Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network.

BACKGROUND: The anal symptoms occurring during pregnancy and post-partum, mainly related to Haemorrhoidal Disease (HD), have been reported with in a wide range of incidence in the literature. Although in many cases the course of the disease is mild and self-limiting, sometimes it is severe enough to affect quality of life. METHODS: Our study has been conducted through a questionnaire administered via social media with the aim of obtaining epidemiologic data on the incidence of the symptoms of HD in an unselected population of pregnant women. In addition, we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake). RESULTS: Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester. Constipation, straining on the toilet, low dietary fibres and fluid intake were not significantly related to incidence of HD. Only a previous history of HD was correlated to onset of symptoms of HD in pregnancy and reached a statistical significance (odds ratio = 5.2, p < 0.001). CONCLUSION: Although with the limitations posed by the nature of our retrospective study via a self-assessment interview, our results suggest that the occurrence of HD in pregnancy seems not sustained by the classical risk factors observed in the general population. At the moment, specific therapeutic measures are lacking and treatment relies on empiric suggestions concerning diet, fluid intake, bowel care, local ointment. Further studies are needed in order to identify a targeted etiologic treatment.

Analgesic effect of local anaesthetic in haemorrhoid banding: systematic review and meta-analysis.

PURPOSE: Rubber band ligation of haemorrhoids can be,painful and there is no consensus regarding the optimal analgesic strategy. This study aims to determine whether there is a difference in post-procedural pain in adults undergoing haemorrhoid banding who have received local anaesthetic, a pudendal nerve block or no regional or local analgesia. METHODS: MEDLINE, Embase, Google Scholar and clinical trial registries were searched for randomised trials of local anaesthetic or pudendal nerve block use in banding. Primary outcomes were patient-reported pain scores. The quality of the evidence was assessed using the GRADE approach. RESULTS: Seven studies were included in the final review. No articles were identified that studied pudendal nerve blocks. The difference in numerical pain scores between treatment groups favoured the local anaesthetic group at all timepoints. The mean difference in scores on a 10-point scale was at 1 h,-1.43 (95% CI-2.30 to-0.56, p < 0.01, n = 342 (175 in treatment group)); 6 h,-0.52 (95% CI-1.04 to 0.01, p = 0.05, n = 250 (130 in treatment group)); and 24 h,-0.31 (95% CI-0.82 to 0.19, p = 0.86, n = 247 (127 in treatment group)). Of reported safety outcomes, vasovagal symptoms proceeded to meta-analysis, with a risk ratio of 1.01 (95% CI 0.64-1.60). The quality of the evidence was rated down to 'low' due to inconsistency and imprecision. CONCLUSION: This review supports the use of LA for reducing early post-procedural pain following haemorrhoid banding. The evidence was limited by small sample sizes and substantial heterogeneity across studies. REGISTRATION: PROSPERO (ID CRD42022322234).

Identification of the microRNA alterations in extracellular vesicles derived from human haemorrhoids.

NEW FINDINGS: What is the central question of this study? What are the morphological features and microRNA (miRNA) expression features of extracellular vesicles (EVs) from haemorrhoids (Hae-EVs) and normal tissues? What are the potential functions of the differentially expressed (DE) miRNAs in Hae-EVs? What is the main finding and its importance? We present, for the first time, the morphological features and miRNA profile of human Hae-EVs. Four hundred and forty-seven significant DE-miRNAs were identified. Gene ontology and pathway analysis of the DE-miRNAs indicated diverse roles of the Hae-EVs through different pathways. Our findings provide EV-based pathological features and the underlying mechanism of haemorrhoids. ABSTRACT: Extracellular vesicles (EVs) play important roles in many pathophysiologies as cell-to-cell communication vehicles. However, the features and potential functions of the EVs in haemorrhoids remain unclear. Therefore, we performed microRNA (miRNA) microarray analysis in EVs derived from haemorrhoid tissue to identify the profile of miRNAs in these EVs and predict their potential functions. We obtained typical EVs from both haemorrhoid and control tissues. Microarray analysis identified 447 miRNAs with significant differential expresssion (DE): 245 upregulated and 202 downregulated. The top three upregulated miRNAs in haemorrhoid EVs (Hae-EVs), namely miR-6741-3p, miR-6834-3p and miR-4254, were detected by RT-qPCR in both Hae-EVs and haemorrhoid tissues. Interestingly, we found a different expression pattern in the haemorrhoid tissues from that in Hae-EVs. The potential target genes of these DE-miRNAs were predicted by the miRWalk and miRDB databases. Gene ontology (GO) analysis of the target genes showed that the DE-miRNAs contributed mainly to protein kinase activity, transcriptional activity and ubiquitin-protein function. KEGG search found that the DE-miRNAs might regulate the MAPK and Ras signalling pathways. These findings revealed, for the first time, the miRNA profiles in Hae-EVs and provided potential targets and pathways involved in the pathological process.

