing haemorrhoidal disease. Its indications are extensive. The success rate is approximately 90%, but may be lower for grade 4 haemorrhoids.

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Bratisl Lek Listy. 2004;105(7-8):270-6.
Radio surgery: a new tool in proctology practice.
Gupta PJ.
Gupta Nursing Home, Laxminagar, Nagpur India. drpjg_ngp@sancharnet.in

BACKGROUND: An apparatus that generates ultra-high frequency current waveform [radiofrequency] has emerged as a new tool to deal with many of the common ano rectal conditions. OBJECTIVE: The purpose of this paper is to enumerate the benefits of radiofrequency with emphasis on its advantages over conventional procedures. Based on extensive personal experience of using radiofrequency surgery in the performance of various anal pathologies, an attempt is made here to relay in narrative form the procedures from a "how-we-do-it" perspective. CONCLUSION: Our experience indicates that radiofrequency surgery not only facilitates but also improves the performance of surgical procedures in treating anal fistula, hemorrhoids, pilonidal sinus, anal papillae, anal polyps, anal warts, anal condylomas, anal antibiomas and papillomas. It significantly shortens operative time, causes negligible intra-operative bleeding, facilitates faster recovery by allowing rapid healing and minimizes the chances of postoperative complications. It permitted us to perform most of the above procedures as a day care surgery. Add to this, its cost-effectiveness coupled with better patient acceptance, radiofrequency surgery, applied judicially, could significantly improve the performance of a proctologist. The technique could be effectively applied in conjunction with conventional maneuvers to better the results of these procedures. Further studies, nonetheless, are called for to define long-term benefits of the treatment. (Tab. 4, Fig. 1, Ref: 36.)

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Dis Colon Rectum. 2004 Sep;47(9):1493-8. Epub 2004 Aug 12.
Thrombosed external hemorrhoids: outcome after conservative or surgical management.
Greenspon J, Williams SB, Young HA, Orkin BA.
Division of Colon and Rectal Surgery, The George Washington University, Washington, D.C., USA.

PURPOSE: Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to recurrence, and factors predicting recurrence of thrombosed external hemorrhoids after conservative or surgical management. METHODS: Two hundred and thirty-one consecutive patients with thrombosed external hemorrhoids treated from 1990 to 2002 were identified. Recurrence was defined as complete resolution of the index lesion with subsequent return of a thrombosed external hemorrhoid and did not include patients with chronic symptoms. Data were gathered retrospectively. Multiple potential risk factors were reviewed. RESULTS: The index thrombosed external hemorrhoid was managed conservatively in 51.5 percent of cases and surgically in 48.5 percent. There were no differences between groups in gender, age, or race, and 44.5 percent of all patients had a prior history of thrombosed external hemorrhoid. A prior history was less common in the conservative group than in the surgical group (38.1 percent vs. 51.3 percent; P < 0.05). The frequency of pain or bleeding as the primary complaint was higher in the surgical group ( P < 0.001 and P < 0.002). In addition, the surgical group was more likely to report all three symptoms of pain, bleeding, and a lump ( P < 0.005). Mean follow-up was 7.6 months, with the range extending to 7 years. Time to symptom resolution averaged 24 days in the conservative group vs. 3.9 days in the surgical group ( P < 0.0001). The overall incidence to recurrence was 15.6 percent-80.6 percent in the conservative group vs. 19.4 percent in the surgical group. The rate of recurrence in the conservative group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 percent of the surgical patients had recurrence ( P < 0.0001). Mean time to recurrence was 7.1 months in the conservative group vs. 25 months in the surgical group ( P < 0.0001). Survival analysis for time to recurrence of thrombosed external hemorrhoid indicated that time to recurrence was significantly longer for the surgical group ( P < 0.0001). Logistic regression analysis of multiple factors (including diverticular disease, constipation, straining, benign prostatic hypertrophy, diarrhea, skin tags, history of travel, anoreceptive sex, anal fissures, internal hemorrhoids, and obesity) was performed to determine the outcome of each group. None of these variables were significant predictors of recurrence. CONCLUSIONS: Patients whose initial presentation was pain or bleeding with or without a lump were more like to be treated surgically. Surgically treated patients had a lower frequency of recurrence and a longer time interval to recurrence than conservatively treated patients. None of the variables analyzed were significant predictors of a particular treatment, except for a prior history of thrombosed external hemorrhoids, which may represent patient choice. Although most patients treated conservatively will experience resolution of their symptoms, excision of thrombosed external hemorrhoids results in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals.

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Dis Colon Rectum. 2004 Aug;47(8):1364-70.
Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.
Iyer VS, Shrier I, Gordon PH.
Division of Colorectal Surgery and Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada.

PURPOSE: Rubber band ligation therapy for symptomatic hemorrhoidal disease has been used for many years and is a well-accepted treatment modality, but information on long-term outcome is limited. Our goals were to determine safety and long-term efficacy of this treatment. METHODS: A retrospective chart review of patients undergoing rubber band ligatures for symptomatic internal hemorrhoids in a single practice was conducted. Information on presenting symptoms, number of bands applied, response to therapy, complications encountered, length of follow-up, interval to recurrent symptoms when applicable, and subsequent therapy were documented. Supplemental information was obtained from telephone follow-up. Outcome was categorized as success or failure, in which success was defined as: permanent relief of symptoms for follow-up period; marked improvement in symptomatology with rare manifestation of bleeding (< or = 1/month); symptom relief for a limited period of time (> or = 100 days), and failure was defined as: modest improvement (decreased but not relief of symptoms); or no improvement in symptoms. RESULTS: A total of 805 patients underwent 2,114 rubber band ligatures. Most common presenting symptoms were bleeding in 731 patients (90.8 percent) and prolapsing in 382 patients (47.5 percent). The median number of bands placed was two (range, 1-17). The median time between bandings was 4.7 (range, 1.1-35.6) weeks. Median follow-up time was 1,204 (range, 14-9,571) days. Excluding 104 patients lost to follow-up (never returned after initial treatment), success was obtained in 70.5 percent (494/701) and failure in 29.5 percent (207/701) of patients. Success rates were similar for all degrees of hemorrhoids. Hemorrhoidal disease requiring the placement of four or more bands was associated with a trend in higher failure rates and greater need for subsequent hemorrhoidectomy. Complications per treatment series included bleeding (2.8 percent), thrombosed external hemorrhoids (1.5 percent), and bacteremia (0.09 percent). Higher bleeding rates were encountered with the use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin. Time to recurrence was less with subsequent treatment courses. Treatment of recurrent symptoms with rubber band ligation resulted in success rates of 73.6, 61.4, and 65 percent for first, second, and third recurrences respectively. This resulted in a cumulative success rate of 80.2 percent for this method of treatment. CONCLUSIONS: Rubber band ligatures are safe and effective therapy for symptomatic internal hemorrhoids. It can be used to treat all degrees of hemorrhoids with similar effectiveness. The likelihood of success is lower if more than four bands are needed to eliminate symptoms. The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin is associated with higher bleeding rates. Rubber band ligatures for recurrence of symptoms is effective; however, time to recurrence is less with subsequent treatments.

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Dis Colon Rectum. 2004 Jul;47(7):1164-9. Epub 2004 May 19.
Stapled hemorrhoidectomy with local anesthesia can be performed safely and cost-efficiently.
Esser S, Khubchandani I, Rakhmanine M.
Lehigh Valley Hospital, Allentown, Pennsylvania, USA.

PURPOSE: This prospective study was designed to assess the feasibility of performing the procedure for prolapsing hemorrhoids, or stapled hemorrhoidectomy, under local anesthesia supplemented with conscious sedation. METHODS: Seventy consecutive patients (mean age, 56 years; 37 males) with Grade 3 or 4 hemorrhoids underwent the procedure for prolapsing hemorrhoids after perianal infiltration of 0.5 percent lidocaine with 1:200,000 epinephrine and supplemental conscious sedation. The procedure was performed in an outpatient setting, with the patient being discharged within two hours of checking into the ambulatory facility. All patients were assessed the following day by telephone, and then in the office at three weeks and two months for degree of postoperative pain, bleeding, continence, and time back to work or social activities. Additionally, all excised mucosal anastomotic rings were analyzed for presence or absence of muscle. RESULTS: Each patient rated the pain as minimal or none. Five patients complained of mild, transient perineal pressure, and three complained of fecal urgency and seepage before their first office visit; one complained of external skin tags at the second office visit. All subjects were back to work or social activities within three to four days-most within 48 hours. Complications included urinary retention in five patients, two of whom had a concomitant urinary tract infection, and one had urosepsis requiring hospitalization. One patient required immediate reoperation for bleeding from the staple line. Another patient was admitted for postoperative bleeding and packed with a hemostatic agent the evening of surgery. Muscularis propria fibers were identified in 68 of 70 pathologic specimens. CONCLUSIONS: Administration of general, spinal, or epidural anesthesia for the procedure for prolapsing hemorrhoids is well described. This study suggests that the use of local anesthesia supplemented with conscious sedation for the procedure for prolapsing hemorrhoids yields results equivalent to those achieved with general or regional anesthesia without the attendant risks and additional costs. This study also suggests that the presence of muscle fibers in the pathologic specimen does not seem to lead to increased pain or impaired continence, although it was not specifically designed to address this issue.

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Dtsch Med Wochenschr. 2004 Jul 23;129(30):1611-7.
[Haemorrhoidectomy: conventional excision versus resection with the circular stapler. Prospective, randomized study]
[Article in German]
Hasse C, Sitter H, Brune M, Wollenteit I, Lorenz W, Rothmund M.
Klinik fur Visceral-, Thorax- und Gefasschirurgie, Philipps-Universitat Marburg. coloproktologie@t-online.de

BACKGROUND AND OBJECTIVE: The goal of this study was to compare two surgical methods of treating for haemorrhoids that aim at closure of the wound: resection with a circular stapler and a conventional, closed haemorrhoidectomy. PATIENTS AND METHODS: 80 patients (41 males, mean age 47,1 years) with haemorrhoids stage 3 were randomized and treated with stapler haemorrhoidectomy (test group; n = 40) or had an haemorrhoidectomy according to Fansler and Anderson (control group; n = 40). Following a standardized study protocol we compared postoperative results on the operating day and one week, six weeks, six months and one year afterwards uni- and multivariate analysis and we also calculated the costs. RESULTS: The stapler haemorrhoidectomy proved to be the method causing significantly reduced pain in the early postoperative period so that the patients needed less pain relief. They were able to return to work earlier. One year after stapler haemorrhoidectomy there were three episodes of postoperative bleedings that required intervention, one in the control group. Six patients still had haemorrhoids stage 3, six patients over the age of 65 had persistent anal incontinence (I degrees according to Parks) with proven sphincter dysfunction and disturbances in voiding their bowel with resulting deterioration of quality of life, significantly more frequent than in the control group. CONCLUSIONS: Stapler haemorrhoidectomy cures stage 3 haemorrhoids on a long term basis in 84.2 % of patients, costing less than all alternative treatments. In some cases, it can be associated with postoperative complications.

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Colorectal Dis. 2004 Jul;6(4):233-5.
One year follow up of a randomized trial comparing Ligasure with open haemorrhoidectomy.
Lawes DA, Palazzo FF, Francis DL, Clifton MA.
Department of Surgery, Princess Alexandra Hospital, Harlow, Essex, UK. dannylawes@hotmail.com

BACKGROUND: Ligasure haemorrhoidectomy is an effective treatment for prolapsing haemorrhoids, however, concerns exist regarding potential damage to the anal sphincters. METHODS: Patients previously included into a randomized trial comparing open and Ligasure haemorrhoidectomy were contacted by postal questionnaire to evaluate their overall satisfaction and continence at 12 months post operatively. RESULTS: Thirteen patients who underwent open and 17 who underwent Ligasure haemorrhoidectomy were evaluated. Three patients from the open group and 2 from the Ligasure group were unhappy with the result (P = 0.37) and minor incontinence was reported in 5 Ligasure and 2 open patients (P = 0.42). CONCLUSION: Patient satisfaction and post operative continence scores at 1 year post operatively are comparable for open and Ligasure haemorrhoidectomy.

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Int J Colorectal Dis. 2004 Jul;19(4):370-3. Epub 2004 Mar 25.
Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study.
Arroyo A, Perez F, Miranda E, Serrano P, Candela F, Lacueva J, Hernandez H, Calpena R.
Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/Huertos y Molinos s/n. C.P., 03203 Elche (Alicante), Spain. arroyocir@hotmail.com

BACKGROUND AND AIMS: Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology. PATIENTS AND METHODS: We carried out a randomised prospective study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy (group A) versus 100 patients undergoing Ferguson haemorrhoidectomy (group B) for symptomatic haemorrhoids, in whom medical treatment or rubber band ligation had failed. RESULTS: Characteristics of the population were: mean age 43.5 years, with predominance of males, 123 vs. 77; 88% ASA I-II. Clinical presentation: 95% rectal bleeding; 87.5% third-fourth degree. The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients (90%). Length of surgery: 24 min (group A) and 30 min (group B) (p=n.s.). Resection of three haemorrhoidal cushions was done in 87.5% of cases. There were no re-operations or re-admissions after discharge. Symptomatic recurrence, stenosis and incontinence were not found during the follow-up of the first year. Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group, but the difference was statistically significant (p<0.05) only during bowel movements. There was complete healing in 40% of the patients in group A and 90% of those in group B (p<0.05) after 1 month. After 1 year, the results and complications were similar in both groups (p=n.s.). CONCLUSIONS: Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year.

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Acta Chir Belg. 2004 Jun;104(3):313-7.
Use of radiofrequency in the treatment of minor anal pathology.
Gupta PJ.
Department of General Surgery, Gupta Nursing Home, Nagpur, India. drpjg@yahoo.co.in

BACKGROUND: Conventional approaches dealing with chronic anal fissures focus on relieving the anal spasm by manipulation of the internal sphincter. The concomitant pathologies like sentinel piles, anal papillae, or haemorrhoids, however, are often ignored for unknown reasons. MATERIAL AND METHODS: This study describes radiofrequency procedures to remove the above named associated pathologies after performing anal sphincterotomy. A separate, blinded and prospective study between conventional and radiofrequency excision of sentinel pile is described. The measured parameters included the procedure time, intraoperative blood loss, postoperative pain and wound healing time. RESULTS: This combined technique was found useful in treating anal fissures as well as the associated pathologies. The comparative study showed that the intraoperative bleeding was less (p < 0.0001) and wound healing was faster (p < 0.0001) in the radiofrequency group. CONCLUSION: Radiofrequency can be used as an alternative in treating pathologies like the sentinel tags, anal papillae, post fissure fistula or non prolapsing haemorrhoids found associated with anal fissures.

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Eur Rev Med Pharmacol Sci. 2004 Mar-Apr;8(2):79-85.
A randomised trial comparing submucosal haemorrhoidectomy with radiofrequency bistoury vs. diathermic haemorrhoidectomy.
Filingeri V, Gravante G, Baldessari E, Craboledda P, Bellati F, Casciani CU.
Department of Surgery, University of Rome Tor Vergata, Rome, Italy.

BACKGROUND: Haemorrhoid disease has become more and more frequent during the past years among western populations. Great attention has been paid in development of surgical procedures, in order to reduce post-operative pain (the main adverse effect of surgical treatment for haemorrhoids) and shorten execution time and hospital stay. This randomised clinical study compares the results obtained using submucosal haemorrhoidectomy with radiofrequency vs. diathermic haemorrhoidectomy. METHODS: Thirty-one patients were randomised to undergo submucosal haemorrhoidectomy with radiofrequency bistoury (16 patients, Group A) or diathermic haemorrhoidectomy (15 patients, Group B). The operating time, amount of pain and postoperative analgesic requirement, intra and post-operative complications and patient satisfaction were documented. RESULTS: The mean values for operative time have been 35.8 min for group A and 23.2 min for group B. According to pain score, patients' mean values for first day postoperative pain were 3.8 (A) and 5.8 (B). Pain at first evacuation 4.7 (A) and 6.5 (B). Pain at 7th postoperative day was 2.3 (A) and 3.7 (B). Patient's postoperative satisfaction rate was 6.0 (A) vs. 5.2 (B) at 3rd day and 6.7 (A) and 5.7 (B) at 6 months. CONCLUSIONS: In spite of relatively difficult execution and longer operating times, submucosal haemorrhoidectomy with radiofrequency bistoury appears to be the most precise and accurate treatment for IV degree haemorrhoids. Performing submucosal haemorrhoidectomy with radiofrequency bistoury allows us to reduce postoperative pain, bleeding and shorten hospital stay.

