"PNR-Bleed" classification and Hemorrhoid Severity Score-a novel attempt at classifying the hemorrhoids / Classificação "PNR-Bleed" e escore de gravidade das hemorróidas - uma nova tentativa de classificação de hemorróidas

ABSTRACT Hemorrhoids are the most common anorectal disorders with a prevalence of 39% in general population. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Goligher's classification does not describe the number of hemorrhoidal columns involved and does not give much consideration to the amount of blood loss. To describe the hemorrhoidal disease more vividly, we devised the "PNR-Bleed" (or PNR-Booking) classification system. We tried to classify the hemorrhoids based on the four main characteristics of the hemorrhoidal disease i.e. the degree of hemorrhoidal Prolapse (P), Number (N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to dentate line and the amount of Bleeding (B) from it. All the four components in this classification system are graded into five grades ranging from 1 to 5. The peculiarity of this new classification system is that it allows more detailed documentation of the hemorrhoids in a particular patient and conveys more explicit meaning and information about the hemorrhoids for future references. Based on this 'PNR-Bleed' classification, we are introducing another concept of scoring the severity of hemorrhoids and referred it as the Hemorrhoid Severity Score (HSS). Hemorrhoid Severity Score (HSS) is the total score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in "PNR-Bleed" classification. This new "PNR-Bleed" system of classifying the hemorrhoids and calculation of HSS seems to be more comprehensive, detailed, more objective and easily reproducible.

RESUMO As hemorróidas são os distúrbios anorretais mais comuns, com uma prevalência de 39% na população em geral. As hemorróidas são geralmente classificadas com base em sua localização e grau de prolapso. A classificação de Goligher não descreve o número de colunas hemorroidais envolvidas e não dá muita importância à quantidade da perda de sangue. Para descrever a doença hemorroidária de maneira mais precisa, criamos o sistema de classificação "PNR-Bleed" (ou PNR-Booking). Tentamos classificar as hemorróidas com base nas quatro principais características da doença hemorroidária, isto é, o grau de prolapso da hemorroida (P), número (N) das colunas hemorroidais primárias envolvidas, a relação (R) do tecido hemorroidário para a linha denteada e a quantidade de sangramento (B) originando-se dele. Todos os quatro componentes deste sistema de classificação são classificados em cinco graus, variando de 1 a 5. A peculiaridade desse novo sistema de classificação é que ele permite uma documentação mais detalhada das hemorróidas em um paciente em particular e transmite o significado e informações mais explícitos sobre as hemorróidas. para referências futuras. Com base nessa classificação "PNR-Bleed", estamos introduzindo outro conceito para o escore da gravidade das hemorróidas e denominado HSS, de "Hemorrhoid Severity Score". O escore de gravidade da hemorroida (HSS) é o escore total obtido pela soma dos graus numéricos de todas as quatro características das hemorróidas na classificação "PNR-Bleed". Esse novo sistema "PNR-Bleed" de classificação de hemorróidas e cálculo do HSS parece ser mais abrangente, detalhado, mais objetivo e facilmente reproduzível.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY.

BACKGROUND: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. AIM: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. METHOD: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). RESULTS: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. CONCLUSION: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

Relief of hemorrhoid symptoms: pilot study of a new topical ally.

