Bio-thermal response during laser haemorrhoidoplasty: an exclusive analytical and numerical approach for theoretical investigation.

Haemorrhoidal disease is identified by declension of the inflamed and bleeding of vascular tissues of the anal canal. Traditionally, haemorrhoids are associated with chronic constipation and the most common symptoms are irritation in anus region, pain and discomfort, swelling around anus, tender lumps around the anus and rectal bleeding (depending upon the grade of haemorrhoid). Among the several conventional treatment procedures (commonly mentioned as, rubber band litigation, sclerotherapy and electrotherapy), laser haemorrhoidoplasty is an out-patient and less-invasive laparoscopic procedure. From literature survey it has been observed that an exclusive theoretical model depicting the impact of 1064 nm wavelength laser wave on living tissues subjected to haemorrhoid therapy is not available. This research work is a pioneering attempt to develop a theoretical study attributing specifically on laser therapy of haemorrhoid treatment based on Pennes' biological heat transfer model. The corresponding mathematical model has been solved by analytical method to establish thermal response of tissue during the treatment and also the same has been solved a numerical approach based on finite difference method to validate the feasibility of former method due to unavailability of any theoretical model. Impact of variation of blood perfusion term, laser pulse time and optical penetration depth on temperature response of skin tissue is captured. The tissue temperature decreases along with time of laser exposure with increasing the blood perfusion rate as it carries away large amount of heat. With the increase in laser pulse time, tissue temperature declines due to shorter pulse time resulting in higher energy consumed by electrons. The research outcome is successfully validated with less than 1% of error observed between the appointed analytical and numerical scheme.

Local anesthesia versus saddle block for open hemorrhoidectomy: cost-analysis from a randomized, double blind controlled trial.

BACKGROUND: Despite the benefits attributed to the use of local anesthesia (LA) for open hemorrhoidectomy (OH) in developed countries, this technique is still not considered as the first line technique in low-income countries such as Uganda; therefore, we aimed at comparing the cost of OH under LA versus Saddle block among patients with 3rd or 4th degree hemorrhoids. METHODS: This trial was conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. The operating time, and direct costs in (US$) including medical and non-medical were recorded. We analysed the cost in the two groups (local anesthesia versus saddle block) using SPSS version 23.0. RESULTS: Findings of fifty-eight patients were analysed including 29 participants per group. There was a significant difference in operating time and cost among the two groups (p < 0.05). The mean operating time was 15.52 ± 5.34(SD) minutes versus 33.72 ± 11.54 min for OH under LA and SB respectively. The mean cost of OH under LA was 57.42 ± 8.90 US$ compared to 63.38 ± 12.77US$ in SB group. CONCLUSION: The use of local anesthesia for OH was found to have less operating time with high-cost effectiveness. Being affordable, local anesthesia can help to increase the turnover of patients who would otherwise wait for the availability of anesthesia provider. Policy makers should emphasize its applicability in low-income settings to help in the achievement of 2030 global surgery goals. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 08/10/2021.

Moxibustion for Managing Postoperative Urinary Retention After Hemorrhoidectomy and Anorectal Surgeries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: Common surgical procedures for conditions affecting the anus and rectum such as hemorrhoidectomy are associated with high risks of postoperative urinary retention (POUR). Little is known about the efficacy of moxibustion in managing POUR after such surgical procedures. This systematic review and meta-analysis aimed to review the related literature and synthesize data on the effectiveness of moxibustion in managing POUR after common anorectal surgeries. DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS: PubMed, EMBASE, CENTRAL, Chinese National Knowledge Infrastructure (CNKI), VIP information, and Wanfang databases were searched to October 1, 2021 using the keywords urinary retention, moxibustion, and moxa. Randomized controlled trials (RCTs) investigating patients who had developed POUR after hemorrhoidectomy or other anorectal surgeries were eligible for inclusion. Patients receiving moxibustion formed the intervention group and the control group received usual care alone. Primary outcomes were markedly effective rate, defined as spontaneous voiding with complete symptom relief within 30 to 60 minutes after treatment; and total effective rate (ie, markedly effective rate plus effective rate, defined as spontaneous voiding with partial relief of symptoms within 60 minutes to 4 hours after treatment). Secondary outcome was time to first urination after treatment. FINDINGS: Thirty-four RCTs met the eligibility criteria. Pooled analysis revealed that the markedly effective rate was significantly higher in the moxibustion group than that in the control group (pooled RR = 2.53, 95% CI = 2.17-2.95), and the total effective rate in the moxibustion group was also higher than that in the control group (pooled RR = 5.02, 95% CI = 4.01-6.28). The intervention group had significantly shorter times to first urination than controls (pooled effect = -2.81, 95% CI = -2.06 to -3.56). CONCLUSIONS: Moxibustion appears superior to usual care in relieving POUR after common anorectal surgeries. Future studies are still warranted to confirm these findings.