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Dtsch Med Wochenschr. 2004 Apr 23;129(17):947-50.
[Doppler-guided ligation of the hemorrhoidal arteries]
[Article in German]
Lienert M, Ulrich B.
Chirurgische Abteilung der Kliniken und Seniorenzentren der Landeshauptstadt Dusseldorf gGmbH, Krankenhaus Gerresheim.

BACKGROUND AND OBJECTIVE: Since the beginning of 2001, Doppler-giuded ligation of the hemorrhoidal arteries (DG-HAL) has been used at this clinic in almost all patients with various forms of hemorrhoidal disease. Aim of this study was to ascertain wether this intervention can be done without general anaesthesia, the hemorrhoidal knots regress and this procedure provides advantages over the classical methods of treating hemorrhoids. PATIENTS AND METHODS: Early results of DG-HAL in 248 patients are presented. Through a special proctoscope the arteries leading to the hemorrhoidal cushions are located in the pain-free rectum under Doppler guidance and suture ligated. The form of anaesthesia, duration of the operation, numbers and sites of the ligatures, additional interventions and postoperative complications were recorded. RESULTS: 171 patients (69%) needed no anaethesia. 147 patients (Without additional interventions) were re-examined 6 weeks after the operation: 61.2% were free of symptoms. A total of 87.7% were at least improves. The complication rate was low. CONCLUSION: In our experience DG-HAL has been a well tolerated efficacious method with few complications in the ambulatory treatment of hemorrhoids. The ideal indication for this methods is nonprolapsing hemorrhoids.

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Medicina (Kaunas). 2004;40(3):232-7.
Radiofrequency coagulation versus rubber band ligation in early hemorrhoids: pain versus gain.
Gupta PJ.
Gupta Nursing Home, D/9, Laxminagar, Nagpur-440022, India. drpjg_ngp@sancharnet.in

OBJECTIVE: Band ligation of internal hemorrhoids is a well-established and accepted office procedure. However, there are several reports focusing on problems associated with this technique, which is perceived by many to be risk-free. This randomized study is aimed to compare radiofrequency coagulation and rubber band ligation of hemorrhoids on the parameters of effectiveness and comfort. MATERIAL AND METHODS: Eighty patients of 2nd degree bleeding piles were randomized prospectively for band ligation (44 patients) or radiofrequency coagulation (36 patients) technique. Parameters measured included postoperative discomfort and pain, time taken to return to work, complications accompanying the procedure and recurrence rate. RESULTS: The post defecation pain was more severe with band ligation (p=0.01) and so was rectal tenesmus (p=0.01). The patients from radiofrequency coagulation group resumed their duties early (2 versus 5 days, p=0.05). Recurrence rate was higher in radiofrequency coagulation group. CONCLUSION: Rubber band ligation is associated with significantly higher post treatment pain and discomfort. As against this, radiofrequency coagulation results in significantly less pain and post defecation discomfort. However, chances of recurrence of bleeding and prolapse of hemorrhoids are comparatively higher using radiofrequency coagulation of hemorrhoids.

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Wien Med Wochenschr. 2004;154(3-4):56-64.
[Surgical treatment of hemorrhoids]
[Article in German]
Staude G.
Enddarm-Zentrum Mannheim, Mannheim, Deutschland. Staude68165@t-online.de

The spectrum of procedures for hemorrhoidal disease can deal with all developmental stages if carried out in a differential way. Stapled hemorrhoidopexy is an effective supplement to actual conventional surgical procedures. Hemorrhoidectomies performed with the stapler were compared with segmental hemorrhoridectomies according to Milligan-Morgan as well as anoplasty according to Fansler-Arnold, and proved to be superior as regards complication rate, need for analgesics and operation time, stay in hospital and time off work. But despite the justified euphoria about this innovative method, its necessary limitations should not be disregarded.

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Wien Med Wochenschr. 2004;154(3-4):50-5.
[Conservative treatment of haemorrhoids]
[Article in German]
Kirsch JJ, Grimm BD.
Enddarm-Zentrum Mannheim, Mannheim, Deutschland. mail@enddarm-zentrum.de

Haemorrhoidal symptoms have been known from time immemorial; they are considered to be a widespread problem, which is progressive if untreated. Treatment is according to the proctological qualification of the doctor and the degree of the changes. If possible, it should be carried out from the point of view of causal therapy. The most frequently occurring 1st degree haemorrhoids can almost always be treated conservatively, i.e. with sclerotherapy. To prevent recurrence, the life style and defecation habits should be changed. Regular monitoring by specialists aids prevention.

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Hautarzt. 2004 Mar;55(3):240-7.
[Hemorrhoids. Differential diagnosis and therapy]
[Article in German]
Lenhard BH.
Praxis fur Enddarmerkrankungen Heidelberg. info@enddarmerkrankungen.de

Hemorrhoidal disease results from the pathological enlargement and distal displacement of the upper hemorrhoidal plexus. This disorder is very widespread in modern industrial society. Hereditary predisposition, malnutrition with constipation and abnormal bowel habits seem to be the most relevant causes for pathogenesis. The exact classification of hemorrhoids according to the degree of prolapse as well as the correct evaluation of accompanying anal diseases are very important in order to choose the appropriate conservative or surgical treatment with the goal of long-term avoidance of recurrence.

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Gastrointest Endosc. 2004 Mar;59(3):380-4.
Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids.
Fukuda A, Kajiyama T, Arakawa H, Kishimoto H, Someda H, Sakai M, Tsunekawa S, Chiba T.
Current affiliations: Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan, Department of Gastroenterology, Department of Surgery, Kansai Denryoku Hospital, Osaka, Japan.

BACKGROUND: Elastic band ligation is a well-established nonoperative method for treatment of internal hemorrhoids that give rise to symptoms. This study assessed the efficacy and safety of retroflexed endoscopic multiple band ligation, a procedure that involves extensive ligation of internal hemorrhoids, and the immediately proximal normal rectal mucosa, by means of a retroflexed endoscope. METHODS: Eighty-two patients with symptoms caused by internal hemorrhoids (15, stage I; 19, stage II; 47, stage III; 1, stage IV) were treated by retroflexed endoscopic multiple band ligation. Symptoms (prolapse, bleeding, pain with defecation) were graded from 0 to 3. Range and form of the internal hemorrhoids were evaluated endoscopically. Retroflexed endoscopic multiple band ligation was performed by using a flexible endoscope with an attached band ligation device in the retroflexed position. RESULTS: A mean of 8 bands (range 4-14) were placed per treatment session. Seventy-six patients were treated in a single session, 5 in two sessions, and one in 3 sessions. Symptom and endoscopic scores improved at 4 weeks after the retroflexed endoscopic multiple band ligation: bleeding, from 1.26 to 0.53 (p<0.01); prolapse, from 1.94 to 0.5 (p<0.01); pain, from 1.03 to 0.93 (p=0.67); Goligher classification, from 2.41 to 1.09 (p<0.01); range, from 3.25 to 0.56 (p<0.01); and form, from 2.81 to 0.56 (p<0.01). Long-term response (mean follow-up 12 months, range 3-40 months) was excellent for 89% of the patients, good for 9%, and poor for 2%. No major complication was noted. CONCLUSIONS: Retroflexed endoscopic multiple band ligation is a safe and effective method for treatment for patients with symptoms caused by internal hemorrhoids.

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Eur J Med Res. 2004 Jan 26;9(1):18-36.
Hemorrhoidectomy: indications and risks.
Holzheimer RG.
University Halle-Wittenberg, Germany. info@praxisklinik-sauerlach.de

Hemorrhoids are a common cause of perianal complaints and affect 1-10 million people in North-America and with similar incidence in Europe. Symptomatic hemorrhoids are associated with nutrition, inherited predisposition, retention of feces with or without chronic abuse of laxatives or diarrhea. Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even incontinence. The significance of hemorrhoids for anal continence (corpus cavernosum) is recognized. In most instances, hemorrhoids are treated conservatively; the surgeon is contacted when conservative measures have failed or complications, e.g., thrombosis, have occurred. 4 degrees prolapsed internal hemorrhoids are the main indication for hemorrhoidectomy: high (Parks) or low (Milligan-Morgan) ligation with excision, closed hemorrhoidectomy (Ferguson) or stapler hemorrhoidectomy. Thrombosed external hemorrhoids are primary treated by incision and secondary by excision. Complications after operative treatment of external thrombosed hemorrhoids are rare. After standard hemorrhoidectomy for internal hemorrhoids approximately 10% may have a complicated follow-up (bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, incontinence); there may be concomitant disease, e.g., perianal cryptoglandular infection, causing complex fistula/abscess, which is associated with an increased risk (30-80%) for complications, e.g., incontinence. Other treatment options, e.g., sphincterotomy, anal stretch, have been accused to cause more complications, e.g., incontinence in 30-50% of cases. However, incontinence is a complex phenomenon; it is evident that an isolated single injury is normally not a sufficient cause, e.g., injury of the internal sphincter. The majority of patients may present with prior obstetric injury, perianal infection or Crohn's disease and other comorbidity. Therefore all systemic and regional disorders, causing incontinence, should be excluded before starting manometric, neurophysiological and sonographic investigations. Variation and overlap in test results, patient-, instrument- or operator-dependent factors ask for cautious interpretation. There is vast evidence that the demonstration of muscle fibers in hemorrhoidectomy specimens is a normal feature. In conclusion, standard hemorrhoidectomy with proper indication is a safe procedure. If complications occur, it is in the interest of the patient and surgeon to perform a thorough investigation.

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Arq Gastroenterol. 2004 Jan-Mar;40(1):35-9. Epub 2003 Oct 06.
Stapled hemorrhoidectomy for the treatment of hemorrhoids.
Nahas SC, Borba MR, Brochado MC, Marques CF, Nahas CS, Miotto-Neto B.
Hospital S rio Liban s.

BACKGROUND: The use of circular staplers in the treatment of hemorrhoidal disease is known as a simple procedure, with low morbidity, less post-treatment pain and with the same efficacy when compared to the classical hemorrhoidectomy. AIM: Analyze the operative technique, intra-operative and immediate postoperative complications and late results in 100 patients treated for hemorrhoid disease by stapling technique. PATIENTS AND METHODS: The group included 53 males and 47 females with mean age of 49.8 years, operated during the period June 2000 to June 2002 in the "Hospital Universit rio" (S o Paulo University Hospital) and "Hospital S rio Liban s", in S o Paulo, SP, Brazil. RESULTS: The majority of patients (78%) were discharged on the first post-operative day. Eight patients required supplementary analgesia and were given intramuscular diclofenac sodium and four of them received intramuscular tramadol. One intraoperative complication was bleeding which was difficult to control and required a blood transfusion. One patient was reoperated on the first postoperative day due to intermittent and persistent bleeding, however without hemodynamic changes or a drop in hematocrit. Two patients presented hemorrhoidal thrombosis in the early postoperative stage. The postoperative follow-up displayed: recurrence of prolapse, five cases (5%); anal sub-stenosis, two cases (2%); anal fissure, one case (1%); persistent pain, two cases (2%). Seven reoperations were performed: one due to bleeding, one due to sub-stenosis and five due to recurrence of hemorrhoidal prolapse and persistence of symptoms. CONCLUSIONS: Stapling is simple to accomplish, has low postoperative pain and rate of complications, however, the incidence of late reoperations is rather high and therefore major follow-up for better analysis is required.

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Gastrointest Endosc. 2003 Dec;58(6):871-4.
Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids.
Su MY, Chiu CT, Wu CS, Ho YP, Lien JM, Tung SY, Chen PC.
Digestive Therapeutic Endoscopy Center, Department of Gastroenterology, Lin-Kou Medical Center, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan, ROC.

BACKGROUND: This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of patients with symptoms caused by internal hemorrhoids. METHODS: A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients). The severity of the hemorrhoids was classified by using the grading system of Goligher. RESULTS: All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8 to 24 months). The mean number of band ligations per session was 2.86. The mean number of treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients (95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered uneventfully. CONCLUSIONS: Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for patients with symptoms caused by internal hemorrhoids.

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Colorectal Dis. 2003 Nov;5(6):573-6.
Surgical treatment of haemorrhoids according to Longo and Milligan Morgan: an evaluation of postoperative tissue response.
Krska Z, Kvasnieka J, Faltyn J, Schmidt D, Svab J, Kormanova K, Hubik J.
Department of Surgery, Charles University, Prague, Czech Republic.

OBJECTIVES: To compare by prospective randomised trial the postoperative tissue reaction of stapled vs. conventional haemorrhoidectomy. PATIENTS AND METHODS: Fifty patients with stage III haemorrhoids underwent surgery for haemorrhoids. Group 1 (n = 25) had the Milligan-Morgan procedure; Group 2 (n = 25) had a stapled haemorrhoidectomy. All patients underwent measurements of endothelial dysfunction markers including E-selectin, P-selectin and intercellular adhesion molecule (ICAM). Acute-phase proteins including C-reactive protein, orosomucoid and fibrinogen were also measured. Estimations were made prior to surgery, immediately afterward surgery and on the first and fifth postoperative days. Assessment of clinical outcome was made one month after the surgery. RESULTS: There was a postoperative increase of acute-phase reactants in both groups. The patterns of the cures of the monitored parameters appeared similar in both groups. Lower values were found in Group 1, but the difference was not statistically significant except the level of fibrinogen on day 5, which was significantly higher in Group 2. E-selectin, P-selectin and ICAM showed similar time curves. Statistical analysis found the differences to be significant only when individual days were compared and not for the types of surgery. Raised ICAM and P-selectin on the fifth postoperative day was found in both groups. In Group 1, pain assessment by patients remained in the lower part of the pain rating scale, while in Group 2 it did not start declining until one week after surgery and became normal in the third to fourth weeks. In Group 1, the duration of hospitalization and the duration of incapacity for work were 50% of the values in Group 2. CONCLUSION: Patients having stapled haemorrhoidectomy have less pain and experience more rapid recovery when compared to classical haemorroidectomy. This was mirrored by the acute-phase protein CRP and fibrinogen levels postoperatively. There was no significant difference in other acute-phase reactants monitored, nor was there any difference in parameters of endothelial dysfunction. The techniques differ in extent of pain and duration of hospital stay and incapacity for work.

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Am Surg. 2003 Oct;69(10):862-5.
Stapled hemorrhoidectomy: a review of our early experience.
Dixon MR, Stamos MJ, Grant SR, Kumar RR, Ko CY, Williams RA, Arnell TD.
Department of Surgery, Division of Colorectal Surgery, Harbor-UCLA Medical Center, Torrance, California, USA.

Treatment of hemorrhoids may safely be accomplished by using a circular stapler instead of the conventional open procedure for large symptomatic hemorrhoids. Our purpose was to assess the safety and early post-op results of this new surgical technique as it was introduced into clinical practice. Medical records from 62 patients treated by circumferential mucosectomy/stapled hemorrhoidectomy were obtained from 6 surgeons. Preoperative factors assessed included demographics, comorbidities, prior anorectal surgery, hemorrhoid grade, and the indications for surgery. Operative factors examined included operating time, use of perioperative antibiotics, and oversewing of the suture line. Postoperative factors included complications and date of last follow-up. Sixty-two patients underwent this operation, and complications were reported in six patients (10%). There was one death unrelated to the hemorrhoid surgery. Postoperative pain, defined as requiring pain control with intravenous medication, hospital admission, or an emergency department visit, occurred in two patients. Two patients reported postoperative bleeding. One patient experienced bleeding the first evening, and the second patient had bleeding 1 week postoperatively. The first patient was admitted overnight and required no blood transfusion or further intervention. The second patient was subsequently found to have a bleeding diverticulum. One patient experienced urinary retention that resolved with conservative management. Postoperative follow-up was available for over 90 per cent of the patients at a median of 4 weeks postoperatively. No additional complications were discovered at follow-up. This data suggests that stapled hemorrhoidectomy is a safe and effective approach to hemorrhoidal disease. Our findings indicate an acceptable complication rate among a group of surgeons beginning to integrate this modality into clinical practice.