The efficacy of laser haemorrhoidoplasty (LHP) in the treatment of symptomatic haemorrhoidal disease: An observational cohort study.

AIM: Laser haemorrhoidoplasty (LHP) is an emerging nonexcisional surgical procedure in which the arteriovenous flow of the haemorrhoidal plexus is interrupted through laser coagulation. The aim of this cohort study was to assess efficacy of LHP in treating symptomatic haemorrhoidal disease through patient satisfaction, remission of symptoms (blood loss, pain, itching, soiling, mucosal prolapse) and recurrence of haemorrhoids. METHODS: Patients who underwent treatment for symptomatic haemorrhoids (degrees 1-4) through an LHP procedure between 2015 and 2021 were included in the study. A 1470 nm-diode laser was used. A total of 200 patients (71% male, average age 51 years) were analysed. Primary outcomes were patient satisfaction and/or complete recovery of symptoms. Secondary outcomes were operating time, complications and recurrence rates. Patient satisfaction, postoperative blood loss, pain and complications were evaluated 6-7 weeks postoperatively. Room turnover time and operating time were documented. Recurrence of haemorrhoids following LHP treatment within 1 year was evaluated. RESULTS: Patient satisfaction regarding LHP treatment was reached in 155 (84,7%) patients. Postoperative blood loss was reported by 44 (24,0%) patients during time of evaluation. Twenty-four (13,1%) patients reported postoperative pain after 6-7 weeks. Postoperative complications occurred in seven patients (3 anal fissures, 2 perianal abscess, 1 perianal fistula, 1 postoperative anaemia). Room turnover time (patient in to patient out) was 21 min with an average operating time of 7 min. Recurrence of haemorrhoids within 1 year occurred in 50 (27,3%) patients. CONCLUSIONS: Laser haemorrhoidoplasty appears to be a promising and effective nonexcisional surgical procedure in the treatment of symptomatic haemorrhoidal disease with high patient satisfaction, acceptable postoperative symptoms, minimal complications and short operating times.

High risk of complications after a "low risk" procedure: A national study of nursing home residents and older adults undergoing haemorrhoid surgery.

AIM: To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery. METHOD: This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents. RESULTS: A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p < 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p < 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence. CONCLUSION: This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.

Sclerotherapy with 3% polidocanol foam to treat second-degree haemorrhoidal disease: Three-year follow-up of a multicentre, single arm, IDEAL phase 2b trial.