AIM: The pathogenesis of hemorrhoids involves vascular congestion, fragmentation of supporting tissues and, in many cases, increased resting anal pressure. A new ointment (Hemolen®) has been devised to control hemorrhoids symptoms acting on all the pathophysiologic mechanisms involved. METHODS: Pilot study on patients with grade I-III hemorrhoids. The ointment was applied twice daily for 30 days and follow-up visits were scheduled 7 days (T1), 14 days (T2) and 30 days (T3) after recruitment (T0). Signs and symptoms (bleeding, discomfort, itching, edema, thrombosis, congestion, inflammation, pain) were evaluated at each visit using dedicated scores and VAS scale. Resting anal pressure was measured at time T0, 1 hour after the first application and at T1. Use of painkiller was recorded. RESULTS: 48 patients (25 females; mean age 47±15.8 years) were enrolled; 52.1% of them had II degree hemorrhoids and 27.1% had III degree hemorrhoids. The severity scores significantly dropped from T0 to each scheduled visit and a significant reduction of resting anal pressure was observed from T0 to 1 hour after application (z=13.5; p<0.001) and from T0 to T1 (z=6; p<0.001). The comparison of the resting pressure among whole time series showed a significant reduction (Fr=124.4; p=<0.001). Use of pain-killers decreased significantly from T0 to T1 (p<0.001) and from T1 to T2 (p=0.001). CONCLUSION: The new ointment tested in the present study is safe and effective for the management of hemorrhoid symptoms in the early stages hemorrhoids, during the acute phases and in patients with more severe hemorrhoids awaiting surgery. Prospective, randomized controlled trials are needed to confirm these encouraging results.

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

ABSTRACT Background: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. Aim: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. Method: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). Results: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. Conclusion: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

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

[Procedure for prolapse and hemorrhoids versus stapled transanal rectal resection in the treatment of grade IV hemorrhoids].

Objective: To compare the efficacy and safety of two procedures in the treatment of hemorrhoid: the procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection (STARR). Methods: A retrospective cohort research was conducted. Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively, while those had other anorectal diseases, emergency surgery, inflammatory bowel disease, tumor and incomplete clinical data were excluded. PPH was performed in 129 patients and STARR was performed in 134 patients. PPH procedure: a circular purse 2-0 string suture was made at 4 cm above the dentate line; in accordance with the standard protocol, the PPH circular stapling devicewas introduced; the suture was closed, and a pull-through followed; the traction was continued; the stapler was fired; the prolapsed mucosa and submucosa were removed. STARR procedure: 3-5 needles were sutured in the anterior rectal mucosa, protecting the posterior wall mucosa; with the help of a finger the PPH stapler was inserted into the vaginal lumen; the sutures were hooked from both sides of the stapler to maintain traction; according to the disease condition, the suturewas tightened appropriately; stapler was screwed and activated; the anterior wall mucosa was removed; the joint of the both ends of anastomosis was cut; the posterior wall mucosa was removed as well. The short-term efficacy, surgical safety and prognosis of the two groups were compared. Results: There were 67 males (51.9%) in the PPH group and 57 (42.5%) males in the STARR group. The median age of the two groups was 51.0 (22.0, 80.0) years and 49.0 (24.0, 74.0) years, respectively. There were no significant differences in the baseline data between the two groups (all P>0.05). No significant differences in the intraoperative bleeding, length of hospital stay, postoperative analgesic drug use, postoperative bleeding, postoperative infection, etc. were found between two groups (all P>0.05). As compared to PPH group, STAAR group had longer operation time and higher hospitalization cost with significant differences [(44.0±19.3) minutes vs. (26.3±8.5) minutes, t=9.701, P=0.001; (11 047±473) yuan vs. (7674±309) yuan, t=32.826, P=0.001]. One case in STAAR group developed rectovaginal fistula. The median follow-up period of the whole group was 40 (33, 52) months. A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up. The 3-year disease-relapse rate was 0 in STARR group and 4.2% in PPH group (P=0.042). Conclusion: STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid, but attention should be paid to the development of complications.

Haemorrhoid energy therapy versus rubber band ligation for the management of grade I and II haemorrhoids: a randomized trial.