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Harefuah. 2003 Oct;142(10):654-8, 720.
[Stapled hemorrhoidectomy--early experience in 30 patients]
[Article in Hebrew]
Amosi D, Werbin N, Kashtan H, Skornik Y, Greenberg R.
Department of Surgery A, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

INTRODUCTION: We report the early results of 30 patients treated by stapled hemorrhoidectomy. PATIENTS AND METHODS: Thirty patients with symptomatic grade 2-4 hemorrhoids were treated by stapled hemorrhoidectomy. The procedure was performed with a 33 mm diameter automatic hemorrhoidal circular stapler. The patients were prospectively evaluated for immediate and functional recovery, postoperative pain and subjective success of the treatment. RESULTS: The median age of the patients was 46.2 years, and the median duration of the symptoms was 27 months. The main symptom was bleeding (in 96% of the patients). The average operative time was 22 minutes. The operation was performed with spinal (63.3%) or general (36.7%) anesthesia. There was no mortality, urinary retention, incontinence, fecal urgency or persistent pain. One patient, who was under anticoagulant treatment, had postoperative bleeding, which required transfusion of 3 units of blood, and another patient was operated on because of perforation of the sigmoid colon. Most patients (twenty eight) had complete functional recovery and returned to their usual daily activities within 10.4 days. Postoperative pain and subjective success were evaluated by a 1 to 10 scale. The average pain score decreased from 5.8 on the first postoperative day to 2.4 on the 7th postoperative day. The average satisfactory score was 9.2. CONCLUSION: Stapled hemorrhoidectomy is an alternative to conventional surgical hemorrhoidectomy. The procedure seems to be associated with less postoperative pain and early recovery with a high satisfaction rate among patients.

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Braz J Med Biol Res. 2003 Oct;36(10):1433-9. Epub 2003 Sep 16.
Infrared coagulation versus rubber band ligation in early stage hemorrhoids.
Gupta PJ.
Gupta Nursing Home, Laxminagar, Nagpur, India. drpjg@yahoo.co.in

The ideal therapy for early stages of hemorrhoids is always debated. Some are more effective but are more painful, others are less painful but their efficacy is also lower. Thus, comfort or efficacy is a major concern. In the present randomized study, a comparison is made between infrared coagulation and rubber band ligation in terms of effectiveness and discomfort. One hundred patients with second degree bleeding piles were randomized prospectively to either rubber band ligation (N = 54) or infrared coagulation (N = 46). Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate. The mean age was 38 years (range 19-68 years). The mean duration of disease was 17.5 months (range 12 to 34 months). The number of male patients was double that of females. Postoperative pain during the first week was more intense in the band ligation group (2-5 vs 0-3 on a visual analogue scale). Post-defecation pain was more intense with band ligation and so was rectal tenesmus (P = 0.0059). The patients in the infrared coagulation group resumed their duties earlier (2 vs 4 days, P = 0.03), but also had a higher recurrence or failure rate (P = 0.03). Thus, we conclude that band ligation, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort to the patient. As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered to be a suitable alternative office procedure for the treatment of early stage hemorrhoids.

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Dis Colon Rectum. 2003 Oct;46(10):1380-3.
Randomized, clinical trial of Ligasure vs conventional diathermy in hemorrhoidectomy.
Franklin EJ, Seetharam S, Lowney J, Horgan PG.
Barnes Hospital, Washington University School of Medicine, St Louis, Missouri, USA.

PURPOSE: Hemorrhoidectomy is frequently associated with significant postoperative pain, and new techniques to reduce this pain are constantly under evaluation. The present study was conducted to determine the usefulness of the Ligasure system and compare it with conventional diathermy for hemorrhoidectomy. METHODS: Thirty-four consecutive patients with Grade 3 or 4 hemorrhoids requiring surgery were recruited and randomized into two groups by preoperative assignment of sealed envelopes. Patients with coexisting perianal disease, previous perianal surgery, or thrombosed hemorrhoids were excluded. All patients were anesthetized and operated on by a single team. In one group, monopolar diathermy in the coagulation mode was used to dissect hemorrhoidal tissue from the internal sphincter. In the second group, tissue was coagulated by Ligasure and then divided with scissors. Operating time was documented by theater staff. Postoperatively, pain scores and Cleveland Clinic incontinence scores were documented. RESULTS: Seventeen patients were randomized into each group. There were no significant differences in age, gender, or clinical symptoms between the groups. The mean operating time in the Ligasure group was 6 (range, 4-10) minutes compared with 11 (range, 7-20) minutes in the other group, and this was statistically significant (P < 0.001). Patients in the Ligasure group reported significantly less pain with first defecation and at postoperative Days 1 and 14 (P < 0.001). The mean hospital stay in both groups was one (range, 1-5) day, and there was no difference in the incontinence scores. CONCLUSIONS: Ligasure diathermy provides a superior alternative to conventional diathermy in hemorrhoidectomy by reducing operating time and postoperative pain.

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Khirurgiia (Mosk). 2003;(8):39-45.
[Choice of hemorrhoidectomy method in chronic hemorrhoid]
[Article in Russian]
Shelygin IuA, Blagodarnyi LA, Khmylov LM.

Seventy patients with hemorrhoid of stage III-IV underwent surgery. In the study group (n = 21) hemorrhoidectomy was performed with ultrasonic knife. In control group 1 (n = 22) closed hemorrhoidectomy with recovery of anal canal mucosa was performed, in control group 2 (n = 27)--standard open hemorrhoidectomy with electrocoagulation. When ultrasonic knife was used, time of surgery reduced significantly compared with standard closed and opened hemorrhoidectomy--14.7 +/- 3.7, 40.2 +/- 6.5 and 32.5 +/- 5.6 min respectively (p < 0.05). On day 1 after surgery intensive pains were seen more rarely in patients of the study group compared with ones of both control groups (34, 75 and 66% patients respectively). In subsequent days intensive pains were seen also more rarely in study group than in control groups: on day 3 in 15, 40 and 35 patients, respectively, on day 7 in 5, 30 and 20 patients, respectively (p < 0.05). Degree of pain syndrome on day 1 after surgery in the study and control groups was 3.0 +/- 0.4, 7.0 +/- 0.2 and 6.0 +/- 0.3 points, respectively (p < 0.05). Patients of the study group demonstrated low requirement in narcotic and non-narcotic analgesics compared with the other groups. The time of postoperative rehabilitation of patients in the study and control groups was 12.3 +/- 2.4, 18.5 +/- 3.8 and 20.1 +/- 4.4 days, respectively (p < 0.05).

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Dis Colon Rectum. 2003 Sep;46(9):1232-7.
Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids and mucosal prolapse.
Chew SS, Marshall L, Kalish L, Tham J, Grieve DA, Douglas PR, Newstead GL.
Colorectal Unit, Department of Surgery, Prince of Wales Hospital, Sydney, Australia.

PURPOSE: Rubber band ligation is a common office procedure for symptomatic hemorrhoids. The aim of the study was to assess our short-term and long-term results of combined sclerotherapy and rubber band ligation in the management of hemorrhoids and incomplete mucosal prolapse. METHODS: Data on 6,739 patients who had previous combined sclerotherapy and rubber band ligation by the senior authors (GLN and PRD) were retrieved from the database dating between January 1976 and June 2000. These patients either had hemorrhoids or incomplete mucosal prolapse. Furthermore, questionnaires were sent to a random sample of 2,400 patients. Telephone interviews were performed for 600 of the nonrespondents. RESULTS: Of 6,739 patients (3,683 males; mean age, 46.7 years) in the database, 4,686 (70 percent) received the procedure once, and 2,053 (30 percent) received the procedure more than once. There were 5,689 patients (84 percent) who had their procedures performed consecutively within a planned period, and only 1,050 patients (16 percent) had repeat procedures after a period of more than 12 months from their last treatments. Thus, the recurrence rate was 16 percent. The overall complication rate was 3.1 percent, with minor bleeding being the major complaint. With regard to the questionnaire, 44 percent responded. The mean follow-up period was 6.5 (range, 1-11) years. There were patients who had residual symptoms of bleeding (19 percent), itch (21 percent), and lump (20 percent). However, 58 percent of patients who replied were asymptomatic. With satisfaction scores ranging from +3 to -3 (+3 indicating complete satisfaction and -3 indicating complete dissatisfaction), 90 percent scored >/=1, 9 percent scored 0 or less, and 1 percent did not specify a score. Hemorrhoidectomy was required in 7.7 percent of the responders. Of 600 phone interviews with the nonrespondents, 152 responded to the questionnaires. Although there was less satisfaction from the phone respondents, which may have accounted for the initial nonresponse, no statistical difference was detected in residual symptoms. CONCLUSIONS: Combined triple sclerotherapy and rubber band ligation is an effective treatment for early hemorrhoids and incomplete mucosal prolapse, with low rates of recurrence, complications, and hemorrhoidectomy, and it can be repeated easily.

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Schweiz Rundsch Med Prax. 2003 Sep 17;92(38):1579-83.
[New modalities and concepts in the treatment of hemorrhoids]
[Article in German]
Hetzer FH, Wildi S, Demartines N.
Klinik fur Viszeral- und Transplantationschirurgie, Universitatsspital Zurich.

The surgical treatment of haemorrhoids has significantly changed by introducing new techniques in the last years. Nowadays, low grade haemorrhoids, grade II and III, are easily and painfree treatable by a minimal invasive, Doppler transducer guided ligation of the haemorrhoidal arteries. In cases of circular protruding haemorrhoids, grade III and IV; the stapled mucosectomy described by Longo is also a new effective treatment. Both procedures can be performed for an outpatient or with short hospital stay and allows patients to return to work earlier compared to conventional techniques. Additionally, due to the new techniques the treatment of haemorrhoids is less painful and has increased patients' satisfaction. Therefore, the traditional haemorrhoidectomy, the Milligan-Morgan or the Ferguson procedure, has become less common and is only performed in a few special indications.

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Dis Colon Rectum. 2003 Aug;46(8):1097-102.
Botulinum toxin (botox) reduces pain after hemorrhoidectomy: results of a double-blind, randomized study.
Davies J, Duffy D, Boyt N, Aghahoseini A, Alexander D, Leveson S.
Department of Colorectal Surgery, York District Hospital, York, United Kingdom.

PURPOSE: Pain after hemorrhoidectomy appears to be multifactorial and dependent on individual pain tolerance, mode of anesthesia, postoperative analgesia, and surgical technique. Spasm of the internal sphincter is believed to play an important role. The aim of this study was to assess the role of botulinum toxin in reducing pain after Milligan-Morgan hemorrhoidectomy. METHODS: This was a double-blind study of 50 consecutive patients undergoing Milligan-Morgan hemorrhoidectomy and assigned to an internal sphincter injection of 0.4 ml of solution containing either botulinum toxin (20 U; Botox) or normal saline. Patients were managed according to standardized perioperative analgesic and laxative regimens. Pain was assessed by use of daily visual analog scores and analgesia requirements for the first seven postoperative days. RESULTS: Patients randomized to receive botulinum toxin had lower daily average and maximal visual analog scores throughout the study period. The difference reached significance on both Day 6 (P < 0.05) and Day 7 (P < 0.05). There was no significant difference (P = 0.12) in morphine requirements in the first 24 hours (botulinum group, 16 (range, 6-27) mg; placebo arm, 22 (range, 13-41) mg). Patients who received Botox used 19 (range, 8-36) coproxamol tablets in the first seven days after surgery compared with 23 (range, 10-40) in the placebo arm (P = 0.63). CONCLUSIONS: Those patients who had botulinum toxin had significantly less pain toward the end of the first week after surgery. Reduction in spasm within the internal sphincter is the presumed mechanism of action. This is the first reported randomized, controlled trial using botulinum toxin in hemorrhoidectomy.

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Int J Colorectal Dis. 2003 Jul 5 [Epub ahead of print].
Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study.
Bursics A, Morvay K, Kupcsulik P, Flautner L.
First Department of Surgery, Semmelweis University, 1082 Budapest, Hungary.

BACKGROUND AND AIMS. Doppler-guided hemorrhoid artery ligation is a new approach for treating hemorrhoids. Early and 1-year follow-up results of the procedure are presented and compared with those of closed scissors hemorrhoidectomy in a prospective randomized study. PATIENTS AND METHODS. Sixty consecutively recruited patients were randomized into two groups: group A ( n=30) was treated with standardized closed scissors hemorrhoidectomy and group B ( n=30) with Doppler-guided hemorrhoid artery ligation. The follow-up period was 11.7+/-4.6 months. RESULTS. The average need for minor analgesics was 11.7+/-12.6 doses in group A and 2.9+/-7.7 in group B. Patients in group A spent 62.9+/-29.0 hours in hospital postoperatively and those in group B 19.8+/-41.8 hours. Return to normal daily activities took 24.9+/-24.5 days in group A and 3.0+/-5.5 days in group B. Neither the disappearance (26 vs. 25 patients) nor the recurrence of preoperative symptoms (5 vs. 6 patients) differed significantly between the two groups. CONCLUSION. Both procedures were effective in treating hemorrhoids. The 1-year results of Doppler-guided hemorrhoid artery ligation do not differ from those of closed scissors hemorrhoidectomy. Doppler-guided hemorrhoid artery ligation seems to be ideal for 1-day surgery, and it fulfills the requirements of minimally invasive surgery.

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Rozhl Chir. 2003 Jun;82(6):307-11.
[Surgery of hemorrhoids using the Long method and its complications]
[Article in Czech]
Hahn M, Simsa J, Horak J.
Chirurgicko-traumatologicke oddeleni Klaudianovy nemocnice, Sdruzeni zdravotnickych zarizeni Mlada Boleslav.

BACKGROUND: The aim of this article is an assessment of new surgical procedure--stapled hemorroidectomy according to Longo. We do concentrate on surgical complications and possibilities of it's management. METHODS: Prospective, clinical follow up of patients in which stapled hemorrhoidectomy was performed during the period of 2 years (1st December 2000--30st November 2002). Observation concentrates on surgical complications of this method. All patients had a clinical check up 3 weeks and 3 months after surgery. In case of any problems treatment and follow up continues. RESULTS: Stapled hemorroidectomy was performed during the period of 2 years in 52 patients (100%). There was 11 patients (21.2%) with some of surgical complication. The most serious one was massive rectal bleeding after surgery, which has been observed in 4 patients (7.6%). Other surgical complications observed in our group were anal stenosis, local infection, acute anal fissure and retention of urine. CONCLUSION: Stapled hemorroidectomy is now one of feasible alternatives for surgical treatment of hemorrhoids. Serious surgical complications observed in our patients were bleeding from the stapled suture line and anal stenosis. The aim of this article is to refer possible surgical complications of this method, it's prevention and management.

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Minerva Chir. 2003 Jun;58(3):355-9.
[Milligan-Morgan hemorrhoidectomy with a radiofrequency scalpel]
[Article in Italian]
Filingeri V, Rosati R, Gravante G, Pietrasanta D, Fiorito R, Casciani CU.
Chirurgia Generale, Universita Tor Vergata, Rome, Italy. v.filingeri@tiscali.it

BACKGROUND: Postoperative pain has always been the main adverse effect of surgical treatment for hemorrhoids. Therefore, surgical techniques evolved mainly to solve this problem and, secondly, postoperative bleeding, recurrences and stenosis. METHODS: Two homogeneous groups of 20 patients each were investigated. Both of them were affected by fourth grade hemorrhoidal prolapse and were homogeneous for age, sex and presentation symptoms. Patients previously treated for other proctologic diseases were excluded. A group was treated with standard Milligan-Morgan hemorrhoidectomy and the other with radiofrequency scissors. Every patient underwent a follow-up protocol based on outpatient visits at 15, 30, 45 postoperative days and 3, 6 and 12 months. RESULTS: The results show a substantial similarity between these techniques. However, radiofrequency scissors further improved the simplicity of the technique and the postoperative adverse effects. In particular, the procedure lasted 7 minutes less with radiofrequency scissors. Patients treated with the radiofrequency technique had their first postoperative evacuation 24 hours before the standard technique and reduced the mean postoperative hospital stay at 2.5 days (4.5 days in the standard group). The incidence of postoperative pain was reduced in patients treated with radiofrequency scalpel and the follow-up controls in both groups didn't show any complication as stenosis or incontinence. CONCLUSIONS: The radiofrequency-performed Milligan-Morgan hemorrhoidectomy is a valuable technique that improves the classical difficulties in execution, reducing the length of hospital stay and the incidence of postoperative pain or other complications.