Pain assessment following open hemorrhoidectomy under local anesthesia versus saddle block: a multicenter randomized controlled trial.

BACKGROUND: There is disparity in evidence on pain assessment post open hemorrhoidectomy (OH) using local anesthesia and its use in developing countries compared to developed countries. Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3rd or 4th degree hemorrhoids. METHODS: This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p < 0.05 as statically significant using visual analogue scale (VAS). RESULTS: We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486-0.773: AUC = 0.63; p = 0.09) with a none significance by Kruskal-Wallis's test (p:0.925). CONCLUSION: Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3rd or 4th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8th October, 2021.

Open Hemorrhoidectomy With Ligasure™ Under Local or Spinal Anesthesia: A Comparative Study.

BACKGROUND: There is increasing evidence that many anorectal surgical procedures may be performed under local anesthesia. The aim of the present study was to evaluate the safety and efficacy of local anesthesia in the outpatient clinic vs spinal anesthesia in the operating room for open hemorrhoidectomy. METHODS: Sixty-two patients with grade III or IV hemorrhoids underwent open hemorrhoidectomy with LigaSure™ between 2018 and 2020. Of them, 32 procedures were performed in the operating room under spinal anesthesia with hyperbaric bupivacaine and other 30 procedures were undertaken in the outpatient clinic under local anesthesia with ropivacaine. RESULTS: There were no significant differences regarding age, gender, American Society of Anesthesiologists class, and Goligher's grade in between groups. No significant differences were observed in postoperative pain score (P = .85), perioperative complications (P = .51), and reoperation rate (P = .96). No recurrences and no differences in patients' satisfaction degree (P = .76) were documented at long-term follow-up in both study groups. DISCUSSION: Our results suggest that open hemorrhoidectomy with LigaSure™ performed in selected patients under local anesthesia in the outpatient clinic is a well-tolerated, safe, and effective procedure.

Electroacupuncture for postoperative pain in mixed hemorrhoids: A meta-analysis.

BACKGROUND: To investigate the efficacy of electroacupuncture for postoperative pain in mixed hemorrhoids. METHODS: Randomized controlled trials were searched in PubMed and Cochrane Library. The risk of bias assessment tool was used to assess methodological quality. Stata 14.0 software was used for meta-analysis. Weighted mean differences were calculated if all outcome variables were reported the same way, while standardized mean differences (SMD) were calculated if they were different. RESULTS: From 27 identified studies, 5 Chinese studies (465 patients) were included in this meta-analysis. The electroacupuncture group had significantly lower postoperative pain scores compared with the control group at 6 hours postoperatively (SMD = -0.89, 95% CI: -1.091 to -0.692; P < .001), at 12 hours postoperatively (SMD = -1.089, 95% CI: -1.336 to -0.843; P < .001), at 24 hours postoperatively (SMD = -0.548, 95% CI: -0.721 to -0.374; P = .547), and 72 hours postoperatively (SMD = -1.089, 95% CI: -1.336 to -0.843; P < .001). CONCLUSION: Electroacupuncture can improve pain after surgery for mixed hemorrhoids. It is an effective method to improve the pain after hemorrhoidectomy, which deserves further research and promotion.

Open hemorrhoidectomy under local anesthesia versus saddle block in western Uganda: a study protocol for a prospective equivalence randomized, double-blind controlled trial.