BACKGROUNDS: Grade I and II haemorrhoids are commonly managed in colorectal practice. Management often involves rubber band ligation. The haemorrhoid energy therapy (HET) device (Medtronic, Minneapolis, MN, USA) has been developed as an alternative to rubber band ligation (RBL). This study is the first to prospectively evaluate the device versus RBL in the management of grade I and II haemorrhoids. METHODS: A single blind, randomized controlled trial was conducted in the colorectal outpatient department. Patients with symptomatic haemorrhoids suitable for banding were prospectively recruited and randomized. Primary outcome was post procedural pain at 1 h as recorded on a 10-point Likert scale. Secondary outcomes were efficacy in reduction of haemorrhoidal symptom score at 12 weeks, daily average and maximum pain scores for 14 days and complications arising from the intervention. RESULTS: Thirty patients were randomized (14 HET, 16 RBL). There was no significant difference between the two group's pre-intervention symptom score and haemorrhoidal grade. The mean pain scores at 1 h in the HET group were 1.5 ± 068 (95% confidence interval), and in the RBL group 4.64 ± 1.74 (95% confidence interval) (P < 0.05). Average (0.7 versus 2.95, P < 0.05) and maximum (1.25 versus 4.4, P < 0.05) pain were lower in the HET group on day one post procedure. At 12 weeks there was no significant difference in the reduction of haemorrhoid symptom scores between the groups (HET 2.27, RBL 1.5 (P > 0.2)). CONCLUSION: HET causes less pain then RBL, and is at least as effective in treating the symptoms associated with grade I and II haemorrhoids in the outpatient setting.

Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications.

BACKGROUND: Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. METHODS: All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. RESULTS: A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). CONCLUSIONS: The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

May radiofrequency be the best choice for III-IV degree hemorrhoids?

BACKGROUND: Hemorrhoidectomy is considered the most efficient method to treat hemorrhoids of III and IV grades. The aim of this study was to compare conventional diathermy hemorrhoidectomy and radiofrequency hemorrhoidectomy based on a large series of patients. METHODS: Between June 2001 and June 2014, 1000 patients have been treated with radiofrequency hemorrhoidectomy (group A) and 500 patients have been treated with diathermy (group B) as a day-case procedure. Operating time, postoperative pain score, hospital stay, early and late postoperative complications, wound healing time and time to return to normal activities were assessed. RESULTS: The mean follow-up was seven years. The mean operating time for radiofrequency hemorrhoidectomy was shorter than diathermy but not significantly. Patients treated with radiofrequency had significantly less postoperative pain (measured on a Visual Analogue Scale; P=0.001), a shorter wound healing time, less time off work and postoperative complications (P=0.001) than patients who had diathermy. Neither wound healing nor mean hospital stay (day-case surgery) was significantly different. CONCLUSIONS: Radiofrequency hemorrhoidectomyis a valid alternative to the conventional diathermy technique, due to the reduction of operative time, postoperative pain, early and late complication rate.

[Anopexy according to Longo for hemorrhoids]. / Anopexie nach Longo bei Hämorrhoiden.

The treatment for hemorrhoids ranges from conservative management to surgical procedures. The procedures are tailored to the individual grading of hemorrhoids and the individual complaints. The standard Goligher classification of the hemorrhoids is the basis for further treatment and no differentiation is made between segmental hemorrhoids and circular hemorrhoids. In the case of advanced circular hemorrhoid disease the surgical procedure with a stapler, so-called stapler anopexy, is the procedure of choice.

Transanal haemorrhoidal dearterialization for the treatment of grade III and IV haemorrhoids: a 3-year experience.

BACKGROUND: Transanal haemorrhoidal dearterialization (THD) is increasingly perceived as an effective and better tolerated alternative to excisional haemorrhoidectomy. The aim of this study was to evaluate outcomes and the patient experience of THD in an Australian population with grade III or IV haemorrhoids. METHODS: A retrospective review of prospectively maintained database on patients who had undergone THD over a 3-year period was performed. Data were collected on demographics, operative data, complications, recurrences and readmissions, postoperative pain and further interventions. Patient perceptions and satisfaction with the procedure were assessed with a telephone survey. RESULTS: A total of 85 patients with a mean age of 55 (±14) years with grade III (85%) or grade IV (15%) haemorrhoids underwent THD. Indications for surgery were predominantly bleeding (87%) and prolapse (41%). Median outpatients follow-up was 42 days and median telephone follow-up was 802 days. Median operating time was 25 min (±12). Twenty-four per cent of patients suffered complications, including postoperative bleeding (7%), constipation (7%), local sepsis (6%), anal fissure (5%) and temporary incontinence (2%). Severe postoperative pain occurred in 16% of the patients. The symptom recurrence rate was 19% and reintervention rate was 14%. About 98.8% of patients reported good or excellent overall satisfaction with the procedure. CONCLUSION: THD is a relatively new technique for the treatment of haemorrhoids, which is increasingly being used as an alternative to excisional haemorrhoidectomy. This study shows that patients' satisfaction with THD is high despite a moderate complication and recurrence rate and significant incidence of postoperative pain.