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Endoscopy. 2003 May;35(5):416-20.
Long-term results of endoscopic hemorrhoidal ligation: two different devices with similar results.
Su MY, Tung SY, Wu CS, Sheen IS, Chen PC, Chiu CT.
Digestive Therapeutic Endoscopic Center, Dept. of Gastroenterology, Lin-Kou Medical Center, Chang-Gung Memorial Hospital, Chang-Gung University, Tao-Yuan, Taiwan.

BACKGROUND AND STUDY AIMS: To evaluate the efficacy of two different endoscopic hemorrhoidal ligation (EHL) devices for symptomatic internal hemorrhoid. PATIENTS AND METHODS: From November 2000 to February 2001, 218 consecutive patients with symptomatic internal hemorrhoids were enrolled. A total of 109 patients were treated with an EHL device 9 mm in diameter (group A); the rest were treated with a device 13 mm in diameter (group B). The patients' clinical presentations were rectal bleeding and prolapse. The severity of the hemorrhoid was classified using Goligher's grading. RESULTS: All patients were treated for one session, and were followed from 19 to 24 months (mean 22.4 months). The number of band ligations averaged 2.59 in group A and 1.68 in group B. Most patients had their hemorrhoids reduced by at least one grade (82.8 % in group A and 90.8 % in group B). Rectal bleeding was controlled in 108 patients (99.1 %) in group A and 109 patients (100 %) in group B, while rectal prolapse was reduced in 93 patients (85.3 %) in group A and 99 patients (90.8 %) in group B. Eleven patients in group A and 12 in group B experienced anal pain after treatment, and eight patients in group A and six in group B had mild bleeding. The patients' subjective satisfaction rates were 90.8 % in group A and 93.6 % in group B. The 1-year recurrence rates were 3.9 % in group A and 2.3 % in group B. CONCLUSIONS: Both EHL devices can effectively treat symptomatic internal hemorrhoids. A device with a smaller diameter requires more band ligations, but appears equivalent with regard to treatment outcome and complications.

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Ned Tijdschr Geneeskd. 2003 May 17;147(20):971-3.
[Favorable results of conservative treatment with isosorbide dinitrate in 25 patients with fourth-degree hemorrhoids: a pilot study]
[Article in Dutch]
van den Berg M, Stroeken HJ, Hoofwijk AG.
Maaslandziekenhuis Sittard, afd. Heelkunde, Postbus 5500, 6130 MB Sittard.

OBJECTIVE: To evaluate application of isosorbide dinitrate 1% ointment in the treatment of fourth-degree haemorrhoids. DESIGN: Prospective pilot study. METHOD: Twenty-five consecutive patients, 12 men and 13 women, with a median age of 48 years (range: 30-78), presenting in the period October 1999-December 2001 with fourth-degree haemorrhoids, were treated with isosorbide dinitrate 1% ointment. RESULTS: In 24 out of 25 patients (96%) the objective, reduction of the stangulated haemorrhoids and relief of pain, was achieved. In one patient the haemorrhoids were not reduced. This patient was cured after classic haemorrhoidectomy. Two patients interrupted the treatment because of severe headache, but after renewed instructions they continued the therapy and were cured. CONCLUSION: Isosorbide dinitrate 1% ointment gave good results in the treatment of fourth-degree haemorrhoids, with only few side effects.

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Di Yi Jun Yi Da Xue Xue Bao. 2003 Apr;23(4):382-3, 386.
Anal cushion resection versus Milligan-Morgan hemorrhoidectomy for circular hemorrhoids: randomized controlled trial.
Chen JF, Huang ZH, Chen YX, Xiao JQ.
Department of General Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou 510282, China. cjf.fimmu@eyou.com

OBJECTIVE: To compare the clinical effect of anal cushion resection with Milligan-Morgan hemorrhoidectomy for the third- or fourth-degree circular hemorrhoids. METHODS: Forty-eight patients with third- or fourth-degree circular hemorrhoids were randomly assigned into two groups to receive either anal cushion resection or Milligan-Morgan hemorrhoidectomy. Comparison of the two approaches were conducted in terms of postoperative pain scores, operation time, wound healing time, mean hospital stay, incidence of postoperative complications and the curative effect. Results No significant difference was found in view of postoperative pain scores according to visual analogue scale between the 2 groups. The operative time of anal cushion resection was significantly longer than that of the other group, however, its wound healing time, mean hospital stay and incidence of postoperative complications were significantly less. Follow-up study for 3 months after operation found that anal cushion resection had significantly better curative effect than Milligan-Morgan hemorrhoidectomy. Conclusion Anal cushion resection is a safe and practical approach for third- or fourth-degree circular hemorrhoids.

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Dis Colon Rectum. 2003 Apr;46(4):491-7.
A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up.
Cheetham MJ, Cohen CR, Kamm MA, Phillips RK.
St. Mark's Hospital, Northwick Park, Harrow, Middlesex, UK.

PURPOSE: Hemorrhoidectomy is the most effective long-term treatment for hemorrhoids. Although it is possible to perform hemorrhoidectomy as a day case with a high degree of patient satisfaction, patients take an average of 14 days off work after surgery. Stapled hemorrhoidectomy is believed to be less painful than conventional hemorrhoidectomy and should allow an earlier return to work. The aim of this study was to compare both the immediate and the long-term results of stapled hemorrhoidectomy with diathermy hemorrhoidectomy in patients with prolapsing internal hemorrhoids in an intended day-care setting. METHODS: Thirty-one patients were randomly assigned to undergo diathermy hemorrhoidectomy (n = 16) or stapled hemorrhoidectomy performed with a purpose-designed endoluminal stapling device, PPH01T (n = 15). All operations were planned as day or short-stay cases. All patients received lactulose, commenced preoperatively, together with postoperative topical glyceryl trinitrate and oral metronidazole. Patients were assessed by structured interview to assess their symptoms before and after surgery, with an intended follow-up of six months. All patients completed a 10-cm visual analog pain scale daily for the first ten days after surgery. RESULTS: The total pain score (sum of all pain scores) was significantly higher in the diathermy group (50 (range, 9.8-79.9) vs. 19.6 (range, 1.3-89.5), P = 0.03). Patients took a median of 14 (range, 3-21) days off work after diathermy hemorrhoidectomy compared with 10 (range, 3-38) days for the patients undergoing stapled hemorrhoidectomy (P = 0.15). At long-term follow-up, three patients (all in the stapled group) developed new symptoms of fecal urgency and anal pain, and three patients required further surgery to remove symptomatic external hemorrhoids after stapled hemorrhoidectomy. CONCLUSIONS: Although stapled hemorrhoidectomy is less painful in the short term, this does not lead to a significantly earlier return to work, and some patients develop new symptoms at long-term follow-up.

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Hong Kong Med J. 2003 Apr;9(2):103-7.
Ambulatory stapled haemorrhoidectomy: a safe and feasible surgical technique.
Law WL, Tung HM, Chu KW, Lee FC.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.

OBJECTIVE: To compare outcomes following stapled haemorrhoidectomy as an in-patient versus day-surgery procedure. DESIGN: Prospective non-randomised study. SETTING: University affiliated hospitals, Hong Kong. SUBJECTS AND METHODS: Forty-eight consecutive patients who underwent stapled haemorrhoidectomy were included in the study. Twenty-four patients had the procedure in an ambulatory setting and the other 24 were treated as in-patients. The symptoms, operative details, postoperative complications, length of hospital stay, pain scores, analgesic requirements, and patient satisfaction scores were collected. Comparison was made between those patients undergoing ambulatory surgery and those treated as in-patients. RESULTS: There were 25 women and 23 men in the study. The mean age was 46.6 years (standard deviation, 12.1 years). The mean operating time was 29.3 minutes (standard deviation, 9.9 minutes). An incomplete 'doughnut' after stapling was found in one patient. There were no other adverse intra-operative events or complications. Postoperative morbidities occurred in eight patients but none required further surgery. One patient in the day-surgery group could not be discharged because of urinary retention and three required re-admission to hospital because of secondary haemorrhage (n=1) or fever (n=2). There were no differences in the postoperative complications, pain scores, analgesic requirements, and patient satisfaction scores between the two groups. The total mean hospital stay was significantly shorter for those undergoing day-surgery stapled haemorrhoidectomy (0.46 versus 1.9 days, P<0.01). The mean follow-up period was 4.6 months (standard deviation, 4.0 months). All patients reported symptomatic improvement during this time and there was no incidence of faecal incontinence. One patient had a soft stricture, one had a fissure, and two had residual skin tags. All of these problems were conservatively managed, without the need for further surgical procedures. CONCLUSIONS: Stapled haemorrhoidectomy is a safe and effective operation for haemorrhoids. It is a feasible procedure to perform as day-surgery. The hospital stay can be significantly shortened, thus reducing the costs associated with in-patient care.

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Khirurgiia (Mosk). 2003;(1):36-8.
[Comparative aspects of surgical treatment of hemorrhoid]
[Article in Russian]
Sazhin VP, Gostkin PA, Siatkin DA.

Based on experience in treating 64 patients with chronic hemorrhoid a comparative clinical evaluation of efficiency of electrosurgical methods is carried out hemorrhoidectomy. Compared with traditional Milligan-Morgan surgery, electrosurgical method demonstrates the absence of intraoperative blood loss, a reduction in the algetic syndrome after surgery, a decrease in postoperative complications rates by 4.8 times. Physiological and physical activity, stool are also recovered by electrosurgery.

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Tech Coloproctol. 2003 Apr;7(1):45-50; discussion 50.
Radiofrequency ablation and plication of hemorrhoids.
Gupta PJ.
Fine Morning Hospital and Research Center, D/9, Laxminagar, Nagpur 440022, India. drpjg@yahoo.co.in

BACKGROUND: Radiofrequency ablation is emerging as a new therapeutic method in various fields of medicine. This study describes procedure of radiofrequency ablation followed by plication of hemorrhoidal mass in advanced grades of hemorrhoids. METHODS: This non-controlled, prospective study included 300 patients (211 men) treated at Fine Morning Hospital, Laxminagar, Nagpur, India, between July 1999 and December 2000. Patients were followed over a median period of 18 months (range, 15-20 months). RESULTS: The hospital stay was less than 24 hours for all patients. After 1 week, most of the patients had symptoms like bleeding and pain. At 4 weeks, 21% complained of pruritus, but none had prolapse, incontinence or anal stenosis. At the last follow-up, 96% had relief from bleeding, while 8% of patients had developed external skin tags and 6% had asymptomatic recurrence revealed by anoscopy. CONCLUSIONS: For advanced degree of piles with prolapse as the main symptom, plication of the pile mass along with radiofrequency ablation may be used as an alternative to the various types of hemorrhoidectomies. With this treatment, hospital stay is minimized, postoperative pain in low, recurrence is low and return to work is faster.

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Lancet. 2003 Apr 26;361(9367):1437-8.
Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised
controlled trial.
Smyth EF, Baker RP, Wilken BJ, Hartley JE, White TJ, Monson JR.
Academic Surgical Unit, University of Hull, Castle Hill Hospital, Castle Road, HU16 5JQ, Cottingham, UK.

Advantages of the stapling procedure for haemorrhoids include reduced postoperative pain and shortened convalescence; however, there are few data with respect to functional and symptomatic outcome. At a dedicated clinic, we reviewed patients between Dec, 2001, and March, 2002, who had taken part in a randomised controlled trial undertaken at the unit in 1999, which compared outcomes after open or stapled haemorrhoidectomy. We noted the presence or absence of haemorrhoid specific symptoms, and assessed overall satisfaction, continence, and quality of life. Rigid sigmoidoscopy and an anorectal examination were also used to examine symptomatic recurrence and disease activity. At minimum follow-up of 33 months since surgery, both techniques seem to be equally effective.

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Dis Colon Rectum. 2003 Mar;46(3):291-7; discussion 296-7.
Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles.
Peng BC, Jayne DG, Ho YH.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.

PURPOSE: The introduction of stapled hemorrhoidectomy may replace local techniques such as rubber band ligation as a first-line treatment for Grade III and small Grade IV piles. We conducted a randomized trial to determine the role of rubber band ligation in the era of stapled hemorrhoidectomy. METHODS: Fifty-five patients with Grade III or small Grade IV hemorrhoids were randomly allocated to either rubber band ligation or stapled hemorrhoidectomy. Patient demographics and procedure-related details were recorded. Follow-up was at two weeks and two and six months to assess complications, symptom relief, incontinence scores, quality of life, and patient satisfaction. RESULTS: Twenty-five patients were randomly assigned to rubber band ligation and 30 to stapled hemorrhoidectomy. The groups were equally matched for age, gender, grade of piles, continence scores, and quality of life. Stapled hemorrhoidectomy was associated with increased pain and analgesia usage at both 2-week and 2-month follow-up (P < 0.001). Rubber band ligation and stapled hemorrhoidectomy were equally effective in controlling symptomatic prolapse, but rubber band ligation was associated with an increased incidence of recurrent bleeding (P = 0.002). There were 6 procedure-related complications in the stapled hemorrhoidectomy group compared with none in the rubber band ligation group (P = 0.027). There was no difference between the two groups in terms of continence scores, patient satisfaction, or quality of life. CONCLUSION: Stapled hemorrhoidectomy is associated with more pain and minor morbidity than rubber band ligation in the treatment of Grade III and small Grade IV piles. However, for those patients who do not want the risk of further intervention procedures, stapled hemorrhoidectomy offers the better chance of a symptomatic cure.

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Colorectal Dis. 2003 Mar;5(2):133-8.
A comparison of the simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately, for the treatment of haemorrhoids: a prospective randomized trial.
Kanellos I, Goulimaris I, Christoforidis E, Kelpis T, Betsis D.
4th Department of Surgery, Aristotle University of Thessaloniki, Antheon 1, GR 55236, Panorama, Thessaloniki, Greece. ik@hol.gr

OBJECTIVE: To compare simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately for the treatment of 2nd degree haemorrhoids. PATIENTS AND METHODS: Between 1993 and 1996, 255 patients that suffered from 2nd degree haemorrhoids were divided into 3 groups of 85 patients, each to receive either simultaneous sclerotherapy for smaller and rubber band ligation for larger piles (SCL/RBL) in one session, or sclerotherapy (SCL), or rubber band ligation (RBL), respectively. After a period of 4 years all patients were examined and their symptoms were recorded. RESULTS: The patients of the SCL group developed significantly fewer complications after treatment compared to the other two methods (P < 0.001), which did not differ from each other. After the SCL/RBL treatment, significantly more patients were symptom free (46%) than after SCL (8%), P < 0.001. There was no significant difference between the SCL/RBL (46%) and the RBL (31%) groups (P = 0.217), although the combined treatment seemed to be more effective than rubber band ligation. Only 10% of the patients of the SCL/RBL group needed additional sessions 6-24 months after the initial treatment compared to 30% of the patients of the SCL group (P = 0.001). However, there was no significant difference between SCL/RBL and RBL (17%) groups (P = 0.151). CONCLUSION: The combination of sclerotherapy and rubber band ligation for treatment of 2nd degree haemorrhoids is significantly more efficient than sclerotherapy on its own.

