Effectiveness of laser hemorrhoidoplasty in the treatment of hemorrhoidal disease.

INTRODUCTION: Minimally invasive techniques still continue to maintain their popularity in hemorrhoidal disease. In this study, we aimed to present the symptomatic recovery and recurrence rates, post-operative pain levels, and complication rates of patients treated with the laser hemorrhoidoplasty (LHP) method in our clinic. METHODS: The data of patients who underwent LHP due to Grades 2, 3, and 4 internal hemorrhoidal disease in our clinic were reviewed retrospectively. The patients enrolled in the study were followed for at least 6 months (6 months, 1 year, and 2 years) and their results were analyzed. RESULTS: A total of 103 patients were included in the study. Seventy-five (72.8%) of them were male and the mean age was 41.6 ± 13.6 years. The mean operation time was 17.9 ± 5.2 min and minor complications developed in 3 (2.9%) patients postoperatively. Mean time to return to normal daily life was 2.17 (1-11) days. Recurrence developed in 16 (17.6%) patients with Grades 2 and 3 disease and in 6 (50%) of 12 patients with Grade 4 disease (p = 0.019). CONCLUSION: LHP is a popular procedure which is effective in selected patient groups with acceptable recurrence rates.

OBJETIVO: Presentar las tasas de recurrencia y recuperación sintomática, los niveles de dolor posoperatorio y las tasas de complicaciones de los pacientes tratados con hemorroidoplastia láser en nuestra clínica. MÉTODO: Los datos de los pacientes que se sometieron a hemorroidoplastia láser debido a enfermedad hemorroidal interna de grados 2, 3 y 4 en nuestra clínica se revisaron retrospectivamente. Los pacientes incluidos en el estudio fueron seguidos durante al menos 6 meses (6 meses, 1 año y 2 años) y se analizaron sus desenlaces. RESULTADOS: Se incluyeron en el estudio 103 pacientes, de los cuales 75 (72.8%) eran de sexo masculino. La edad media fue de 41.6 ± 13.6 años. El tiempo operatorio medio fue de 17.9 ± 5.2 minutos. Se desarrollaron complicaciones menores en 3 (2.9%) pacientes en el posoperatorio. El tiempo medio de reincorporación a la vida diaria normal fue de 2.17 (1-11) días. La recurrencia se observó en 16 (17.6 %) pacientes con enfermedad de grados 2 y 3, y en 6 (50%) de 12 pacientes con enfermedad de grado 4 (p = 0.019). CONCLUSIONES: La hemorroidoplastia láser es un procedimiento popular que es efectivo en grupos de pacientes seleccionados, con tasas de recurrencia aceptables.

Benefits of flavonoid and metronidazole use after excisional hemorrhoidectomy: a randomized double-blind clinical trial.

BACKGROUND: Excisional hemorrhoidectomy remains the most effective treatment for a significant group of patients with hemorrhoids, despite the potential for postoperative pain. The purpose of this study was to evaluate the effects of flavonoid and metronidazole use in the postoperative period on patients undergoing excisional hemorrhoidectomy. METHODS: A double-blind randomized clinical study was performed. Sixty-eight patients underwent excisional hemorrhoidectomy and were randomized into 4 groups of 17 patients each to receive double-placebo (G1), metronidazole plus placebo (G2), flavonoids plus placebo (G3) or metronidazole plus flavonoids (G4) in the postoperative period. A standard analgesic protocol was offered equally for all groups. Postoperative pain, bleeding, edema, pruritus and tenesmus were evaluated during the following three periods: from immediately after the operation until postoperative day (POD)7, from POD 8 to POD 14, and from POD 15 to POD 30. The patients were required to complete symptom questionnaires and to attend postoperative follow-up on PODs 7, 14 and 30. The effect of each drug was assessed for each symptom, and the groups were compared with each other and over time. RESULTS: There was less severe pain in all postoperative periods in the groups using flavonoids (G3 and G4, both p < 0.0001), with an observed synergistic effect of flavonoids combined with metronidazole during the first 14 days after surgery (p < 0.0001). Flavonoid use was also associated with decreased bleeding (G3, p = 0.031 and G4, p = 0.016) between the first and second postoperative weeks CONCLUSIONS: The use of flavonoids alone and in combination with metronidazole resulted in a reduction of most symptoms, particularly pain, after excisional hemorrhoidectomy. TRIAL REGISTRATION: The present study was registered in the SISNEP (document CAAE-0035.0.240.000-11), after approval by the research ethics committee (CEP) of the Hospital Felício Rocho (protocol nº393 / 11).