The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results.

The purpose of the paper is to compare Goligher Classification with the Single Pile Hemorrhoid Classification (SPHC) to show the possible bias and limits of Goligher's use and the possible advantage with the employment of the new classification. SPHC considers the number of pathological piles(N), the characteristics of each internal pile and the characteristics of each external pile, reporting the presence of a fibrous inelastic redundant pile(F), the presence of the subversion of dentate line or the congestion of the external pile(E) and the presence of not tolerated skin tags(S). From September 2010 to December 2012, 197 consecutive patients were analysed according to both classifications. Considering pathological piles, I and II Goligher patients showed a complete agreement between pathological pile and grade, III Goligher patients had 80.5 % of pathological piles of III grade while IV Goligher patients had only 44.3 % of IV grade pathological piles (p < 0.001). Regarding the distribution of the other anatomical variables: F, E, S described in SPHC, the results showed that F was present in 18.3 % while ES was present in 46.2 %. Goligher's Classification has showed to be an inadequate tool to overview surgical outcome or to compare surgical procedure, particularly for high grades, while SPHC showed to be a feasible instrument both to describe and to compare patients affected by hemorrhoid disease.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement.

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Stapled haemorrhoidectomy in the operative treatment of grade III and IV haemorrhoids.

Stapled haemorrhoidectomy (SH) is a minimally invasive intervention that uses a stapling device which avoids the need for wounds in the sensitive anal area and reduces the pain after surgery. This study was undertaken in Nepal Medical College Teaching Hospital from January 2010 to December 2012 to evaluate the efficacy of this modality of treatment among patients (32) who presented in the Surgery OPD with grade III and grade IV haemorrhoids. The results of SH were evaluated by the relief of symptoms, severity of post operative pain, and complications of SH. Twenty five (78.1%) patients had grade III and 7 (21.9%) presented with grade IV hemorrhoids. The most frequent presentation reported in our study was bleeding per rectum with perianal prolapse. Mean operating time was 40-60 minutes whereas mean hospital stay was 1.9 days. Urinary retention was the most common complication found in 12 (37.5%) patients in the immediate post operative period. SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoperative pain, and shorter hospital stay.

Diagnosis and treatment of haemorrhoids.

These guidelines provide a review of diagnosis, conservative and surgical treatment of haemorrhoids with primary focus on the surgical treatment. In symptomatic hemorrhoids it is recommended, that conservative treatment is used as basic treatment regardless of grading. The vast majority of grade II haemorrhoids are treated conservatively, but surgery may be considered in a few cases with pronounced symptoms. In these cases chirurgia minor, Doppler guided dearterilization procedures or stapled haemorrhoidopexy are recommended. In grade III and IV Doppler guided dearterilization procedures, stapled haemorrhoidopexy (Grade III) or conventional Milligan Morgan haemorrhoidectomy are recommended.

Impact of less invasive treatments including sclerotherapy with a new agent and hemorrhoidopexy for prolapsing internal hemorrhoids.

Conventional hemorrhoidectomy is applied for the treatment of prolapsing internal hemorrhoids. Recently, less-invasive treatments such as sclerotherapy using aluminum potassium sulphate/tannic acid (ALTA) and a procedure for prolapse and hemorrhoids (PPH) have been introduced. We compared the results of sclerotherapy with ALTA and an improved type of PPH03 with those of hemorrhoidectomy. Between January 2006 and March 2009, we performed hemorrhoidectomy in 464 patients, ALTA in 940 patients, and PPH in 148 patients with second- and third-degree internal hemorrhoids according to the Goligher's classification. The volume of ALTA injected into a hemorrhoid was 7.3 ± 2.2 (mean ± SD) mL. The duration of the operation was significantly shorter in ALTA (13 ± 2 minutes) than in hemorrhoidectomy (43 ± 5 minutes) or PPH (32 ± 12 minutes). Postoperative pain, requiring intravenous pain medications, occurred in 65 cases (14%) in hemorrhoidectomy, in 16 cases (1.7%) in ALTA, and in 1 case (0.7%) in PPH. The disappearance rates of prolapse were 100% in hemorrhoidectomy, 96% in ALTA, and 98.6% in PPH. ALTA can be performed on an outpatient basis without any severe pain or complication, and PPH is a useful alternative treatment with less pain. Less-invasive treatments are beneficial when performed with care to avoid complications.