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World J Surg. 2003 Feb;27(2):203-7.
Stapled and open hemorrhoidectomy: randomized controlled trial of early results.
Palimento D, Picchio M, Attanasio U, Lombardi A, Bambini C, Renda A.
Department of Surgery, Civil Hospital San Rocco, Via Sessa Mignana, 81037 Sessa Aurunca, Caserta, Italy.

The aim of the study was to compare the early results in 52 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Seventy-four patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (37 patients) or open (37 patients) hemorrhoidectomy. Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique. Postoperative pain was assessed by means of a visual analogue scale (V.A.S.). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and a 17.5 (10 to 27)-month median telephone follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (median 25 [range 15 to 49] minutes versus 30 [range 20 to 44] minutes, p = 0.041). Median (range) V.A.S. scores in the stapled group were significantly lower (V.A.S. score after 4 hours: 4 [2 to 6] versus 5 [2 to 8], p = 0.001; V.A.S. score after 24 hours: 3 [1 to 6] versus 5 [3 to 7], p = 0.000; V.A.S. score after first defecation: 5 [3 to 8] versus 7 [3 to 9], p = 0.000). Resumption of pain-free defecation was significantly faster in the stapled group (10 [6 to 14] days vs 12 [9 to 19] days, p = 0.001). At follow-up 4 weeks and 6 months postoperatively the median (range) symptom severity score was similar in both groups (1 [0 to 2] versus 0 [0 to 3], p = 0.150 and 0 [0 to 2] versus 0 [0 to 2], p = 0.731). At long-term follow-up occasional pain was present in 6/37 (16.2) patients in the stapled group and 7/37 (18.9%) in the Milligan-Morgan group (p = 1.000); episodes of bleeding were reported by 8/37 (21.6%) patients in the stapled group and 5/37 (13.5%) patients in the Milligan-Morgan group (p = 0.542). No problems related to continence and defecation were reported in either group. Patients were satisfied with the operation in 33/37 (89.2%) cases in the stapled group and 31/37 (83.8%) cases in the Milligan-Morgan group (p = 0.735). Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan-Morgan technique in terms of postoperative pain and recovery. Comparable results are obtained at long-term follow-up.

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Rev Esp Enferm Dig. 2003 Feb;95(2):110-4, 105-9.
Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.
[Article in English, Spanish]
Perez Vicente F, Fernandez Frias A, Arroyo Sebastian A, Serrano Paz P, Costa Navarro D, Candela Polo F, Ferrer Riquelme R, Oliver Garcia I, Lacueva Gomez FJ, Calpena Rico R.
Unidad de Coloproctologia. Hospital Universitario de Elche. Alicante, Spain. faperez@airtel.net

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.

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Colorectal Dis. 2003 Jan;5(1):29-32.
Stapled anoplasty for haemorrhoids: a comparison of ambulatory vs. in-patient procedures.
Guy RJ, Ng CE, Eu KW.
Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608.

OBJECTIVE: Haemorrhoids are commonly seen in colorectal practice. Stapled anoplasty is a novel approach to the treatment of this condition and is usually performed as an in-patient procedure. The aim of this study was to investigate the suitability of this technique for ambulatory surgery. PATIENTS AND METHODS: Fifty consecutive patients undergoing stapled anoplasty under general anaesthesia as day cases (DC) (mean age 41 years; 27 females) by a single consultant surgeon over a 12-month period were compared with 50 consecutive patients undergoing the same procedure as in-patients (mean age 44 years; 25 females) (IP) during the same period. RESULTS: Eight DC patients (16%) were admitted overnight from the day surgery unit for urinary retention (3), pain (2), bleeding (2) and anaesthetic reasons (1). Three other DC patients were re-admitted after a mean period of 4 days with bleeding (2), one of which required surgical haemostasis, and a septic complication (1). Mean hospital stay for IP cases was 2.6 (range 1-9) days. Two IP cases were re-admitted after 4 and 11 days for bleeding and wound infection, respectively. At review 2-4 weeks after discharge, satisfaction in both groups was high. Minor staple-line strictures were seen in 1 DC and 2 IP cases but all were easily dilated digitally. Mean costs incurred were significantly less for day surgery patients. CONCLUSIONS: Stapled anoplasty is suitable for use in day-case surgery as it is a quick and relatively painless procedure. The advantages, particularly financial, support the technique for use in an ambulatory setting, preferably in the morning, and provided detailed patient advice is given.

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Dis Colon Rectum 2003 Jan;46(1):93-9
Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome.
Kairaluoma M, Nuorva K, Kellokumpu I.
Department of Gastroenterological Surgery, Central Hospital of Jyvaskyla, Jyvaskyla, Finland.

PURPOSE: Stapled hemorrhoidectomy may be associated with less pain and faster recovery than conventional hemorrhoidectomy for prolapsing hemorrhoids. Therefore, the outcome of stapled hemorrhoidectomy was compared with that of diathermy hemorrhoidectomy in a randomized, controlled trial. METHODS: Sixty patients with third-degree hemorrhoids were randomly assigned to stapled hemorrhoidectomy (n = 30) or to diathermy hemorrhoidectomy in a day-case setting. Visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at six weeks and one year after surgery. RESULTS: Operation time was a median of 21 (range, 11-59) minutes in the stapled group. 22 (range, 14-40) minutes in the diathermy group. Day-case surgery was successful in 24 patients (80 percent) in the stapled group vs. 29 patients (97 percent) in the diathermy group. Average pain in the stapled group was significantly lower than in the diathermy group (median, 1.8 (0.1-4.8) vs. 4.3 (1.4-6.2), 95 percent confidence interval difference medians, 1.15-3.85, P = 0.0002, Mann-Whitney U test) as was the average pain expected by the patients (median -2.7 (-0.15-0.8) vs. 0.006 (-4.05-0.5) respectively, 95 percent confidence interval difference medians, 0.5-3.55, P = 0.0018, Mann-Whitney U test). Postoperative morbidity and time off work were not significantly different between the diathermy and stapled groups. Seven treatment failures in the stapled group and one in the diathermy group necessitated other treatments at a later date. Patient satisfaction scores in the stapled and diathermy group were similar. Symptoms attributed to difficult rectal evacuation decreased significantly after surgery. CONCLUSIONS: Stapled hemorrhoidectomy is a significantly less painful operation than diathermy hemorrhoidectomy, but does not seem to offer significant advantages in terms of hospital stay or symptom control in the long term. Hemorrhoidectomy may improve symptoms of difficult rectal evacuation.

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Dis Colon Rectum 2003 Jan;46(1):87-92
Clinical experience of sutureless closed hemorrhoidectomy with LigaSure.
Chung YC, Wu HJ.
Department of Surgery, Hsin-Chu Hospital, Department of Health, Taiwan, Republic of China.

PURPOSE: The purpose of this study was to evaluate the LigaSure vessel sealing system as an alternative to closed hemorrhoidectomy. METHODS: Sixty-one patients with Grade 3 or 4 symptomatic hemorrhoids were prospectively randomly assigned to undergo hemorrhoidectomy with the LigaSure vessel sealing system or hemorrhoidectomy using the conventional Ferguson procedure. We determined the operation time, postoperative pain, amount of time taken off from work, and complications associated with both techniques. RESULTS: Mean operative time for the LigaSure hemorrhoidectomy was 15 +/- 5.4 minutes and for the Ferguson operation, 21.2 +/- 8.2 minutes. The difference was significant (P < 0.01). There was also a significant decrease in pain measurements reported on postoperative Days 1 and 2 (P < 0.05) in the LigaSure group. The incidence of postoperative wound swelling and complications were similar between two groups. There was no difference in the period of time off from work between patient groups. CONCLUSION: This study confirms that LigaSure system can achieve a radical ablation of hemorrhoids, reduce operative time, and result in less postoperative pain on postoperative Days 1 and 2.

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J Natl Med Assoc 2002 Dec;94(12):1089-92
Massive life-threatening lower gastrointestinal hemorrhage following hemorrhoidal rubber band ligation.
Odelowo OO, Mekasha G, Johnson MA.
Division of Gastroenterology, Department of Medicine and Department of Surgery, Howard University Hospital, Washington, DC, USA. oodelowo@hotmail.com

Hemorrhoids are common, and a significant proportion of patients who have hemorrhoids experience symptoms such as bleeding, pain and itching. Endoscopic hemorrhoidal ligation is a safe and effective technique indicated for the treatment of grade 1 to 3 hemorrhoids, with a high success and low complication rate. Complications, when they occur, are minor and may include painful thrombosed prolapsed hemorrhoids, slippage of bands, minor rectal bleeding and chronic longitudinal ulcer. Rare, potentially life-threatening complications are massive hemorrhage and pelvic sepsis. A case of massive, life-threatening lower gastrointestinal hemorrhage following endoscopic hemorrhoidal rubber-band ligation is presented. Our patient ingested aspirin intermittently following the procedure. In a study documenting complications after hemorrhoidal band ligation, two of three individuals requiring transfusion for massive hemorrhage were taking aspirin on a regular basis. The risk of massive hemorrhage after hemorrhoidal rubber band ligation is probably increased by ingestion of nonsteroidal anti-inflammatory drugs. It may be wise to withhold such drugs soon after the procedure, if feasible.

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Arch Surg 2002 Dec;137(12):1395-406; discussion 1407
A systematic review of stapled hemorrhoidectomy.
Sutherland LM, Burchard AK, Matsuda K, Sweeney JL, Bokey EL, Childs PA, Roberts AK, Waxman BP, Maddern GJ.
ASERNIP-S, 51-54 Palmer Pl, North Adelaide, South Australia 5006, Australia.

HYPOTHESIS: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. DATA SOURCES: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. STUDY SELECTION: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. DATA EXTRACTION: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. DATA SYNTHESIS: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. CONCLUSIONS: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

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MedGenMed 2002 Jul 31;4(3):1
Novel technique: radiofrequency coagulation--a treatment alternative for early-stage hemorrhoids.
Gupta PJ.
Gupta Nursing Home, Nagpur, India.

BACKGROUND: For early-stage hemorrhoids, in which bleeding is the primary symptom, conventional approaches to management include injection of sclerosing solutions, band ligation, and infrared coagulation. In our study, we used the radiofrequency coagulation technique as an alternative strategy to treat early-stage hemorrhoids. MATERIALS AND METHODS: A total of 210 patients with bleeding hemorrhoids were treated with radiofrequency coagulation at the Gupta Nursing Home in Nagpur, India. RESULTS: Follow-up was at 2 weeks, 3 months, and 12 months after procedure. Results were recorded as follows: (1) Bleeding--Twenty-eight (13%) patients had recurrence of bleeding during the observation period. (2) Pain--Some degree of discomfort was reported by all patients within the first 48 hours. (3) Retention of urine--Only 1 patient had retention of urine; this patient was 74 years old and had an enlarged prostate. (4) Discharge--Thirty-four (16%) patients complained of discharge in the first 2 weeks after procedure. (5) Return to work--Seventy percent (n = 145) of patients resumed their duties after 48 hours; the remainder required 1 additional day. (6) Sepsis--There were no reports of postprocedure sepsis. (7) Sphincter function--None of the patients experienced problems with continence or stenosis. Overall patient satisfaction was 84% (n = 177). CONCLUSION: Although these initial results of coagulation of hemorrhoids by radiofrequency appear quite exciting and encouraging, long-term follow-up is needed to assess the duration of relief and potential side effects. Continued work in this area will likely provide promising new dimensions in the effective management of early-stage hemorrhoids in which bleeding is the main symptom. A separate, randomized trial was carried out to assess the difference in efficacy between infrared coagulation and radiofrequency coagulation in 100 patients with early-stage hemorrhoids. Radiofrequency coagulation was found to be more effective than infrared coagulation in terms of recurrence of bleeding, asymptomatic recurrences of hemorrhoids, and overall satisfaction of technique.

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Dis Colon Rectum 2002 Nov;45(11):1452-7
Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study.
Khubchandani IT.
Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, PA, USA.

PURPOSE: Pain after hemorrhoidectomy is universal. Several attempts have been made to reduce or alleviate the pain after excisional hemorrhoidectomy. The origin of pain is undetermined. Current theories propose that the pain is mediated through the internal sphincter. This prospective, randomized study was performed to assess the degree of discomfort in patients with and without a sphincterotomy when performing a closed hemorrhoidectomy. METHODS: Between December 1999 and September 2001, 42 patients (22 males), median age 52 (range, 30-80) years, who underwent excisional hemorrhoidectomy were randomly chosen to have an internal sphincterotomy in the base of the left lateral wound. RESULTS: Thirty-nine patients were available for the study. Parameters elicited in the study were pain, postoperative bleeding, urinary retention, impairment of continence by day and by night, and day the patient returned to work. There was no statistical difference in the postoperative pain in each of the two categories at four hours after surgery, after the first bowel movement, or four days after surgery. CONCLUSIONS: Results showed no difference in the perception of pain after hemorrhoidectomy in patients who had an internal sphincterotomy compared with those who did not. Both groups were equally likely to have difficulty with control of gas and soiling.

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Dis Colon Rectum 2002 Nov;45(11):1437-44
Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial.
Wilson MS, Pope V, Doran HE, Fearn SJ, Brough WA.
Department of Surgery, Christie Hospital, Wilmslow Road, Withington, Manchester M20 4BX, United Kingdom.

PURPOSE: This trial compares stapled anopexy with open hemorrhoidectomy in patients with prolapsing (Grade 3) hemorrhoids. Particular attention was paid to changes in anorectal physiology, nature of tissue resected, quality-of-life assessments, and cost implications of the treatments studied. METHODS: An initial pilot study was followed by a randomized, controlled trial in a District General Hospital in the United Kingdom. All patients had Grade 3 hemorrhoids. Nineteen patients were studied in the pilot study, with 99 patients in the randomized, controlled trial. All patients in the pilot study and 59 in the randomized, controlled trial underwent stapled anopexy. Thirty patients in the randomized, controlled trial underwent open hemorrhoidectomy. Of the 59 patients in the stapled group, 32 were treated with the Ethicon PPH stapling device, and 27 received stapling with a reusable Autosuture stapling device. The following variables were measured: demographic details, quality of life (Medical Outcomes Study Short Form 36 and directed questions), anorectal manometry, and histology. RESULTS: There was no difference in the case mix within or between the groups. The stapled anopexy groups showed a significant reduction in operative time (P < 0.001) and blood loss (P < 0.001) compared with open hemorrhoidectomy. Open hemorrhoidectomy resulted in significantly greater usage of protective pads postoperatively (P < 0.001) and longer rehabilitation (P < 0.006). CONCLUSIONS: Stapled anopexy is an effective alternative treatment for prolapsing hemorrhoids that allows reduced operative time and shorter rehabilitation. It does not appear to affect continence or overall quality of life.

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Tech Coloproctol 2002 Sep;6(2):105-8
Two-quadrant semiclosed hemorrhoidectomy. A preliminary report.
Pescatori M.
Coloproctology Unit of Villa Flaminia Hospital, Via L. Bodio 58, I-00191 Rome, Italy. ucpclub@virgilio.it

Bleeding and delayed healing may affect the postoperative course following hemorrhoidectomy and cause discomfort to the patient. The present report deals with a modification of the Milligan-Morgan operation: the upper part of the surgical wound is covered with rectal mucosa and the distal edge is stitched with a running suture, with the aim of decreasing both the risk of bleeding and the healing time. The operation has been performed in 12 consecutive patients with two quadrant internal and external piles. The median operative time was 32 minutes (range, 21-30). The mean postoperative pain after 12 hours, measured from 1 to 10 on a visual analogue scale, was 4.4 (SEM, 1.4). All patients but three had their wounds healed within 3 weeks and none of them had postoperative bleeding requiring treatment. Acute urinary retention occurred in one case. All patients were discharged after 48 hours. None had anal incontinence or short-term recurrence. In conclusion, two-quadrant semiclosed hemorrhoidectomy provided good results in terms of both bleeding rate and healing process with an acceptable operative time and postoperative pain.