Randomized clinical trial with topical diltiazem for post-hemorrhoidectomy wound healing. / Ensayo clínico aleatorizado con diltiazem tópico para la cicatrización de heridas posthemorroidectomía.

Anal sphincter spasm contributes to the delay in surgical wound healing after hemorrhoidectomy. A prospective, experimental, randomized, double-blind trial was conducted on two groups of patients that underwent closed hemorrhoidectomy. There were 26 patients in each group. Group A received topical diltiazem in the anal region three times a day. Group B received a placebo. Cicatrization time was documented for 6 weeks through digital photography. Mean healing time for the group treated with diltiazem was 3.19 weeks (22.33±0.884 days) and 3.92 weeks (27.44±1.130 days) for the control group (p=0.012 95% CI). At week three, the wounds in 73.07% of the patients in the diltiazem group had healed, compared with 46.15% of the patients in the control group.

Randomized clinical study on the analgesic effect of local infiltration versus spinal block for hemorrhoidectomy.

BACKGROUND AND OBJECTIVES:: Postoperative analgesia and early recovery are important for hospital discharge. The primary objective of this study was to compare the analgesic effectiveness of perianal infiltration and subarachnoid anesthesia for hemorrhoidectomy. The secondary objective was to compare time to discharge, adverse effects and complications. DESIGN AND SETTING:: Randomized, prospective and comparative study at Dr. Mário Gatti Hospital. METHODS:: Forty patients aged 18-60, in American Society of Anesthesiologists physical status category 1 or 2, were included. The local group (LG) received local infiltration (0.75% ropivacaine) under general anesthesia; the spinal group (SG) received subarachnoid block (2 ml of 0.5% bupivacaine). Analgesic supplementation consisted of fentanyl for LG and lidocaine for SG. Postoperative pain intensity, sphincter relaxation, lower-limb strength, time to discharge, analgesic dose over one week and adverse effects were assessed. RESULTS:: Eleven LG patients (52.4%) required supplementation, but no SG patients. Pain intensity was higher for LG up to 120 min, but there were no differences at 150 or 180 min. There were no differences in the need for paracetamol or tramadol. Times to first analgesic supplementation and hospital discharge were longer for SG. The adverse effects were nausea, dizziness and urinary retention. CONCLUSIONS:: Pain intensity was higher in LG than in SG over the first 2 h, but without differences after 150 and 180 min. Time to first supplementation was shorter in LG. There were no differences in doses of paracetamol and tramadol, or in adverse effects. REGISTRATION:: ClinicalTrials.gov NCT02839538.

Randomized clinical study on the analgesic effect of local infiltration versus spinal block for hemorrhoidectomy / Estudo clínico randomizado do efeito analgésico da infiltração local versus bloqueio espinal para hemorroidectomia

ABSTRACT BACKGROUND AND OBJECTIVES: Postoperative analgesia and early recovery are important for hospital discharge. The primary objective of this study was to compare the analgesic effectiveness of perianal infiltration and subarachnoid anesthesia for hemorrhoidectomy. The secondary objective was to compare time to discharge, adverse effects and complications. DESIGN AND SETTING: Randomized, prospective and comparative study at Dr. Mário Gatti Hospital. METHODS: Forty patients aged 18-60, in American Society of Anesthesiologists physical status category 1 or 2, were included. The local group (LG) received local infiltration (0.75% ropivacaine) under general anesthesia; the spinal group (SG) received subarachnoid block (2 ml of 0.5% bupivacaine). Analgesic supplementation consisted of fentanyl for LG and lidocaine for SG. Postoperative pain intensity, sphincter relaxation, lower-limb strength, time to discharge, analgesic dose over one week and adverse effects were assessed. RESULTS: Eleven LG patients (52.4%) required supplementation, but no SG patients. Pain intensity was higher for LG up to 120 min, but there were no differences at 150 or 180 min. There were no differences in the need for paracetamol or tramadol. Times to first analgesic supplementation and hospital discharge were longer for SG. The adverse effects were nausea, dizziness and urinary retention. CONCLUSIONS: Pain intensity was higher in LG than in SG over the first 2 h, but without differences after 150 and 180 min. Time to first supplementation was shorter in LG. There were no differences in doses of paracetamol and tramadol, or in adverse effects. REGISTRATION: ClinicalTrials.gov NCT02839538.

