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

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

Anatomical Anal Stenosis after PPH: Insights from a Retrospective Study and Rat Model.

High-grade hemorrhoids are usually recommended to receive operational treatments. However, these traditional surgeries are associated with severe postoperative pain. A procedure for prolapse and hemorrhoids (PPH), a circular staple device, has been developed to improve short-term outcomes, including reducing the severity of postoperative pain. PPH, compared to conventional surgery, has been associated with the incidence of anatomical anal stenosis. The causes of stenosis after PPH are not yet clear. We first analyzed the complications of our patients with PPH, and then developed a rat model to verify the tension force of PPH using Hematoxylin-eosin, Masson's trichrome, immunohistochemistry, and immunofluorescence staining. Our clinical data showed that PPH significantly improved postoperative pain, but that it resulted in higher incidences of complications, including anal stenosis, than hemorrhoidectomy. We simulated the status of PPH and developed a rat model to verify PPH's tension force, including the scarring area and the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors. The tension wound histological data showed more extensive granulation tissue and inflammatory cell infiltration and a thicker epidermis than the control group on day 12 post-operation and tension treatment. In addition to IL-1ß and IL-10 cytokines on day 3 and IL-1ß, IL-6, and IL-10 cytokines on day 12 post-operation in the tension group, two angiogenic factors, CD31 and VEGF-A, were found to have a more significant expression on day 7 post-operation in the tension group. The mean scar area was larger and the distribution of fibrotic proteins (collagen 1, α-SMA, CTGF, and MMP2) in the tension group was significantly broader than in the control on day 12 post-operation and tension treatment. Based on the findings of our animal model, the development of a lesser tensile force for PPH to decrease the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors is urgently required.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance / Distribución de las arterias hemorroidales en pacientes con hemorroides de grado III y IV tratados mediante ligadura arterial y reparación rectoanal. Evaluación del guiado Doppler

Introduction: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. Methods: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. Results: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21–84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2–12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1–4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. Conclusions: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.(AU)

Introducción: Aunque la desarterialización hemorroidal y mucopexia es técnica aceptada como alternativa válida a la hemorroidectomía, existen divergencias en lo que se refiere a una localización fija o variable de las arterias a ligar. Nuestro objetivo ha sido arrojar luz sobre esta cuestionada distribución arterial en pacientes quirúrgicos. Métodos: Se han incluido consecutivamente pacientes con diagnóstico de hemorroides de III y IV grado operados mediante desarterialización hemorroidal guiada por Doppler (D-HAL) y reparación rectoanal (RAR) en dos centros hospitalarios españoles. El principal objetivo fue evaluar el número necesario de ligaduras arteriales y su localización horaria para conseguir un silencio Doppler. Resultados: Se han incluido consecutivamente 146 pacientes, 111 (76%) varones y 35 (24%) mujeres, con una media de edad de 54 años (21–84), 106 (73%) fueron diagnosticados como grado III y 40 (27%) como grado IV. La media de ligaduras por paciente fue de 7 (2–12). Se encontraron porcentajes de ligaduras superiores al 60% en las posiciones horarias 7, 11, 10, 12, 9 y 1. La media de mucopexias por paciente fue 3 (1–4), siendo las localizaciones más frecuentes los octantes posterior izquierdo, posterior derecho y anterior derecho. Conclusiones: Aunque los puntos horarios impares son los de mayor frecuencia de localización arterial, porcentajes no despreciables de localización ocurren en las posiciones pares lo que, en nuestra opinión, hace que el uso del Doppler sea necesario dado que la distribución arterial no es constante en todos los pacientes. Hemos podido constatar también que en la semicircunferencia derecha han sido necesarias más ligaduras y pexias que en el lado izquierdo, lo que sugiere una mayor vascularización derecha.(AU)

Long-term results and quality of life after stapled hemorrhoidopexy vs Doppler-guided HAL-RAR: a propensity score matching analysis.