BACKGROUND: Sclerotherapy with 3% polidocanol foam is becoming increasingly popular for the treatment of symptomatic I-II or III degree haemorrhoidal disease (HD). However, there are no studies that have reported a follow-up of more than 1 year. The purpose of this study was to analyse the long-term outcomes of sclerotherapy with 3% polidocanol foam in the treatment of II-degree HD. METHODS: This was an open label, single-arm, phase 2b trial conducted in 10 tertiary referral centres for HD. A total of 183 patients with II-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification and unresponsive to medical treatment, were included in the study and underwent sclerotherapy with 3% polidocanol foam. The efficacy was evaluated in terms of bleeding score, haemorrhoidal disease symptom score (HDSS) and short health scale for HD (SHS-HD) score. Successful treatment was defined as the complete absence of bleeding episodes after 7 days (T1) according to the bleeding score. RESULTS: The overall success rate ranged from 95.6% (175/183) at 1 year to 90.2% (165/183) after the final 3 year follow-up. The recurrence rate, based on the primary outcome, ranged from 12% (15/125) to 28% (35/125). The greatest increase in recurrence (15) was recorded between 12 and 18 months of follow-up, then another five between 18 and 24 months. Both the HDSS and the SHS score remained statistically significant (p < 0.001) from a median preoperative value of 11 (10-13) and 18 (15-20) to 0 (0-2) and 4 (0-4), respectively. Symptom-free (HDSS = 0) patients, excluding patients converted to surgery, increased from 55.5% (101/182) at 1 year to 65.1% at 3 years (110/169). There were no intraoperative complications in redo-sclerotherapy nor additional adverse events (AEs) compared to the first 12 months. CONCLUSIONS: Sclerotherapy with 3% polidocanol foam is gradually establishing itself in the treatment of bleeding HD due to its repeatability, safety, convenience in terms of direct and indirect costs with the absence of discomfort for the patient as well as AEs rather than an excellent overall success rate.

Quality of life and outcomes after rubber band ligation for haemorrhoidal disease.

PURPOSE: The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores. METHODS: This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications. RESULTS: A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%). CONCLUSION: Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

French multicentre prospective evaluation of radiofrequency ablation in the management of haemorrhoidal disease.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) in the management of haemorrhoidal disease with 1 year's follow-up. METHOD: This prospective multicentre study assessed RFA (Rafaelo©) in outpatients with grade II-III haemorrhoids. RFA was performed in the operating room under locoregional or general anaesthesia. Primary endpoint was the evolution of a quality-of-life score adapted to the haemorrhoid pathology (HEMO-FISS-QoL) 3 months after surgery. Secondary endpoints were evolution of symptoms (prolapsus, bleeding, pain, itching, anal discomfort), complications, postoperative pain and medical leave. RESULTS: A total of 129 patients (69% men, median age 49 years) were operated on in 16 French centres. Median HEMO-FISS-QoL score dropped significantly from 17.4/100 to 0/100 (p < 0.0001) at 3 months. At 3 months, the rate of patients reporting bleeding (21% vs. 84%, p < 0.001), prolapse (34% vs. 91.3%, p < 0.001) and anal discomfort (0/10 vs. 5/10, p < 0.0001) decreased significantly. Median medical leave was 4 days [1-14]. Postoperative pain was 4/10, 1/10, 0/10 and 0/10 at weeks 1, 2, 3 and 4. Seven patients (5.4%) were reoperated on by haemorrhoidectomy for relapse, and three for complications. Reported complications were haemorrhage (3), dysuria (3), abscess (2), anal fissure (1), external haemorrhoidal thrombosis (10), pain requiring morphine (11). Degree of satisfaction was high (+ 5 at 3 months on a - 5/+ 5 scale). CONCLUSION: RFA is associated with an improvement in quality of life and symptoms with a good safety profile. As expected for minimally invasive surgery, postoperative pain is minor with short medical leave. CLINICAL TRIAL REGISTRATION AND DATE: Clinical trial NCT04229784 (18/01/2020).

Protocol for the ORION trial (RadiO fRequency ablatION for haemorrhoids): a randomised controlled trial.