RESUMO CONTEXTO E OBJETIVO: A analgesia pós-operatória e a recuperação precoce são relevantes para a alta hospitalar. O objetivo primário deste estudo foi comparar a eficácia analgésica da infiltração perianal e da anestesia subaracnóidea para hemorroidectomia. O objetivo secundário foi comparar o tempo para alta, efeitos adversos e complicações. TIPO DE ESTUDO E LOCAL: Estudo randomizado prospectivo e comparativo, no Hospital Dr. Mário Gatti. MÉTODOS: Foram incluídos 40 pacientes com idades 18-60 anos, na categoria 1 ou 2 de status físico da Sociedade Americana de Anestesiologistas. O grupo local (LG) recebeu infiltração local (ropivacaína a 0,75%) sob anestesia geral; o espinal (SG) recebeu bloqueio subaracnóideo (2 ml de bupivacaína a 0,5%). A suplementação analgésica foi com fentanil para LG e lidocaína para SG. Foram avaliados: intensidade da dor no pós-operatório, relaxamento do esfíncter, força dos membros inferiores, tempo de alta, dose de analgésico em uma semana e efeitos adversos. RESULTADOS: Onze (52,4%) pacientes em LG necessitaram de complementação, e nenhum em SG. A intensidade da dor foi maior para LG até 120 minutos, sem diferenças em 150 ou 180 minutos. Não houve diferenças na necessidade de paracetamol ou tramadol. O tempo para a primeira complementação analgésica e a alta hospitalar foram maiores para SG. Os efeitos adversos foram náuseas, tonturas e retenção urinária. CONCLUSÕES: A intensidade da dor foi maior na LG que na SG nas primeiras 2 horas, porém sem diferenças após 150 e 180 minutos. O tempo para a primeira suplementação foi menor na LG; sem diferenças nas doses de paracetamol e tramadol e efeitos adversos. REGISTRO: ClinicalTrials.gov NCT02839538.

Topical diltiazem for pain after closed hemorrhoidectomy. / Diltiazem tópico en el dolor postoperatorio de hemorroidectomía con técnica cerrada.

BACKGROUND: Anal sphincter spasm contributes to the appearance of postoperative pain following hemorrhoidectomy. AIM: To determine the efficacy of topical diltiazem in the control of post-hemorrhoidectomy pain. MATERIAL AND METHODS: A randomized, prospective, experimental, double-blind study was conducted on 2 groups of patients in the postoperative period of closed hemorrhoidectomy. Each group consisted of 17 patients. Group A received topical diltiazem in the anal region 3 times a day and group B received a placebo. Ketorolac was administered to both groups as rescue therapy. RESULTS: In group A, the mean score on the visual analog scale was 2.97±1.18cm at 24h, 1.51±1.18cm at 48h, and 0.84±0.92cm at 72h. In group B, it was 6.82±1.9cm at 24h, 5.3±1.66cm at 48h, and 4.32±2.13cm at 72h (P<.001, 95% CI). The mean number of analgesic doses in group A was 2.41±0.87 at 24h, 1.11±0.85 at 48h, and 0.94±0.96 at 72h. In group B, it was 3.82±0.52 at 24h, 3.64±0.70 at 48h, and 2.88±1.26 at 72h (P<.001, 95% CI). CONCLUSIONS: In this study, topical administration of diltiazem resulted in a statistically significant reduction of postoperative pain in patients that underwent closed hemorrhoidectomy.

