Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years.

AIM: The management of haemorrhoids has changed significantly in the last two decades as a result of new insights into their pathophysiology and the availability of new surgical devices. The aim of this survey was to evaluate changes in the management of haemorrhoids in Italy over the last 17 years. METHOD: An electronic database which recorded details of management relating to the severity of haemorrhoids between 2000 and 2016 was obtained from 18 of 34 colorectal surgeons who were invited to participate. RESULTS: A total of 32 458 patients were treated for haemorrhoids by 18 expert coloproctologists during a 17-year period. Patients were classified as Grade II (7542, 23.2%), Grade III(15 360, 47.3%) and Grade IV (9556, 29.4%). Grade II haemorrhoids were treated with rubber band ligation in over 90% of the cases, and patients with Grade IV had a Milligan-Morgan (MM) haemorrhoidectomy in over 90% of the cases. In Grade III, the use of stapled haemorrhoidopexy progressively decreased from 30% to 35% (between 2000 and 2007) to 5% of the cases. Meanwhile, commencing from 2006 the use of Doppler-guided haemorrhoid artery ligation (DGHAL) with mucopexy increased progressively from 6% to 24%. Over the years, the percentage of MM haemorrhoidectomy remained consistent at between 65% and 70% of the cases. CONCLUSION: Relevant changes in the surgical choice of haemorrhoid treatment have occurred in Italy over the last 17 years. MM haemorrhoidectomy remains the most frequently performed procedure for Grade III haemorrhoids. Stapled haemorrhoidopexy has become much less popular in contrast to DGHAL with mucopexy which is being performed much more frequently.

Evolution in the surgical management of hemorrhoidal disease.

Hemorrhoidal disease is a very common condition requiring surgical management in approximately 10% of cases. Despite its long history and high prevalence, we are still trying to identify the best treatment. Earlier surgical approaches were soon abandoned and now only detain an historic significance. For long, proctologists have given their preference to hemorrhoidectomy that was gradually perfected through the years. The true innovation came in 1937, with the famous Milligan-Morgan hemorrhoidectomy, still one of the leading interventions for treatment of hemorrhoids. Less fortune encountered alternative techniques, such as the Whitehead hemorrhoidectomy, and closed and semi-closed techniques. Later on, the advent of a new concept of the pathogenesis of hemorrhoidal disease has brought to the development of stapled prolassectomy techniques. This approach has encountered both supporters and detractors between the experts in this field and has received a strong impulse by the emerging trend towards "day-surgery". Today the search for the best surgical technique for hemorrhoidal disease is far from being over and witnesses the introduction of new techniques for hemorrhoidal dissection. The choice of the best strategy remains in the hands of the clinician in the modern conception of tailored surgery. KEY WORD: Hemorrhoidal disease, Hemorrhoidectomy, Milligan-Morgan hemorrhoidectomy.

[Evidence-based treatment of hemorrhoidal disease]. / Evidenzbasierte Therapie des Hämorrhoidalleidens.

Hemorrhoidal disease represents a prevalent benign condition of the lower gastrointestinal tract. As a common and early symptom of hemorrhoids, patients present with painless rectal bleeding during or after defecation. For the treatment of hemorrhoidal disease, a large variety of operative and non-operative therapeutic options exists. In the present article, the authors aim to provide guidance for stage-directed therapy of hemorrhoidal disease based on up-to-date knowledge and the authors' own clinical experience.