BACKGROUND: While open hemorrhoidectomy under local anesthesia has been shown to be more cost-effective with shorter operation times and lower complication rates, local anesthesia is still not considered as a first-line technique in low-income countries like Uganda. The objective of this trial is to compare open hemorrhoidectomy using local anesthesia versus saddle block among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids in western Uganda. METHODS: The protocol for a prospective equivalence randomized, double-blind controlled trial was conducted among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids. Recruitment was started in December 2021 and is expected to end in May 2022. Consenting participants who require open hemorrhoidectomy indicated at Kampala International Teaching Hospital, Uganda, will be randomized into two groups of 29 patients per arm. DISCUSSION: The primary outcome of this study is to compare the occurrences of postoperative pain following open hemorrhoidectomy using the visual analog scale in an interval of 2, 4, and 6 h and 7 days postoperatively. Furthermore, the mean operative time from the induction of anesthesia to the end of the surgical procedure as well as the cost-effectiveness of the 2 techniques will be assessed in both groups. Open hemorrhoidectomy under local anesthesia has the potential to offer benefits to patients but most importantly expediting return to baseline and functional status, shorter hospital stay by meeting the faster discharge criteria, and reduction in costs associated with reduced length of stay and complications. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202110667430356. Registered on 8 October 2021.

The Effect of Perianal Tramadol Infiltration on Postoperative Pain Following Hemorrhoidectomy.

INTRODUCTION: The present study was attempted to evaluate the effect of perianal infiltration of tramadol on postoperative pain in patients undergoing hemorrhoidectomy. METHOD: This double-blind clinical trial study was carried out on 90 patients with grade 3 and 4 hemorrhoids undergoing hemorrhoidectomy. Patients were randomly assigned into 3 groups of control or bupivacaine or tramadol. Before the surgery, perianal infiltration of .25% bupivacaine or tramadol or normal saline was prescribed to each group, respectively. Data on pain severity (based on the visual analog scale (VAS), the duration of surgery, sedation score, pain at the first defecation, first request time for additional analgesia, nausea and vomiting, and analgesic intakes) were evaluated and analyzed. RESULTS: Duration of surgery was almost similar in all 3 groups (P = .974). The results showed a significant difference in pain score between 3 groups (P ≤.05) at all times after the surgery. In addition, the means of sedation scores (P = .03), pain score at the first defecation (P = .001), the time to first analgesic request (P = .001), and ketorolac administration times (P = .01) were significantly different between 3 groups. Finally, no complication was reported regarding postoperative nausea and vomiting. CONCLUSION: Given the notable efficacy of tramadol in reducing pain after hemorrhoidectomy and its minor side effects, this medication is suggested as an effective topical anesthetic to decrease pain after hemorrhoidectomy.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis.

BACKGROUND: Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids. METHODS: A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed. RESULTS: Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence. CONCLUSION: Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Haemorrhoidectomy under local anaesthesia versus spinal anaesthesia: a systematic review and meta-analysis.

AIMS: To evaluate comparative outcomes of local anaesthesia (LA) and spinal anaesthesia (SA) in patients undergoing haemorrhoidectomy. METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane Database, The Virtual Health Library, Clinical trials.gov , and Science Direct. Only randomised controlled trials (RCTs) comparing excisional haemorrhoidectomy under LA and SA were included. Post-operative pain score, need for rescue analgesia, urinary retention, headache, rectal bleeding, and operative time were the evaluated outcome parameters. RESULTS: Seven RCTs reporting a total number of 440 patients of whom 222 patients underwent haemorrhoidectomy under LA and 218 patients had the procedure under SA were included. LA was associated with significantly lower post-operative pain at 6 h (mean difference (MD) - 2.25, P = 0.0001) and at 24 h (MD - 0.87, P = 0.0002), need for a rescue analgesia (risk ratio (RR) 0.18, P = 0.002), urinary retention (RR 0.17, P = 0.0001), and headache (RR 0.09, P = 0.0003) compared with SA. However, there was no significant difference in rectal bleeding (RR 0.89, P = 0.70) and operative time (MD 1.15, P = 0.19) between LA and SA. CONCLUSION: Compared with SA, LA may be associated with significantly lower post-operative pain, need for rescue analgesia, urinary retention, and headache making it an attractive choice of anaesthesia in day-case surgery for those who are not either fit for GA or refuse such anaesthetic modality.

Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial.

BACKGROUND: Hemorrhoids are one of the most common conditions that lead to surgery, and until now surgical hemorrhoidectomy has been the major effective treatment. Post-operative pain from hemorrhoidectomy has been experienced by thousands of patients and remains a major inconvenience of the operation. OBJECTIVE: This study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: This was a single-center, patient-assessor-blinded and randomized controlled trial with 154 patients receiving Milligan hemorrhoidectomy surgery. Eligible patients were randomly assigned to either a treatment group or a control group at a ratio of 1:1. The treatment group received the pestle needle therapy, with manual stimulation at Yaoshu (DU2), Mingmen (DU4), Changqiang (DU1), Chengshan (BL57), Erbai (EX-UE2) and the perianal points (1, 3, 5, 7, 9, and 11o'clock around the lesion); while the control group received a sham treatment with very light pressure. Three sessions of treatment were performed at 30 min, 4 h and 12 h after the surgery, and each lasted for 15 min. MAIN OUTCOME MEASURES: The primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery. The secondary outcomes included the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery, the analgesic dose, the time and the VAS score of the patients' first defecation after surgery, as well as the Hamilton Rating Scale for Anxiety (HAMA) evaluated before discharge. RESULTS: The mean pain score of the treatment group was significantly lower than that of the control group (3.10 ± 1.27 vs 4.82 ± 1.29; P < 0.001) at 12 h after surgery. Compared with the control group, patients in the treatment group needed a smaller dose of analgesic within the first 24 hours after surgery (P = 0.002); and their HAMA scores before discharge were lower (4.07 ± 2.40 vs 5.10 ± 2.45, P = 0.009). Compared to the treatment group, patients in the control group had a greater time to the first defecation after surgery ([52.34 ± 15.72] h vs [27.08 ± 13.68] h; P < 0.001), but there was no difference in their VAS scores at the first defecation (P = 0.092). CONCLUSION: The pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.

Local Anaesthesia Alone Versus Regional or General Anaesthesia in Excisional Haemorrhoidectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Excisional haemorrhoidectomy has been traditionally performed under general or regional anaesthesia. However, these modes are associated with complications such as nausea, urinary retention and motor blockade. Local anaesthesia (LA) alone has been proposed to reduce side effects as well as to expedite ambulatory surgery. This systematic review aims to assess LA versus regional or general anaesthesia for excisional haemorrhoidectomy. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE and CENTRAL databases were searched to 13 January 2020. All randomised controlled trials comparing LA only versus regional or general anaesthesia in patients who received excisional haemorrhoidectomy were included. The main outcomes included pain, adverse effects and length of stay. RESULTS: Nine trials, consisting of six studies comparing local versus regional anaesthesia and three comparing LA versus general anaesthesia, were included. Meta-analysis showed a significantly lower relative risk for need of rescue analgesia (RR 0.32 [95% CI 0.16-0.62]), intra-operative hypotension (RR 0.17 [95% CI 0.04-0.76]), headache (RR 0.13 [0.02-0.67]) and urinary retention (RR 0.17 [95% CI 0.09-0.29]) for LA when compared with regional anaesthesia. There was mixed evidence for both regional and general anaesthesia in regard to post-operative pain. CONCLUSIONS: LA alone may be considered as an alternative to regional anaesthesia for excisional haemorrhoidectomy with reduced complications and reduction in the amount of post-operative analgesia required. The evidence for LA compared to general anaesthesia for haemorrhoidectomy is low grade and mixed.

Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial.