Surgical treatment of hemorrhoids: a critical appraisal of the current options.

INTRODUCTION: Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence. AIM: To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease. METHODS: A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate. RESULTS: Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates. CONCLUSION: Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results.

Surgical treatment of hemorrhoids: a critical appraisal of the current options / Tratamento cirurgico das hemorroidas: uma analise critica das atuais opcoes

Introduction : Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence. Aim : To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease. Methods : A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate. Results : Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates. Conclusion : Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results. .

Introdução : O tratamento cirúrgico da doença hemorroidária é ainda um dilema. Novas técnicas foram desenvolvidas levando à taxa menor de dor pós-operatória, contudo com maior chance de recorrência. Objetivo : Revisar as indicações atuais de tratamento cirúrgico da doença hemorroidária, assim como os resultados e complicações das técnicas hoje utilizadas. Método : Foi realizada revisão sistemática das publicações sobre as opções de tratamento cirúrgico da doença hemorroidária, utilizando dados da Medline/Pubmed, Cochrane e UpToDate, até dezembro de 2012. Resultados : As opções de tratamento cirúrgico disponíveis são procedimento para correção de prolapso (PPH), dearterialização hemorroidária trans-anal (THD) e técnicas convencionais de hemorroidectomia. As técnicas excisionais têm resultados semelhantes quanto à dor, tempo de retorno às atividades e índice de complicações. O PPH e o THD apresentam menos dor pós-operatória, menor taxa de complicações, porém têm maior recidiva pós-operatória. Conclusão : As técnicas de cirurgia convencional têm melhores resultados a longo prazo. Apesar de bons resultados no período pós-operatório imediato, PPH e THD não apresentam resultados consistentes a longo prazo. .

Surgical complications in 2,840 cases of hemorrhoidectomy by Milligan-Morgan, Ferguson and combined techniques

The analysis of 2,840 cases of hemorrhoidectomy by open techniques of Milligan-Morgan (2,189 cases), Ferguson (341 cases) and mixed (310 cases) in 11,043 patients with hemorrhoidal disease (HD) allowed the following conclusions. The patients' acceptance of surgical indication for hemorrhoidectomy was 25.7%. Hemorrhoidectomy was more common among women (53.8%) than men (46.2%), and more accepted by women (26.5%) than men (24.8%). Hemorrhoidectomy was more common in patients of the fourth (27.7%), fifth (21.9%) and third (21.0%) decades of age. Most patients who agreed to undergo hemorrhoidectomy were those of the second (38.2%), eighth (35.9%) and ninth (34.5%) decades of age. The overall incidence of surgical complications was 3.0% (87 cases): anal stenosis (1.8%), bleeding (0.8%), worsening of anal hypotonia (0.2%), sepsis (0.1%) and systemic complications (0.1%), with no difference among the techniques used. The incidence of surgical complications by Milligan-Morgan technique was 3.0% - stenosis (1.9%), bleeding (1.9%), worsening of anal hypotonia (0.2%) and systemic complications (0.04%). The incidence of surgical complications by Ferguson's technique was 3.5% - stenosis (1.7%), bleeding (0.6%), worsening of anal hypotonia (0.6%) and sepsis (0.6%). And the incidence of surgical complications by mixed techniques was 2.5% - stenosis (1.0%), bleeding (0.3%), worsening of anal hypotonia (0.3%), sepsis (0.3%) and systemic complications (0.3%). The incidence of surgical complications according to gender was 3.0% among women and 3.2% among men, with higher incidence of stenosis in women (2.0%) and hemorrhage in men (1.1%). Surgical complications were more observed in the eighth (5.1%) and seventh (3.8%) decades of age. The incidence of anal stenosis was 1.8%, being 64.0% without hypotonia and 66.0% without anal fissure (66.0%), with annular stenosis as the most common anatomical shape (70.0%). Anal stenosis was more common among women (2.0%) presenting mean age of 38.2 years, with no relation to age decades. The most common technique for anal stenosis was single anotomy without sphincterotomy (46.0%). All cases of anal bleeding had surgical ligation of all hemorrhoidal pedicles, no matter if the bleeding site was found or not. (AU)