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Tech Coloproctol 2002 Sep;6(2):89-92
Harmonic scalpel hemorrhoidectomy: preliminary results of a new alternative method.
Ramadan E, Vishne T, Dreznik Z.
Department of Surgery A, Rabin Medical Center, Campus Golda, Sacklar Medical School, Tel-Aviv University, 7 Keren Kayemet Street, Petach-Tikva, Israel.

Surgical treatment is considered to be the best therapeutic modality for severe hemorrhoidal disease. Different surgical methods of hemorrhoidectomy aim to decrease pain, bleeding, stenosis and discharge. The aim of this study was to evaluate the efficacy of harmonic scalpel hemorrhoidectomy. During a period of seven months, 54 consecutive patients with third- and fourth-degree hemorrhoids were prospectively randomized for harmonic scalpel hemorrhoidectomy (HS) or Milligan-Morgan procedure (MM). These patients were examined at one, two, and six weeks after the operation. All patients had a lower gastrointestinal investigation prior to operation to exclude other colorectal pathologies. All patients had the same kind of preoperative preparation and analgesia during the postoperative course. Pain was assessed using a visual analog scale from 0 to 10. Patient satisfaction was defined as decrease or absence of symptoms and return to normal daily activities. HS groups included 29 patients, while the MM group had 25 patients. There as no difference between the groups in terms of age, gender, hemorrhoidal degree and indication for operation. The types of intra-operative anesthesia administered to the two groups were similar. Duration of surgery was significantly higher in the MM group ( p<0.0001). Postoperative hospitalization was longer in the MM group ( p<0.0001), and the pain degree was higher in MM group ( p<0.0001). No significant difference was noted in the overall amount of analgesics used in the two groups at week 1, although it was significantly higher in the MM group 2 and 3 weeks after the operation. Early complication occurred more frequently in the MM group but overall the difference was not statistically significant. In conclusion, harmonic scalpel hemorrhoidectomy is virtually a bloodless operation with minimal tissue damage. It is associated with significant less postoperative pain and a fast return to normal activity.

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Tech Coloproctol 2002 Sep;6(2):83-8
Complications after stapled hemorrhoidectomy: can they be prevented?
Ravo B, Amato A, Bianco V, Boccasanta P, Bottini C, Carriero A, Milito G, Dodi G, Mascagni D, Orsini S, Pietroletti R, Ripetti V, Tagariello GB.
Rome American Hospital, Via Emilio Longoni 69, I-00155 Rome, Italy. nadia.fabrini@rahonline.com

Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.

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Dis Colon Rectum 2002 Oct;45(10):1367-74.
Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial.
Correa-Rovelo JM, Tellez O, Obregon L, Miranda-Gomez A, Moran S.
Colon and Rectum Clinic, Medica Sur Hospital, Mexico City, Mexico.

INTRODUCTION: We compared the safety and clinical outcome between stapled rectal mucosectomy and closed hemorrhoidectomy for the surgical treatment of noncomplicated hemorrhoidal disease. METHODS: Eighty-four patients with Grade III and IV hemorrhoidal disease were randomly assigned to two groups: 1) stapled rectal mucosectomy group (n = 42) and 2) closed hemorrhoidectomy group (n = 42). Postoperative pain, analgesic use, symptoms, disability, early and late complications, and patient satisfaction were evaluated, among others. Follow-up was six months. RESULTS: Eighty-four patients, averaging 45 +/- 9 years of age, underwent surgery. Two were lost to follow-up. Length of surgery and disability, postoperative pain, and use of analgesics were significantly less for patients in the stapled rectal mucosectomy group. In the closed hemorrhoidectomy group early complications were more frequent but not statistically significant, and there were no statistically significant differences regarding the frequency of late complications. No serious complications were reported in either group. Closed hemorrhoidectomy proved to be superior for bleeding control (95.1 percent closed hemorrhoidectomy 80.5 percent stapled rectal mucosectomy; P= 0.04). Patient satisfaction was similar in the two groups, but stapled rectal mucosectomy patients were more willing to undergo the same procedure (P = 0.02). CONCLUSION: Both stapled rectal mucosectomy and closed hemorrhoidectomy are safe procedures. Closed hemorrhoidectomy was superior for bleeding control in Grade III and IV hemorrhoidal disease, but more painful and disabling than stapled rectal mucosectomy.

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Br J Surg 2002 Nov;89(11):1376-81
Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy.
Ortiz H, Marzo J, Armendariz P.
Unit of Coloproctology, Department of Surgery, Hospital Virgen del Camino, Irunlarrea 4, E-31008 Pamplona, Navarra, Spain. HHORTIZ@teleline.es

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.

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J Nippon Med Sch 2002 Oct;69(5):451-5
[Endoscopic hemorrhoidal ligation from the rectum]
[Article in Japanese]
Shioda Y, Onda M, Sakuma T, Hori M, Takasaki H, Hasegawa H.
Department of Surgery, Shioda Hospital, Chiba, Japan.

Endoscopic hemorrhoidal ligation with a rubber band was carried out on 40 patients with internal hemorrhoids. All the patients were treated in the outpatient ward. Seven patients complained of mild to moderate aches in the early postoperative days, which were easily controlled by medication. One week after the treatment, no patient complained of pain. None of the patients had any postoperative bleeding. The results of this treatment were classified as good (no complaint or symptoms after the treatment), fair (at least some improvement), or poor (no change or worse than before the treatment). Twenty-nine of the 40 patients were classified as good, and the remaining 11 patients were fair. No patients were classified as poor. EHL is a harmless and painless procedure and is easily performed in the outpatient ward. When internal hemorrhoids of operative indication are detected by colonoscopy, EHL can be easily and simultaneously carried out.

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Rom J Gastroenterol 2002 Sep;11(3):191-5
Use of enzyme and heparin paste in acute haemorrhoids.
Gupta PJ.
Gupta Nursing Home, Nagpur, India.

BACKGROUND: While treating acutely inflammed piles, surgeons in general prefer to stick to the conservative method of treatment. This includes bed rest in a Trendelenburg's or jack-knife position, administration of liquid diet, stool softeners, antibiotics, and anti-inflammatory drugs along with warm Sitz baths and local application of glycerin and magnesium sulphate paste. We introduced an additional method in treating acutely inflammed piles. Ten tablets of trypsin and chymotrypsin (Chymoral forte, Elder Pharmaceuticals India) were powdered and were mixed with 30 grams of heparin (Thrombophobe, German Remedies Ltd, Germany) ointment. This paste was applied to the inflammed pile mass. In all, 67 received this in patient treatment with an average hospital stay of 2 days. The results were compared using chi2 test with similarly placed 22 patients who were treated with the conventional method only. RESULTS: In the patients receiving the application of the enzyme paste, local pain was reduced to a great extent, the defecation was comfortable, there was negligible local pruritus, and the routine body movements of the patient were painless. Local signs observed in the form of the size of the piles, perianal edema, and tenderness, were also found to be significantly reduced. CONCLUSION: The results of this study demonstrate that the additional use of a heparin-enzyme paste applied directly over the pile masses significantly improves the healing and resolution of acutely inflammed hemorrhoids. The effectiveness of the traditional conservative method of treatment could be gainfully supplemented by use of the pharmaceutical preparation suggested in this study.

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Dis Colon Rectum 2002 Sep;45(9):1186-90; discussion 1190-1
A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy.
Balfour L, Stojkovic SG, Botterill ID, Burke DA, Finan PJ, Sagar PM.
Department of Surgery and Centre for Digestive Diseases, The General Infirmary at Leeds, United Kingdom.

PURPOSE: Patients consider hemorrhoidectomy to be a painful operation. Attempts to reduce the length of inpatient stay have concentrated mainly on a reduction in postoperative pain. Metronidazole has been shown to reduce pain after open hemorrhoidectomy. The aim of this study was to evaluate the effect of metronidazole after closed hemorrhoidectomy. METHODS: Thirty-eight patients undergoing closed hemorrhoidectomy were randomly allocated to receive metronidazole 400 mg (n = 18) or placebo (n = 20) three times daily for seven postoperative days. All patients received a stool softener and analgesics perioperatively. Linear analog scales were used to assess expected pain, actual pain and patient satisfaction. Time to first bowel movement, return to normal activity, complications, and use of additional analgesics were recorded. RESULTS: Both groups of patients experienced less pain than expected. Patients in the metronidazole group required fewer additional analgesics postoperatively (6.3 vs. 26.3 percent), and satisfaction scores in the placebo group were higher at one week (0.5 vs. 2.5), although these differences were not statistically significant. There were no differences in pain actually experienced, time to first bowel movement, return to normal activity, or complications between the two groups. Satisfaction scores at six weeks for all patients were relatively high, with no significant difference between the groups. CONCLUSION: Closed hemorrhoidectomy results in high patient satisfaction and low pain scores. The use of postoperative metronidazole did not reduce postoperative pain.

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Ugeskr Laeger 2002 Aug 12;164(33):3862-5
[Stapled anopexy for prolapsed hemorrhoids--a new operation]
[Article in Danish]
Raahave D.
Organkirurgisk afdeling, Tarm-Laboratoriet, Helsingor Sygehus, DK-3000 Helsingor. dera@fa.dk

INTRODUCTION: Haemorrhoidectomy is associated with pain and open wounds. A new closed technique uses an intraluminal stapler to replace the prolapsed haemorrhoidal tissue to a normal anatomical position (anopexy) and to interrupt the vessels. We report our results, including the learning curve. MATERIAL AND METHODS: Forty patients with grade 4 haemorrhoids underwent operation, 26 women, median age 47 years (33-86), and 14 men, median age 53 years (34-75). Outcome parameters were hospital stay, pain score, surgical anatomy score before and after the operation, and complications, symptom-control and patient satisfaction. RESULTS: Eleven patients left hospital on the day of operation, 19 the day after. The median pain score was 3 (2-10) for the first four days and 1 on day 7 (0-4). The postoperative surgical anatomy score was 1 (normal anus) in 24 patients, 2 in nine patients, which was not different significantly at follow up (p > 0.05). Postoperative bleeding required haemostasis in two patients. One patient had a stenosis temporarily, and two patients had persistent pain and faecal urgency, which disappeared. No sphincter lesions occurred. Control of symptoms and satisfaction were excellent in 20 patients, good in 11, and satisfactory in five. DISCUSSION: Stapled anopexy restored surgical anatomy towards normal, with moderate pain and few complications. Control of symptoms and patient-satisfaction was high. The procedure is a new option in the treatment of severe haemorrhoids rather than an alternative to open haemorrhoidectomy.

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Ann Ital Chir 2002 Mar-Apr;73(2):181-4; discussion 185-6
[Hemorrhoidectomy with stapler vs. traditional hemorrhoidectomy: comparative outcome of
2 groups of patients]
[Article in Italian]
Gentile M, Cricri AM, D'Antonio D, Bucci L.
Dipartimento di Chirurgia Generale, Geriatrica, Oncologica e Tecnologie Avanzate Universita degli Studi di Napoli Federico II.

Authors compare the results of two groups of patients, with III and IV degree haemorrhoids. The first group (48 patients) were treated with traditional surgery, open or closed. The second group (42 patients) treated with stapling haemorrhoidectomy. The groups were compared in order to determine if a true advantage exists regarding post-operative pain and functional recovery. Authors conclude that stapler haemorrhoidectomy, is somehow better in reducing the pain and offers a quick functional recovery. But the technique must be adopted in selected patients with mucosal prolapse, when the haemorrhoidal plexus is below the dentate line. In those cases, with inveterate mucosal prolapse, and thickened external fibrous tissue, or an irreducible prolapse of the external haemorrhoidal plexus, the choice must be carefully evaluated.

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Dis Colon Rectum 2002 Aug;45(8):1096-9
Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies.
Chen HH, Wang JY, Changchien CR, Chen JS, Hsu KC, Chiang JM, Yeh CY, Tang R.
Colorectal Section, Chang Gung Memorial Hospital, Kao-Hsiung, Taiwan, Republic of China.

PURPOSE: Posthemorrhoidectomy secondary hemorrhage is a rare but serious complication after hemorrhoidectomy. The determination of risk factors for this complication may provide information to improve outcome. A prospective study was conducted to determine the risk factors associated with posthemorrhoidectomy secondary hemorrhage. METHODS: We studied 4,880 patients who underwent an elective closed hemorrhoidectomy by 9 proctologists in a single institution between January 1994 and July 1996. The variables analyzed included age, gender, surgeon, surgeon's seniority, suture material, aseptic preparation, and use of antibiotics. The logistic regression model was used to assess the independent association of variables with posthemorrhoidectomy secondary hemorrhage. RESULTS: Among the 4,880 patients, 45 (0.9 percent) developed posthemorrhoidectomy secondary hemorrhage. The mean interval from operation to the onset of secondary hemorrhage was 8.8 (range, 5-19) days. Multivariate analysis revealed that patient's gender and individual surgeons were both independently associated with risk of hemorrhage. Male patients were more likely than females to develop posthemorrhoidectomy secondary hemorrhage (relative risk, 2.1; 95 percent confidence interval, 1.1-4.1; P = 0.021). The posthemorrhoidectomy secondary hemorrhage rates among individual surgeons ranged from 0.2 to 2.4 percent (P = 0.003). CONCLUSION: Our data suggest that male patients are more likely to develop posthemorrhoidectomy secondary hemorrhage than female patients and that intersurgeon variability is highly correlated with this risk.

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Chir Ital 2002 May-Jun;54(3):389-94
[Our experience in the treatment of hemorrhoids and circumferential mucosal rectal prolapse using Longo muco-prolapsectomy]
[Article in Italian]
Trentin G, Agresta F, Mainente P, Ciardo L, Michelet I, Bedin N.
U.O. di Chirurgia Generale, Presidio Ospedaliero di Vittorio Veneto (TV), Azienda ULSS n. 7 della Regione Veneto.

The authors report their experience with the treatment of hemorrhoid disease and circumferential mucosal rectal prolapse with the use of a mechanical suturing device, according to the Longo technique. Over the period from March 98 to December 2000, 106 patients were treated with the above-mentioned procedure (100 patients for haemorrhoids and 6 for circumferential prolapse). Twenty-one patients had grade 4, 77 grade 3 and only 2 grade 2 disease. One hundred patients were followed up over a median period of 16.5 months (for the group with haemorrhoids) and 19 months (for the prolapse group). In 81% of cases the procedure was one-day surgery. Mucohaemorrhoidectomy with a stapler was well tolerated in terms of severity of postoperative symptomatology: in 42% of the patients operated on there was no need for any analgesic treatment. The time to return to work was 9.9 days for self-employed subjects and 15.6 days for the others. Refinement of the procedure and better patient selection may improve the results achieved with this technique. Stapled haemorrhoidectomy may be regarded as a sound technique that should be part of the surgeon's armamentarium. We suggest an "eclectic" approach whereby the stapling procedure may be included among the possible therapeutic options, with a view to optimising the choice of therapy for each individual patient.

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Arzneimittelforschung 2002;52(7):515-23
Local treatment of hemorrhoidal disease and perianal eczema. Meta-analysis of the efficacy and safety of an Escherichia coli culture suspension alone or in combination with hydrocortisone.
Wienert V, Heusinger JH.
University Hospital, Aachen, Germany. anvowie@aol.com

The objective of this paper was to assess the available clinical data on the efficacy and safety of ointments containing either a bacterial culture suspension (BCS) from Escherichia coli or a combination of BCS with hydrocortisone (CAS 50-23-7) (BCS: Posterisan, and BCS + HC: Posterisan forte). The BCS is assumed to act by immunomodulation in hemorrhoidal disease and perianal eczema. Six randomized, double-blind trials are reported: three of them using BCS ointment and one using BCS + HC, against ointment base, and two trials using BCS + HC against hydrocortisone ointment alone. Patients with hemorrhoids and/or perianal eczema were included and treated over 2 weeks with weekly assessments. Efficacy parameters included score changes for burning, itching, redness and soiling as well as the investigators' overall efficacy rating. Safety was assessed from adverse drug reactions and an overall safety rating. Out of 1,070 patients (mean age 50 years), 273 received BCS and 229 BCS + HC; 568 patients were given the various controls. In the overall efficacy rating, BCS ointment was significantly superior to the ointment base in all three studies (p = 0.028, p = 0.016, and p = 0.045). Moreover, BCS + HC was superior to the ointment base (p < 0.001) and to hydrocortisone alone (p = 0.156 and p = 0.021), confirming the distinct effect of the E. coli suspension. Satisfactory results were achieved in 83% of patients after the BCS + HC combination, 77% after BCS-containing ointment, 75% after hydrocortisone ointment and 52% after ointment base. Symptom scores decreased consistently more after administration of BCS than after the ointment base (p = 0.095, p = 0.006, and p = 0.029), and likewise, the combination of BCS + HC was significantly superior to the ointment base (p < 0.001) and to hydrocortisone alone (p = 0.036 and p = 0.019). Adverse events were less frequent for BCS and BCS + HC than for the ointment base. It can therefore be concluded that ointments containing either only E. coli BCS or a combination of BCS and hydrocortisone provide significant relief in perianal eczema as well as in early stages of hemorrhoidal disease.