BACKGROUND: Haemorrhoids are common and can significantly impact the personal and working lives of individuals. Those with more severe symptoms and those not responding to conservative management may require surgery. Current surgical techniques are associated with a degree of postoperative discomfort which may delay return to normal activity. Recurrence is lower in more radical procedures but resulting pain is higher. Radiofrequency ablation (RFA) is a new technique that is gaining popularity and has several hypothesised benefits, including reduced pain and recurrence. However, available evidence is limited. A recent overview from the National Institute for Health and Clinical Excellence recommended more research, in the form of randomised controlled trials, be carried out before further investment is made by national health services. Our aim is to assess whether RFA is at least as good in terms of recurrence as existing surgical interventions, but superior in terms of pain, for patients with symptomatic grade II and III haemorrhoids. METHODS: The RadiO fRequency ablatION for haemorrhoids (ORION) trial will be a pragmatic multicentre patient/assessor-blind parallel group-controlled trial with economic evaluation. The target sample size is 376 participants (188 per arm) and is based on two co-primary endpoints: (i) a non-inferiority design for recurrence and (ii) superiority design for pain at seven days. Participants with grade II or III haemorrhoids will be recruited in 16 National Health Service hospitals and randomised (1:1) to either RFA or surgeon's choice of surgery. CONCLUSIONS: Results will inform future practice for the treatment of grade II-III haemorrhoids and provide evidence for national health services on future investments in RFA. TRIAL REGISTRATION: ISRCTN14474552.

Systematic review and meta-analysis of postoperative pain and symptoms control following laser haemorrhoidoplasty versus Milligan-Morgan haemorrhoidectomy for symptomatic haemorrhoids: a new standard.

PURPOSE: Haemorrhoidal disease (HD) plagues one in every ten people, with a plethora of surgical treatment modalities, of which laser haemorrhoidoplasty (LHP) is a relatively novel option. This systematic review and meta-analysis objectively evaluated the efficacy, safety, and tolerability of LHP compared against conventional (Milligan-Morgan) open haemorrhoidectomy (CoH). METHOD: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Google Scholar was conducted. Randomised controlled trials (RCTs) and comparative cohort studies (CCSs) which compared LHP against CoH were included, with postoperative pain as the primary outcome. Secondary outcomes included intraoperative characteristics, short- and moderate-term outcome, and complications. RESULTS: A total of 12 studies (6 RCTs and 6 CCSs), with a total of 1824 patients, were analysed. LHP resulted in reduced postoperative pain for the first day (mean difference of 2.07 visual analogue scale units), week, and month. The mean dosage and duration of postoperative analgesia use was similarly lower, with a mean difference of 4.88 mg (morphine) and 2.25 days, respectively. Crucially, recurrence was equivocal (HR: 0.72, CI: 0.21-2.40) at a mean follow-up duration of 8.58 ± 9.55 months. LHP resulted in lower blood loss and was 12.74 min shorter on average. LHP's postoperative recovery time was 9.03 days less with equivalent or decreased risk of most short- and moderate-term complications except anal thrombosis. CONCLUSION: Our study suggests that LHP is more tolerable than CoH, providing patients with superior postoperative quality of life at equivalent moderate-term efficacy. These findings contribute to improved understanding of LHP and its potential at enhancing the quality of HD care.

Guidelines, guidelines and more guidelines for haemorrhoid treatment: A review to sort the wheat from the chaff.

AIM: Guidelines benefit patients and clinicians by distilling evidence into easy-to-read recommendations. The literature around the management of haemorrhoids is immense and guidelines are invaluable to improve treatment integrity and patient outcomes. We identified current haemorrhoid guidelines and assessed them for quality and consistency. METHODS: A systematic search of the literature from January 2011 to October 2021 was carried out. Guidelines identified were assessed for quality using the AGREE II instrument and for consistency in terms of tabulated treatment recommendations. RESULTS: During this period nine guidelines were identified worldwide. The general quality was poor with only one guideline considered of high enough quality for use. In general, expert selection criteria for guideline development groups were vaguely defined. There were inconsistencies in the interpretation of the published evidence leading to variation in treatment recommendations. DISCUSSION: Fewer, higher quality guidelines, with more consistent results, are needed. Particular attention should be given to defining the selection of experts involved.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM).

BACKGROUND: The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. METHODS: A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. RESULTS: There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18-75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125). Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred. CONCLUSIONS: Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

Early and midterm results of radiofrequency ablation (Rafaelo® procedure) for third-degree haemorrhoids: a prospective, two-centre study.