Phlebotonics' effects were evaluated to reduce time-to-stop bleeding and anal irritation in 130 patients who complained of hemorrhoidal disease (HD); bleeding and pain after hemorrhoidectomy (31 patients) and hemorrhoidal thrombosis (34 patients) in the short time. Sixty patients were randomized to receive the routine treatment (both conservative and surgical) (control Group C). The treated group (both conservative and surgical) was divided into two subgroups: one treated with flavonoids (Group A, n = 73), the other with Centella (Group B, n = 66). Time-to-stop bleeding was checked at baseline and checkups (0 up to day 42). Healing was estimated with Kaplan-Meier method, the Kruskal-Wallis test estimated changes in the VAS scores. The HD median time-to-stop bleeding was 2 weeks for Groups A and B; 3 weeks for Group C. VAS scores comparison among Groups (irritation): A vs C, p = 0.007; B vs C, p = 0.041; and A vs B, p = 0.782 resulted respectively. As for operated hemorrhoids, the time-to-stop bleeding was 3 and 4 weeks in Groups A and B and 5 in Group C. Histopathology showed an association between flavonoids and piles' fibrosis (p = 0.008). Phlebotonics in HD, as well as after surgery, showed significant beneficial effects. Flavonoids are the most effective phlebotonics against bleeding and anal irritation.

Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam.

INTRODUCTION: Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment. METHODS: This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure. RESULTS: A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence. CONCLUSION: The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.

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

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

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

Outpatient management of proctologic disease. Which techniques for local anesthesia? The experience of a single center.

INTRODUCTION: Since 1899 outpatient management of surgical patients had been increasing, becoming the best option when possible. In 1988 was described the first experience of outpatient management of proctologic disease. Advances in local anesthesia techniques have improved the outpatient approach to surgical disease, particularly in patients with proctological diseases. METHODS: From 2010 to 2016, 1160 patients who needed surgery for proctologic disease have been recruited: 239 hemorrhoidectomies using the variant of Milligan Morgan technique described by Phillips, 45 trans-anal hemorrhoidal DE-arterialization (THD), 315 sphincterotomies, 12 anal polypectomies, 230 loop seton positions, 65 cone-like fistulectomies and 254 fistulotomies for perianal fistulas. In 329 cases, we used the posterior perineal block, 603 local perineal blocks, and 228 tumescent anesthesia. RESULTS: On a total of 1160 procedure failure rate was of 4.7% (55 cases). Urinary retention (69% 38 cases); bleeding 18% (10 cases), uncontrolled pain 12% of cases (7 cases). The chi-square test demonstrates (p<0.01) that the failure rate of the three types of anesthesia is very different with high statistical significance. The failure rate in patient underwent Posterior Perineal Block was 27/329 cases (8.2%), 8/228 (3.5%) in patients who underwent Tumescent Anesthesia and 20/603 (3.3%) in who underwent Local Perineal Block. CONCLUSIONS: Outpatient protocols represent the most common approach to minor proctologic disease that needs a good local block, with a good analgesic and sedative assistance, the different local block seems to be the same concerning the pain control, but presents some little, not relevant difference concerning urinary retention rate.

[Effect of electroacupuncture preconditioning combined with induced urination on urinary retention after milligan-morgan hemorrhoidectomy].

OBJECTIVE: To investigate the effect of electroacupuncture preconditioning combined with induced urination on urinary retention after milligan-morgan hemorrhoidectomy. METHODS: Eighty patients with mixed hemorrhoids were randomly divided into an electroacupuncture group and a routine group, 40 cases in each group. Anesthesia at Yaoshu (GV 2) was given in the two groups. In the electroacupuncture group, electroacupuncture at Zhongji (CV 3)，Guanyuan (CV 4)，Pangguangshu (BL 28) and Sanyinjiao (SP 6) was applied with tolerant intensity for 30 min before operation, 2 Hz/100 Hz in frequency. After operation, induced urination was given, namely hot compress of bladder area and sound of hearing water. In the routine group，induced urination was given after operation. The score of the first urination waiting time, the distension of lower abdomen on the evening of the postoperative, the first time urinary volume and incidence of urinary retention were compared between the two groups. RESULTS: The scores of the first urination waiting time after operation and distension of lower abdomen in the evening of the postoperative in the electroacupuncture group were lower than those in the routine group, the first time urinary volume was more than that in the routine group, and the incidence of urinary retention was lower than that in the routine group (5.0% (2/40) vs 22.5% (9/40), all P<0.05). CONCLUSION: Electroacupuncture preconditioning combined with induced urination can effectively prevent the incidence of urinary retention after milligan-morgan hemorrhoidectomy.

[Effect of electroacupuncture preconditioning with different frequencies on anal pain after milligan-morgan hemorrhoidectomy].

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