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J Med Assoc Thai 2002 Mar;85(3):345-50
Comparative study between multiple and single rubber band ligation in one session for bleeding internal, hemorrhoids: a prospective study.
Chaleoykitti B.
Department of Surgery, Phramongkutklao Hospital, Bangkok, Thailand.

OBJECTIVE: The aim of this study was to compare the cessation of bleeding and the complications between multiple and single ligation using high ligation technique. MATERIAL AND METHOD: All first-visit patients with bleeding internal hemorrhoids were studied and randomly divided into multiple and single ligation groups. High ligation technique was used. Patients visited the clinic in the second week and were invited to visit the clinic or completed questionnaires after one year. RESULTS: 109 patients were included in the study. 61 patients had multiple ligation and 48 patients had single ligation. The cessation of bleeding in one week occurred in 96.7 per cent of patients in the multiple group and 79 per cent of patients in the single group (p = 0.004). There were no differences between the multiple group and single group concerning postligation pain and tenesmus (6.5% vs 2%, p = 0.532), urinary hesitancy and frequency (6.5% vs 4%, p = 0.904), and rebleeding in one year (27.9% vs 34%, p = 0.710). No major complications such as massive bleeding and pelvic sepsis were noted. CONCLUSIONS: Multiple ligation of bleeding internal hemorrhoids in one session can stop bleeding better than single ligation with no more complications.

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Ann R Coll Surg Engl 2002 May;84(3):172-4
Rubber band ligation of haemorrhoids in the out-patient clinic.
Kumar N, Paulvannan S, Billings PJ.
Department of Surgery, Wrexham Maelor Hospital, UK. nkumar1402@hotmail.com

Rubber band ligation (RBL) is an effective treatment for symptomatic haemorrhoids but carries significant morbidity. We performed a prospective study of 98 consecutive patients treated by RBL in the out-patient clinic. Immediate, intermediate (within 2 weeks) and late (within 2 months) complications were recorded. Immediate complications occurred in 66 (67.3%) patients. Pain was the predominant symptom in 50 patients (51%). Fifteen (15.3%) patients had vasovagal attacks and 1 (1%) had bleeding. Twenty-five patients (25.5%) were unable to perform normal activities on the day of RBL. One patient needed hospital admission for control of pain. Seventy four (75.5%) patients would have RBL if they needed further treatment for haemorrhoids. Symptomatic cure was achieved in 71 patients (72.4%). RBL is an effective treatment but with significant complications. Patients should be adequately warned, especially of pain and vasovagal attacks.

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Dis Colon Rectum 2002 Jun;45(6):789-94
Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique.
Chung CC, Ha JP, Tai YP, Tsang WW, Li MK.
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong Special Adminisrative Region, China.

PURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel, bipolar scissors, and the conventional scissors excision-ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

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Dis Colon Rectum 2002 Mar;45(3):416-7
Modified Longo's hemorrhoidectomy.
Lloyd D, Ho KS, Seow-Choen F.
Department of Colorectal Surgery, Singapore General Hospital.

The Longo technique of stapled hemorrhoidectomy is rapidly gaining world-wide acceptance. However, hemorrhoids with large external components are often left with troublesome skin tags after the Longo technique. In this article we present modifications to the Longo technique that make it easier to perform and provide adequate treatment of hemorrhoids that have a significant external component or skin tags.

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Dis Colon Rectum 2002 Mar;45(3):360-7; discussion 367-9
Early experience with stapled hemorrhoidectomy in the United States.
Singer MA, Cintron JR, Fleshman JW, Chaudhry V, Birnbaum EH, Read TE, Spitz JS, Abcarian H.
Department of Surgery, University of Illinois, Chicago 60612, USA.

INTRODUCTION: We report the early results of patients treated with stapled hemorrhoidectomy, which has recently been introduced into the United States. METHODS: Sixty-eight patients with symptomatic hemorrhoids were treated at two institutions with the Proximate HCS Hemorrhoidal Circular Stapler supplied by Ethicon Endo-Surgery. Patients were prospectively evaluated for functional recovery and postoperative pain on a 1 to 10 scale. RESULTS: There were 45 (66 percent) males and 23 (34 percent) females with a mean age of 56 years and median duration of symptoms of 5 years. The mean operative time was 22.2 minutes. The operation was performed with spinal (50 percent), local (40 percent), or general (10 percent) anesthesia and as an outpatient (56 percent) or overnight admission (44 percent). Ninety-three percent of patients remained asymptomatic with a mean follow-up of 34 weeks, whereas the remaining 7 percent required either surgical excision or rubber band ligation for persistent symptoms. There was no mortality, new incontinence, fecal impaction, or persistent pain. The total morbidity was 19 percent, with urinary retention as the most common complication (12 percent). The mean pain score decreased from 3.6 on postoperative Day 1 to 1.4 at postoperative Day 7. Ninety-nine percent of patients made a complete functional recovery by postoperative Day 7. CONCLUSIONS: Stapled hemorrhoidectomy is safe, effective, and can be performed as an outpatient procedure with local or regional anesthesia. There seems to be minimal postoperative pain and early recovery, although a benefit over traditional hemorrhoidectomy needs to be proven in a randomized trial.

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Dis Colon Rectum 2002 Mar;45(3):354-9
Harmonic scalpel hemorrhoidectomy: five hundred consecutive cases.
Armstrong DN, Frankum C, Schertzer ME, Ambroze WL, Orangio GR.
Georgia Colon & Rectal Surgical Clinic, Atlanta 30342, USA.

PURPOSE: The aim of this study was to evaluate the incidence of postoperative complications after Harmonic Scalpels hemorrhoidectomy and to identify any predisposing factors leading to postoperative complications. METHODS: Five hundred consecutive cases of Harmonic Scalpel hemorrhoidectomy were studied in a prospective manner. Postoperative complications were recorded, and any predisposing factors were evaluated. RESULTS: Three hundred fifty-five patients (71 percent) underwent Harmonic Scalpel hemorrhoidectomy alone. One hundred twenty patients (24 percent) underwent additional fissurectomy/sphincterotomy for fissure-in-ano, and 25 patients (5 percent) underwent additional fistulotomy. A total of 24 (4.8 percent) patients experienced some form of postoperative complication. Three patients (0.6 percent) experienced a secondary postoperative hemorrhage requiring reexploration under anesthesia. Two of the three patients were taking postoperative oral Toradol, and both had undergone an "open" hemorrhoidectomy technique. The third patient required suture ligation of multiple bleeding sites on two separate occasions at 7 and 14 days postoperatively. The patient was subsequently diagnosed as having Ehlers-Danlos syndrome. One patient experienced postoperative incontinence to flatus and stool. The patient had large, Grade TV postpartum hemorrhoids and had undergone a three-quadrant closed hemorrhoidectomy. The sphincter mechanism was intact on postoperative ultrasound, and an underlying pudendal neuropathy likely contributed to the sphincter dysfunction. Postoperative urinary retention was noted in 10 (2 percent) patients, postoperative fissure in 5 (1 percent), and abscess/fistula in 4 (0.8 percent). One patient (0.2 percent) required readmission for colonic pseudo-obstruction. CONCLUSION: Harmonic Scalpel hemorrhoidectomy is a safe surgical modality, and postoperative complication rates compare favorably with previously published studies. The combination of an "open" hemorrhoidectomy technique and prolonged oral Toradol administration may result in a higher incidence of postoperative hemorrhage.

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Am J Surg 2002 May;183(5):519-24
Initial experience with stapled anoplasty in the operative management of prolapsing hemorrhoids and mucosal rectal prolapse.
Orrom W, Hayashi A, Rusnak C, Kelly J.
Department of Surgery, Capital Health Region, 302-2020 Richmond Ave., Victoria, British Columbia, Canada V8R 6R5.

BACKGROUND: Excisional hemorrhoidectomy has remained the standard procedure in the operative management of hemorrhoids. Innovations in surgical technique have recently been introduced to try to decrease the pain associated with it. Stapled anoplasty has had promising early results in this regard. The aim of this study was to determine the ease or difficulty in introducing this new procedure, its efficacy, safety, and pain profile. DATA SOURCES: Nineteen patients underwent stapled anoplasty and were followed up from 8 weeks to 6 months postoperatively. Data were accrued through clinical evaluation and patient questionnaires. CONCLUSIONS: Seventy-two percent of patients had good to excellent results. There were no significant complications. Eighteen patients underwent surgery in an ambulatory setting and were discharged from hospital in a mean of 189 minutes. The procedure is safe and easily mastered. The staple line should be placed precisely at 3.5 to 4 cm from the dentate line to ensure greater efficacy.

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Rozhl Chir 2002 Apr;81(4):201-2
[Personal experience with the Barron method of treatment of hemorrhoidal nodules]
[Article in Czech]
Pivonka J, Andel P, Bartos J.
Chirurgicke oddeleni Statni nemocnice, Vitkov.

The authors present their experience with the treatment of haemorrhoidal nodes by Barron's method, having used this method for 2.5 years at the surgical department of the Vitkov hospital. By this method in 1999-2001 122 patients with clinical manifestations of grade I-III haemorrhoids were treated. In the described group six relapses were recorded.

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Khirurgiia (Sofiia) 2001;57(3-4):34-7
[Hemorrhoidal disease. Current surgical treatment and the place of Whitehead's operation]
[Article in Bulgarian]
Germanov G, Radionov M, Ziia D.

In the presented material a review of the current data and comprehensions of the anatomy and physiology of the hemorrhoids is made, as like of the ethiology and pathogenesis of the disease. The new conceptions of the surgical treatment of the disease are pointed out. An attempt was made to differentiate the operative methods in patogenetical principal. The operative results of the General Surgery Clinic by the University Hospital "St. Ann", Sofia for the period 1991-2000 of 157 treated patients with hemorrhoidal disease are presented. Based on these results the authors come to a conclusion, that the Whitehead's operation remains "the golden standard" as a choice of an operative method for the treatment of the hemorrhoidal disease in advanced stages (III-d or IV-th).

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Int J Colorectal Dis 2002 Jan;17(1):50-3
Comment in: Int J Colorectal Dis. 2002 Sep;17(5):362-3.
Modern stapled Longo procedure vs. conventional Milligan-Morgan hemorrhoidectomy: a randomized controlled trial.
Pavlidis T, Papaziogas B, Souparis A, Patsas A, Koutelidakis I, Papaziogas T.
Second Surgical Department, Medical College, Aristotles University of Thessaloniki, G Gennimatas Hospital, Greece. pavlidth@med.auth.gr

BACKGROUND AND AIMS: Postoperative pain is the most distressing sequela of conventional hemorrhoidectomy. A modern alternative of circumferential mucosectomy has been proposed to reduce the pain in this procedure. PATIENTS AND METHODS: This controlled trial included 80 patients with second to fourth degree hemorrhoidal disease operated on over a 2-year period. The patients were randomly allocated to undergo either the stapled Longo procedure (group 1) or Milligan-Morgan hemorrhoidectomy (group 2) under epidural anesthesia. The operating time, postoperative pain scores at 3, 6, 12, and 24 h, analgesic consumption, hospital stay, and complication rate were recorded. At follow-up the outcome and patient satisfaction were evaluated. RESULTS: The mean operating time in group 1 was shorter than in group 2, postoperative pain scores at all time points and the mean epidural morphine requirement was lower, and mean hospital stay was shorter. The complication rate did not differ (three cases of postoperative bleeding in group 1 and two cases in group. At follow-up no recurrence or complains were recorded except three cases of mild incontinence (one in group 1 and two in group 2). The patients in group 1 (95%) were more satisfied than in group 2 (89%). CONCLUSION: The Longo procedure is thus a simple, safe, and effective method that entails less postoperative pain, more satisfaction, and shorter hospital stay than the standard Milligan-Morgan hemorrhoidectomy.

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Am Fam Physician 2002 Apr 15;65(8):1629-32, 1635-6, 1639
Hemorrhoidectomy for thrombosed external hemorrhoids.
Zuber TJ.
Saginaw Cooperative Hospital, Michigan, USA.

External hemorrhoids represent distended vascular tissue in the anal canal distal to the dentate line. Persons with thrombosed external hemorrhoids usually present with pain on standing, sitting or defecating. Acutely tender, thrombosed external hemorrhoids can be surgically removed if encountered within the first 72 hours after onset. Hemorrhoidectomy is performed through an elliptic incision over the site of thrombosis with removal of the entire diseased hemorrhoidal plexus in one piece. Caution must be exercised to avoid cutting into the muscle sphincter below the hemorrhoidal vessels. Infection after suture closure is rare secondary to the rich vascular network in the anal area. Stool softeners must be prescribed postoperatively to help prevent tearing at the suture line. Training and experience in general and skin surgery are necessary before the physician attempts this procedure unsupervised.

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Chirurg 2002 Mar;73(3):269-73
[Doppler ultrasound assisted hemorrhoid artery ligation. A new therapy in symptomatic hemorrhoids]
[Article in German]
Arnold S, Antonietti E, Rollinger G, Scheyer M.
Chirurgische Abteilung, Krankenhaus der Stadt Bludenz, Spitalsgasse 13, 6700 Bludenz, Osterreich. docarno@aon.at

In 1995, Morinaga et al. (Japan) reported on a new technique in the treatment of hemorrhoids. We report the results of our first 105 patients thus treated. By a specially designed proctoscope coupled with a Doppler transducer, the hemorrhoidal arteries are looked for and ligated. All stages of hemorrhoid were treated. This method is painless, successful, and has a low rate of complications. It is for outpatients and is an alternative to all other methods in the treatment of hemorrhoids.

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Swiss Med Wkly 2002 Jan 26;132(3-4):38-42
Influence of stapler haemorrhoidectomy on anorectal function and on patients' acceptance.
Fantin AC, Hetzer FH, Christ AD, Fried M, Schwizer W.
Department of Internal Medicine, University Hospital of Zurich, Switzerland. dracfantin@bluewin.ch

PRINCIPLES: Symptomatic haemorrhoids surgery has been shown to be the most successful and definite therapy. Recently a new method using a transanally inserted circular stapler has been presented for treatment of symptomatic prolapsing haemorrhoids. This prospective study investigated the influence of the stapling procedure on the anorectal function and patients' acceptance. METHODS: Eighteen consecutive patients (10 males, 8 females) mean age 44.7 years (range 18- 66) with symptomatic second (n = 3), third (n = 14), and fourth degree (n = 1) haemorrhoids were included. All patients underwent the day before and 8 weeks after the operation a standardised anal manometry using a water perfused system. Mean resting (MRAP) and mean maximal squeeze anal pressures (MSAP) were recorded. Volumes of initial rectal sensation (VIRS), constant rectal sensation (VCRS), and maximal tolerable volume (MTV) of a rectal balloon were assessed. Anorectal symptoms (bleeding, pain, faecal incontinence) were assessed in a standardised fashion preoperatively and 1, 8, and 12 weeks postoperatively. RESULTS: The stapling procedure led to no manometric or symptomatic change in anal sphincter function. Pre- and postoperative MRAP (91.7 mm Hg, SD 23.59 / 83.8 mm Hg, SD 14.53, p = 0.053), MSAP (162.6 mm Hg SD 78.68 / 173.9 mm Hg, SD 69.93, p = 0.162), VIRS (55.8 ml, SD 26.12 / 51.7 ml, SD 28.90, p = 0.410), VCRS (109.4 ml SD 41.67/ 96.4 ml, SD 38.44, p = 0.181), and MTV (204.7 ml SD 47.65/ 173.3 ml, SD 43.22, p = 0.053) were similar. No symptoms of rectal pain or faecal incontinence were registered during follow up. Patients' acceptance and satisfaction for the operation were high. CONCLUSIONS: Stapling haemorrhoidectomy is a safe procedure which does not alter anorectal functions. Patients' acceptance and satisfaction are high.