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years. METHODS: We conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine. RESULTS: Ninety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization. CONCLUSIONS: RFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years.

Radiofrequency thermocoagulation of haemorrhoidal bundles, an alternative technique for the management of internal haemorrhoids.

PURPOSE: To describe our experience of radiofrequency thermocoagulation (RFT), assessing patient symptoms and quality of life (QoL) before and after the intervention. METHODS: Between April 2016 and April 2018, 42 outpatients were operated for internal haemorrhoids using RFT. Haemorrhoids were externalised to the anal margin and treated by using the Rafaelo® procedure, using the HPR45i probe (F-Care-Systems) under general anaesthesia. Assessment was performed prior to the intervention and during follow-up for prolapse degree using the Goligher scale; bleeding, improvement, and satisfaction using a verbal analogical scale; and the burden of haemorrhoidal disease using the HEMO-FISS-QoL questionnaire. RESULTS: In September 2018, 39 patients (26 males, mean age 51 [22-77]) were interviewed after an RFT intervention, during which a mean of 4.296 J was applied per patient. After a mean follow-up of 15 months, bleeding drastically decreased from 7/10 to 1/10 (p < 0.0001) and entirely stopped in 62% of patients. Prolapse significantly reduced from grade 3 to 2 (p < 0.0001) and completely disappeared in 9 out of 33 patients. Only 49% required postoperative level 2 analgesics, and 7 external thromboses were the only complication reported. Average incapacity for work was 1.72 days. All patients reported improvement of haemorrhoidal disease with a satisfaction rate mean score + 4/5. Haemorrhoidal discomfort decreased from 7/10 to 2/10 (p < 0.0001). HEMO-FISS-QoL score significantly improved, dropping from 24.91 to 5.94 (p < 0.001). Among all patients, 85% would choose RFT again if necessary and 90% would recommend it. CONCLUSION: RFT treatment reduced haemorrhoidal bleeding and prolapse, and improved patient QoL.

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study.

AIM: Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. METHOD: This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. RESULTS: A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. CONCLUSION: There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD).

BACKGROUND: Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. METHODS: Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. RESULTS: Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. CONCLUSIONS: These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

Rubber band ligation versus haemorrhoidectomy for the treatment of grade II-III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: The aim of this study was to review clinical outcome of haemorrhoidectomy and rubber band ligation in grade II-III haemorrhoids. METHODS: A systematic review was conducted. Medline, Embase, Cochrane Library, Clinicaltrials.gov, and the WHO International Trial Registry Platform were searched, from inception until May 2018, to identify randomised clinical trials comparing rubber band ligation with haemorrhoidectomy for grade II-III haemorrhoids. The primary outcome was control of symptoms. Secondary outcomes included postoperative pain, postoperative complications, anal continence, patient satisfaction, quality of life and healthcare costs were assessed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Three hundred and twenty-four studies were identified. Eight trials met the inclusion criteria. All trials were of moderate methodological quality. Outcome measures were diverse and not clearly defined. Control of symptoms was better following haemorrhoidectomy. Patients had less pain after rubber band ligation. There were more complications (bleeding, urinary retention, anal incontinence/stenosis) in the haemorrhoidectomy group. Patient satisfaction was equal in both groups. There were no data on quality of life and healthcare costs except that in one study patients resumed work more early after rubber band ligation. CONCLUSIONS: Haemorrhoidectomy seems to provide better symptom control but at the cost of more pain and complications. However, due to the poor quality of the studies analysed/it is not possible to determine which of the two procedures provides the best treatment for grade II-III haemorrhoids. Further studies focusing on clearly defined outcome measurements taking patients perspective and economic impact into consideration are required.

Comparison of harmonic scalpel versus Milligan Morgan technique in haemorrhoidectomy patients.