A randomized trial of transanal hemorrhoidal dearterialization with anopexy compared with open hemorrhoidectomy in the treatment of hemorrhoids.

BACKGROUND: Doppler guidance in hemorrhoidal surgery has become more frequent during the past decade. The method is mainly studied in nonrandomized trials. Data from randomized controlled trials are lacking. OBJECTIVE: The aim of this study was to compare early and midterm results of transanal hemorrhoidal dearterialization with anopexy to open hemorrhoidectomy. DESIGN, SETTINGS, PATIENTS, AND INTERVENTIONS: Forty patients with grade 2 to 3 hemorrhoids were randomly assigned to transanal hemorrhoidal dearterialization with anopexy (group A, n = 20) or open hemorrhoidectomy (group B, n = 20). A diary was used during the first 2 postoperative weeks. A self-reported symptom questionnaire was answered, and a clinical examination was performed preoperatively, after 2 to 4 months, and after 1 year. MAIN OUTCOME MEASURE: The main outcome measure was postoperative pain. RESULTS: Postoperative peak pain was lower in group A during the first week than in group B (p < 0.05), whereas no difference in overall pain was noted. More patients expressed normal well-being in group A (p = 0.045). Pain, bleeding, and the need for manual reduction of the hemorrhoids were all improved in both groups after 1 year (p < 0.05). Soiling had decreased after both methods at early follow-up. After 1 year, soiling was significantly decreased only after open hemorrhoidectomy. The grade of hemorrhoids was significantly reduced after 1 year for both methods, but there was a trend to more patients with remaining grade 2 hemorrhoids in group A (p = 0.06). LIMITATIONS: There was no blinding, the sample size was small, and follow-up was for only 1 year. The questionnaire was not validated. CONCLUSION: The difference in postoperative pain between transanal hemorrhoidal dearterialization with anopexy and open hemorrhoidectomy may be less than expected based on previous literature.

[Operations for hemorrhoids: indications and techniques]. / Operationen beim Hämorrhoidalleiden: Indikation und Technik.

Haemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000-50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.

Stapled haemorrhoidopexy vs. Milligan-Morgan haemorrhoidectomy for grade III haemorrhoids: a randomized clinical trial.

The aim of this double blind randomized clinical trial was to compare the short-term and long-term outcomes of stapled haemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan-Morgan haemorrhoidectomy (MMH group). A total of 79 consecutive patients with grade III haemorrhoids were randomized into two groups treated with SH (n. 39) and MMH (n. 40). The outcomes of the procedures were evaluated postoperatively and over a follow-up period of minimum 2 years. Patients undergoing the SH procedure showed greater short term advantages than MMH group with reduced pain, shorter length of hospital stay, earlier return to work and high patient satisfaction. Long-term follow-up has indicated more favourable results in MMH group in terms of resumption of symptoms with absence of residual prolapse and risk of recurrence of prolapse. At two years follow-up recurrent prolapse was confirmed in six patients of SH group (13%) whereas in none of the MMH group. At six months follow-up there weren't significant difference in the mean satisfaction score for the two groups. At two years the mean satisfaction score was higher in the MMH group vs SH group. Seven patients in the SH group needed a reoperation whereas none in MMH group. From January 2009, in our Surgery Unit the patients are always informed about a higher recurrence rate of SH and we perform this technique only when the patient choices to accept this risk to take advantage of the short-term benefits of this procedure.