O seguimento de uma casuística de 2.840 hemorroidectomias pelas técnicas de Milligan-Morgan (2.189 casos), Ferguson (341 casos) e mista (310 casos) em 11.043 pacientes portadores de doença hemorroidária (DH) permitiu as seguintes conclusões. A aceitação da indicação cirúrgica para doença hemorroidária (DH), pelos pacientes, foi de 25,7%. A doença hemorroidária (DH) foi mais comum entre mulheres (53,8%) que em homens (46,2%) e a hemorroidectomia foi mais aceita pelas mulheres (26,5%) que pelos homens (24,8%). A hemorroidectomia foi mais realizada em pacientes de quarta (27,7%), quinta (21,9%) e terceira (21,0%) décadas etárias. Os pacientes que mais aceitaram a indicação cirúrgica foram os da segunda (38,2%), oitava (35,9%) e nona (34,5%) décadas etárias. A incidência global de complicações cirúrgicas foi de 3,0% (87 casos): estenose anal (1,8%), hemorragia grave (0,8%), agravamento da hipotonia anal (0,2%), sepse (0,1%) e sistêmicas (0,1%), sem diferença entre as técnicas usadas. A incidência de complicações cirúrgicas pela técnica de Milligan-Morgan foi de 3,0%: estenose (1,9%), hemorragia grave (1,9%), agravamento da hipotonia anal (0,2%) e sistêmicas (0,04%). A incidência de complicações cirúrgicas pela técnica de Ferguson foi de 3,5%: estenose (1,7%), hemorragia grave (0,6%), agravamento da hipotonia anal (0,6%) e sepse (0,6%). A incidência de complicações cirúrgicas pela técnica mista foi de 2,5%: estenose (1,0%), hemorragia grave (0,3%), agravamento da hipotonia anal (0,3%), sepse (0,3%) e sistêmicas (0,3%). A incidência de complicações cirúrgicas pelos gêneros foi de 3,0% entre as mulheres e 3,2% entre os homens, com maior incidência de estenose nas mulheres (2,0%) e hemorragia nos homens (1,1%). As décadas em que mais ocorreram complicações foram a oitava (5,1%) e a sétima (3,8%). A incidência de estenose anal foi de 1,8%, prevalecendo sem hipertonia anal (64,0%) e com fissura anal (66,0%), sendo a forma anatômica mais comum a anular (70,0%); foi mais comum entre mulheres (2,0%) com idade média de 38,2 anos, sem relação com as décadas etárias. A cirurgia corretiva da estenose anal mais usada foi a anotomia simples ou com fissurectomia sem esfincterotomia (46,0%). Em todos os casos de hemorragia anal cirúrgica foi feita ligadura de todos os pedículos da ressecção hemorroidária, independentemente de se encontrar ou não o local da hemorragia. (AU)

[Rectal perforation as a result of stapled hemorrhoidectomy]. / Perforación rectal posterior a hemorroidectomía con engrapadora.

BACKGROUND: The procedure for prolapsing hemorrhoids (PPH) has the potential to overcome many of the disadvantages of excisional hemorrhoidectomy; nevertheless, rare serious postoperative complications have been reported. CLINICAL CASE: We present a case of a 31-year-old male who was admitted and treated at another hospital with a stapled mucosectomy, which was carried out using a PPH01 33-mm stapling device. During the immediate postoperative period a fistula presented from the rectum to the right gluteus and a primary closure was attempted. However, the patient continued with the same symptoms and was referred to our hospital in October 2009. On examination at our Department of Colorectal Surgery, a right gluteus abscess was found and a primary orifice in the rectum with a diameter of 10 mm at 4 cm from the anal verge, confirmed with magnetic resonance imaging. A primary closure was attempted; however, during follow-up the patient presented edema, erythema and induration of the right gluteus and a failed closure of the fistula. Afterwards an endorectal advancement flap was successful in the closure of the fistula. CONCLUSIONS: Complications with PPH may compromise function or may be life-threatening for the patient, requiring further surgeries with increased morbidity and mortality. Therefore, it is recommended to be performed by surgeons with special training in this procedure.