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Chir Ital 2002 Jan-Feb;54(1):65-9
[A prospective study of 106 patients with hemorrhoids treated with PPH stapler.
Early and long-term results]
[Article in Italian]
Castagnola M, De Silva GM, Muia R, Ciferri E, Bertirotti S, Toccafondi G, Municino O, Bondanza GS.
U.O. Chirurgia Generale, Ospedale Gallino, Genova Pontedecimo, A.S.L. 3 Genovese, Via Ospedale Gallino 5, 16164 Genova.

Muco-mucosal resection with a PPH stapler according to Longo allows repair of arterial hyperaemia, venous dilation and mucosal prolapse. From September 1 1997 to October 31 2000 a prospective study was conducted in 106 patients. The results show that the Longo haemorrhoidectomy technique is well tolerated and almost painless, and is characterised by a low complication rate and good results in the long term.

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Zhongguo Zhong Xi Yi Jie He Za Zhi 2000 Dec;20(12):899-902
[Study on lumbricus in promoting ligation hemorrhoidectomy postoperative wound healing]
[Article in Chinese]
Li D, Wang P, Zeng Y.
Beijing Municipal Erlonglu Hospital, Beijing 100032.

OBJECTIVE: To investigate the effect of Lumbricus in promoting wound healing of ligation hemorrhoidectomy. METHODS: Spray the artificial grown fresh Lumbricus solution on the wound surface of the mixed hemorrhoid patients (treated group) after hemorrhoidectomy and also on wound of the experimental animals, and Lithospermum erythrorhizon medicated gauze was taken as control to observe the effect of treatment on wound healing and histologic change. RESULTS: The mean wound healing time of the treated group was 16.5 +/- 1.8 days, as compared to the control group (21.2 +/- 2.8 days), it was obviously shortened (P < 0.01), 3 days after medication, the growth of epidermis of the treated group was obviously more rapid than that of the control group, no wound infection and granulation hyperplasia were found. The experimental study showed that Lumbricus preparation could inhibit inflammation, bacteria such as Staphylococcus aureus, coli and proteus bacillus was inhibited. In comparison with the control group, the experimental group shortened the healing period for 4 days. On the 4th and 7th day, sacrificed rabbits' capillary count, vessel lumen endothelial cell count, and mesenchymal fibroblast count of the experimental group grower obviously than those of the control group, on the 4th day, the mesenchymal cell mitosis of the experimental group was higher than that of the control group, while on the 7th day, the cell nucleus mitotic index in the experimental group also was higher than that in the control group, from the 3rd day on, wound healing and granulation filling speed of the experimental group obviously more rapid than that of the control group. CONCLUSION: The Lumbricus preparation is cheap in price, easy to preserve, can be used in promoting wound healing, without any toxic and side-effects.

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Curr Med Res Opin 2001;17(4):256-61
Parenteral troxerutin and carbazochrome combination in the treatment of post-hemorrhoidectomy status: a randomized, double-blind, placebo-controlled, phase IV study.
Basile M, Gidaro S, Pacella M, Biffignandi PM, Gidaro GS.
Surgery Unit, University of Chieti-Pescara, Pescara Regional Hospital, Italy.

Flavonoids, such as troxerutin, have been shown to be safe and effective agents for the treatment of chronic venous insufficiency. The fixed combination between troxerutin 150 mg and carbazochrome 1.5 mg (Fleboside ampoules) was previously shown to have a good efficacy and safety profile in non-surgical patients with acute uncomplicated hemorrhoids. The purpose of this randomized, double-blind, placebo-controlled study was to investigate the efficacy and tolerability of the active combination in the treatment of post-hemorrhoidectomy patients. 30 patients were randomized to receive one of two treatments: troxerutin 150 mg and carbazochrome 1.5 mg, or placebo, i.m. 3 ml ampoules twice a day for five consecutive days after the surgical procedure, starting from the day of surgery. Efficacy parameters were assessed as follows: at baseline (T1), after the first administration (T2; day of surgery), the second day after the surgical procedure (T3), and the fifth day after the surgical procedure (T4); hemorrhoidal symptoms based on a visual analogue scale (VAS): pain, discharge, bleeding, inflammation, and pruritus; analgesic intake, if any; time to restore a physiological defecation; edema evaluation (based on a four-point scale: 0 = absent; 1 = mild; 2 = moderate; 3 = severe); camera pictures taken at T1 and T4 (in selected patients); and blood coagulation tests. Analysis between treatment groups revealed a highly significant difference at T3 and T4 for the total VAS score (p = 0.007 and p = 0.001, respectively) in favor of the active combination treatment. A statistically significant difference was also observed for bleeding and pruritus at T3 and for these two parameters and both inflammation and edema at T4 (p < 0.001) in favor of the active combination group. No adverse events were reported. Neither the active combination nor placebo affected blood coagulation tests. We conclude that intramuscular administration of the fixed combination of troxerutin 150 mg and carbazochrome 1.5 mg is effective, well tolerated and superior to placebo in improving hemorrhoidal and post-surgical symptoms during the five days following surgery.

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Gastrointest Endosc 2002 Apr;55(4):532-7
Retroflexed endoscopic band ligation of bleeding internal hemorrhoids.
Berkelhammer C, Moosvi SB.
Division of Gastroenterology, Christ Hospital, University of Illinois, Oak Lawn, Illinois, USA.

BACKGROUND: Elastic band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids, stages II-III. Usually, one or two bands are placed at a single session by using rigid instruments. The aim of this study was to assess the feasibility, tolerability, safety, and efficacy of multiple band ligation of internal hemorrhoids performed in one session by using a flexible endoscope with an attached band ligation device in the retroflexed position. METHODS: Eighty-three patients with chronically bleeding and/or prolapsing internal hemorrhoids were treated by retroflexed endoscopic band ligation. From 1 to 6 bands were placed in a single session. Bands were targeted at the apex and proximal body of the internal hemorrhoid so that final band placement was entirely proximal to the dentate line. Malpositioned bands were removed by using a novel method. Patients were followed prospectively to assess tolerance, complications, and efficacy. Retreatment was offered if the desired result was not achieved. RESULTS: A mean of 3.0 (SD 1.2) bands (range 1-6) were placed in a single session. Five percent of bands were malpositioned and removed. Patients were followed for 26 (17) months (range 1-52 months). An excellent result was achieved in 80% of patients with stage II hemorrhoids. Patients with stage II hemorrhoids were more likely to have an excellent result compared with patients with stage III hemorrhoids (80% vs. 54%, p < 0.01). Retroflexed endoscopic band ligation was well tolerated overall. The rate of major, nonfatal complications was 4%. CONCLUSIONS: Retroflexed endoscopic band ligation is a feasible, well-tolerated, effective, and safe for treatment of bleeding stage II internal hemorrhoids. A novel method of endoscopic band removal is described.

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Zentralbl Chir 2002 Jan;127(1):22-4
[Anal pressures after stapler hemorrhoidectomy—a prospective analysis of 33 patients]
[Article in German]
Weyand G, Webels F, Celebi H, Ommer A, Kohaus H.
Abteilung Koloproktologie, St. Josefs-Hospital, Wiesbaden.

PURPOSE: Determination of the effects of staplerhemorrhoidectomy as a new method of surgery, type of staplers and way of anal retraction on anal pressures. PATIENTS AND METHODS: In 33 patients (mean age 56 ys.) with third degree hemorrhoids who underwent staplerhemorrhoidectomy in the Marienhospital Gelsenkirchen between 1998 and 1999, anal resting and squeezing pressures were measured before and after the operation. On an average the postoperative examination was performed 47 days after operation. RESULTS: Anal resting pressures decreased significantly from 69 (23) to 58 (18) mmHg (p < 0.01) in contrast to the anal squeezing pressures (171 (60) and 170 (58) mmHg). There was a relatively greater decrease in anal resting pressure using a Parks' retractor in comparison to the use of a vaginal speculum. The decrease of resting pressure did not depend on the type of stapler used (Ethicon(c) SDH 33, n = 14 and Autosuture(c) CEEA 31, n = 19). CONCLUSION: Hemorrhoidectomy using a circular stapler leads to a significant reduction of the anal resting pressure, whereas squeezing pressures remain constant. The reduction is more pronounced if a Parks' retractor is used.

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Zentralbl Chir 2002 Jan;127(1):19-21
[Evaluation of Longo's technique for haemorrhoidectomy by doppler ultrasound measurement of the superior rectal artery]
[Article in German]
Kolbert GW, Raulf F.
Chirurgie II/Koloproktologie, Raphaelsklinik, Munster. g.kolbert@raphaelsklinik.de

Stapler-haemorrhoidectomy causes theoretically a durable reposition of the prolapsed haemorrhoidal cushions and a reduction of the arterial inflow by clipping mucosa and submucosa. Until now, however, no exact data exist with respect to a potential reduction of the arterial inflow. METHODS: The question of a sufficient interruption of the end branches of the superior rectal artery should be answered with doppler ultrasound measurements before and after stapler-haemorrhoidectomy. RESULTS: The measurements were performed on 45 patients before and one month after stapler-haemorrhoidectomy. Preoperatively in all patients the three main branches of the artery at three, seven and eleven o'clock could be detected by doppler ultrasound. In 67 % of the patients a fourth, in 16 % a fifth and in 13 % a sixth vessel could be located. One month postoperatively in 80 % of the patients all main branches were further seen. In 16 % of the cases two main vessels, in 4 % only one main vessel could be identified. There was no correlation between postoperative outcome and number of vessels detected postoperatively. CONCLUSION: It is concluded that the postoperative outcome after stapler-haemorrhoidectomy does not depend on the complete interruption of the arterial inflow of the haemorrhoids. The complete reposition of the haemorrhoidal prolapse and thereby the improvement of the venous reflux out of the haemorrhoidal cushions might be more important.

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Zentralbl Chir 2002 Jan;127(1):9-14
[Results two years after stapler hemorrhoidectomy versus Milligan-Morgan procedure]
[Article in German]
Ebert KH, Meyer HJ.
Chirurgische Klinik, St. Martinus-Hospital gGmbH, Olpe. chirurg.oe@t-online.de

The aim of this investigation was to demonstrate possible advantages of stapler hemorrhoidectomy in comparison to the Milligan-Morgan procedure. 96 patients with an average age of 54 years were treated in a two year period (7/1998-8/2000) by stapler hemorrhoidectomy. The complication rate was 12.5 % and included one mechanical stapler defect, two cases of bleeding, five cases of urinary retention and four of perianal edema. The use of analgesics was small with 70 % requiring no medication at all. Hospitalisation post-operatively was 3.3 days with patients under 65 years old and 4.7 days in those over 65 years. These data were compared retrospectively to that of Milligan-Morgan hemorrhoidectomy (214 patients) performed between January 1990-December 1997. The stapler patients had less pain, fewer complications and shorter hospitalisation.Using a questionnaire, all stapler patients and 50 Milligan-Morgan controls were evaluated. 78 % responded at 13.8 months after stapler hemorrhoidectomy, 63 % 54.1 months after Milligan-Morgan. The degree of satisfaction was high in both groups (93 vs 94 %). One patient in the Milligan-Morgan group suffered a recurrence. No further symptoms had been experienced by 57 % after stapler, 68 % after Milligan-Morgan procedure. Faecal continence represents a problem in the stapler group.Stapler hemorrhoidectomy is an effective treatment for IIIrd degree hemorrhoids. In comparison to the Milligan-Morgan procedure, it has advantages in the early post-operative period. Defecation problems can occur with an unknown prognosis. Without long-term results and because of the comparatively high cost of the procedure the indication for stapler hemorrhoidectomy should be carefully made.

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Arch Surg 2002 Mar;137(3):337-40
Stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial.
Hetzer FH, Demartines N, Handschin AE, Clavien PA.
Department for Visceral and Transplantation Surgery, University Hospital of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.

HYPOTHESIS: Stapled hemorrhoidectomy offers several advantages over excision hemorrhoidectomy, including reduced postoperative pain, a reduced hospital stay, and an earlier recovery time. Furthermore, stapled hemorrhoidectomy is associated with lower hemorrhoidal recurrence on long-term follow-up. DESIGN: A randomized prospective trial. Patients were blinded to the operation technique used. Follow-up occurred at 1 and 3 weeks and 12 months postoperatively. SETTING: A university hospital providing primary, secondary, and tertiary care. PATIENTS: Forty patients with second- and third-degree hemorrhoid disease were randomized to undergo either stapled or excision hemorrhoidectomy. Two patients were excluded. All patients were subject to a follow-up examination. INTERVENTIONS: Stapled hemorrhoidectomy (Longo technique) vs excision hemorrhoidectomy (Ferguson technique). MAIN OUTCOME MEASURES: Operating time, postoperative pain (measured by the visual analog scale), hospital stay, histologic features, morbidity, defecation habit, continence, recovery time (return to work), and hemorrhoid recurrence at 1 year. RESULTS: Stapled vs excision hemorrhoidectomy was associated with a significantly reduced operating time (30 vs 43.25 minutes; P<.001), reduced postoperative pain scores (visual analog score) on the first 4 postoperative days (day 1: 2.7 vs 6.3; day 2: 1.7 vs 6.3; day 3: 0.8 vs 5.4; and day 4: 0.5 vs 4.8, where 0 indicates no pain, and 10, maximum pain; P < or = .001), and an earlier return to work (6.7 vs 20.7 days;P =.001). There were no differences for stapled vs excision hemorrhoidectomy in length of hospital stay (2.4 vs 2.1 days), complications (3 [15%] of 20 patients vs 5 [25%] of 20 patients), and recurrence rate (1 [5%] of 20 patients vs 1 [5%] of 20 patients). CONCLUSIONS: Stapled hemorrhoidectomy is associated with reduced postoperative pain, earlier recovery time and return to work, and a similar recurrence rate compared with the excision technique. Provided further clinical trials confirm these findings, stapled hemorrhoidectomy may become a future gold standard.

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Surg Today 2002;32(1):40-7
A prospective randomized comparison between an open hemorrhoidectomy and a semi-closed (semi-open) hemorrhoidectomy.
Mikuni N, Oya M, Komatsu J, Yamana T.
Department of Surgery, Koshigaya Hospital Dokkyo University School of Medicine, Koshigaya, Saitama, Japan.

A semi-closed hemorrhoidectomy is a popular surgical procedure among Japanese coloproctologists because it is thought that the risk of postoperative bleeding is reduced, and postoperative pain is milder after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. However, no prospective randomized trial comparing an open and semi-closed hemorrhoidectomy has yet been published. We conducted a prospective randomized trial comparing both clinically and physiologically an open and semi-closed hemorrhoidectomy. Thirty-four consecutive patients undergoing a hemorrhoidectomy for third-degree hemorrhoids were randomized to receive either an open hemorrhoidectomy (n = 17) or a semi-closed hemorrhoidectomy (n = 17). Postoperative pain was evaluated using an analog scale by the patients themselves. An anorectal physiological study was performed before the operation and 2 months after the operation. Pain at 1 week after operation was significantly more severe after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. The postoperative physiological parameters including sphincter pressures did not differ between the two forms of hemorrhoidectomy. However, younger patients and patients having higher sphincter pressures preoperatively had more severe pain at 2 weeks after a semi-closed hemorrhoidectomy. Although both forms of hemorrhoidectomy appear to be almost equivalent, the degree of early postoperative pain may be less after an open hemorrhoidectomy in both young patients and in those patients having high preoperative anal sphincter pressures.

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