OBJECTIVE: To compare the efficacy of harmonic scalpel versus Milligan Morgan technique in patients undergoing haemorrhoidectomy. METHODOLOGY: The comparative study was conducted at the General Hospital, Lahore, Pakistan, from March to September 2019, and comprised patients undergoing haemorrhoidectomy who were randomised into haemorrhoidectomy group A and open haemorrhoidectomy group B which was exposed to the Milligan Morgan procedure. Data was collected through a predesigned questionnaire. Data was analysed using SPSS 25. RESULTS: Of the 60 patients, there were 30(50%) in group A; 17(56.7%) males and 13(43.3%) females with an overall mean age of 44.6±7.6 years. The remaining 30(50%) patients were in group B; 19(63.3%) males and 11(36.7%) females with an overall mean age of 43.8±8.2 years. In group A, mean operative time was 20.8±2.8 minutes, while it was 26.5±2.8 minutes in group B (p=0.001). In group A, mean convalescence period was 9.7±2.9 days, while it was 13.4±3.7 days in group B (p=0.001). Group A required less time for complete wound healing compared to group B (p<0.05). CONCLUSIONS: Harmonic scalpel haemorrhoidectomy was found to be an advantageous method compared to the Milligan Morgan technique in patients undergoing haemorrhoidectomy.

Scoring systems as outcomes assessment of the treatments for haemorrhoidal disease: a systematic review of the literature.

PURPOSE: The comparison between haemorrhoidal treatments is still unclear. Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials. We aimed to systematically review the available outcome scores of haemorrhoidal treatment. METHODS: MEDLINE/Pubmed, Web of science, Embase and Cochrane were searched from database implementation until the December 6th 2019. All studies describing or referencing a score to assess haemorrhoidal disease treatment were included. Likert scale alone, incontinence score alone, general assessment of quality of life or scores developed for other proctologic disorders were excluded. The main outcome measures were validation of the scores and correlation of the score items to the core outcome set for haemorrhoidal disease developed by the European Society of Coloproctology. RESULTS: From the 633 records initially screened, 22 studies were included: 8 original articles describing a scoring system and 14 referencing a previously described scoring system. Only 1 score was validated by an external prospective cohort. All the scores evaluated the symptoms of haemorrhoidal disease. No score integrated the disease recurrences or patient's satisfaction. Scores values tended to decrease postoperatively. CONCLUSIONS: The scores described by Gerjy et al. and by Shanmugan et al. are available questionnaires, which have been validated and used in various studies. These scores might help researchers for comparative studies between treatment modalities and optimize haemorrhoids treatment.

Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Post-operative pain following excisional haemorrhoidectomy poses a particular challenge for patient recovery, as well as a burden on hospital resources. There appears to be an increasing role for topical agents to improve this pain, but their efficacy and safety have not been fully assessed. This systematic review aims to assess all topical agents used for pain following excisional haemorrhoidectomy. METHODS: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently assessed MEDLINE, EMBASE, and CENTRAL databases to 27 June 2019. All randomised controlled trials (RCTs) in English that investigated topical agents following excisional haemorrhoidectomy were included. Meta-analysis was performed using Review Manager, version 5.3. RESULTS: A total of 3639 records were identified. A final 32 RCTs were included in the qualitative analysis. Meta-analysis was performed on 9 RCTs that investigated glyceryl trinitrate (GTN) (5 for diltiazem, 2 for metronidazole and 2 for sucralfate). There were mixed significant changes in pain for GTN compared with placebo. Diltiazem resulted in significant reduction of pain on post-operative days 1, 2, 3 and 7 (p < 0.00001). Metronidazole resulted in significant reduction of pain on days 1 (p = 0.009), 7 (p = 0.002) and 14 (p < 0.00001). Sucralfate resulted in signification reduction of pain on days 7 and 14 (both p < 0.00001). CONCLUSION: Topical diltiazem, metronidazole and sucralfate appear to significantly reduce pain at various timepoints following excisional haemorrhoidectomy. GTN had mixed evidence. Several single trials identified other promising topical analgesics.