AIM: The study aimed to evaluate and compare the short and long-term outcomes of doppler-guided (DG) hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) using a wireless-doppler-guided probe and stapled hemorrhoidopexy (SH) for treatment of II-III hemorrhoids. METHODS: This cohort study included patients who underwent HAL-RAR (n = 89) or SH (n = 174) for grade II-III hemorrhoids between January 2020 and December 2021. After propensity score matching at a 1:1 ratio, 76 patients for each group were analyzed. Short and long-term outcomes were collected. Pain was measured using a Visual Analogue Scale (VAS) at POD1, POD 10, 1 month, and 6 months after surgery. The enrolled patients completed the Hemorrhoidal Disease Symptom Score and Short Health ScaleHD quality of life (HDSS/SHS QoL) questionnaire preoperatively and during a regular follow-up visit at 24 months after surgery. RESULTS: Groups exhibited comparable overall postoperative complication rates (23% HAL-RAR/ 21% SH; p = 0.295). Postoperative pain via VAS showed median scores of 4, 3, 1, 1 for HAL-RAR and 6, 4, 2, 1 for SH at POD1, POD10, 1 month, and 6 months, respectively (p = < 0.001, 0.004, 0.025, 0.019). At a median follow-up of 12 months, the recurrence rate was 10.5% in the HAL-RAR group and 9.2% in the SH group (p = 0.785), respectively. At 24 months, 15.7% of HAL-RAR patients and 19.7% of SH patients remained symptomatic (p = 0.223). Median post-op QoL index was 1 (HAL-RAR) and 0.92 (SH), p = 0.036. CONCLUSIONS: HAL-RAR is a safe and feasible technique in treating grade II-III hemorrhoids showing better outcomes in terms of postoperative pain and QoL. SIGNIFICANCE: This paper adds a new perspective in comparing the HAL-RAR and SH, focusing the attention on the patients and not surgical techniques. A long and difficult follow-up was completed to fully understand the long-term results and the impact on the QoL of the patients who underwent these procedures.

Comparison of Laser Hemorrhoidoplasty and Milligan-Morgan Hemorrhoidectomy Techniques in the Treatment of Grade 2 and 3 Hemorrhoidal Disease.

INTRODUCTION: The estimated prevalence of hemorrhoidal disease (HD) worldwide ranges from 2.9% to 27.9%. Conservative, medical, non-operative, and surgical therapy approaches are applied in HD treatment. Milligan-Morgan (MM) hemorrhoidectomy which is the most well-known and frequently applied surgical treatment method, and Laser hemorrhoidoplasty (LH) are among the accepted treatment methods in Grade 2-3 HD treatment where medical treatment is insufficient. PURPOSE: In this study, the early results of laser hemorrhoidoplasty and Milligan-Morgan hemorrhoidectomy techniques were compared. MATERIAL AND METHODS: A randomized clinical trial. The study included ASA 1-3, total 85 patients aged 18-70 years old with symptomatic Grade 2 and Grade 3 hemorrhoidal disease whose symptoms persisted despite at least one month of medical treatment. Fifty-four patients were allocated to Group L, whereas 31 were allocated to Group M. Age, gender, weight, body mass index, preoperative symptoms, presence of additional disease, use of anticoagulant medication, and length of hospital stay of the patients included in the study were recorded. Rescue analgesic used was recorded. Postoperative VAS score and complications were recorded within 10 days. The total energy numbers applied to all packages were recorded. RESULTS: The incidence of minor perioperative hemorrhage was significantly lower in Group L compared to Group M (P = .035). The postoperative 3rd-hour VAS scores were statistically significantly lower in Group L compared to Group (P < .001). At the 3rd hour postoperatively, the need for rescue analgesia was statistically significantly higher in Group M compared to Group L. On the seventh postoperative day, Group M needed considerably more rescue analgesia compared to Group L (P < .001, P = 1.00, P = .035, respectively). The cut-off value of 571 J was calculated in Group L. CONCLUSION: We believe that it is not an advantageous method compared to MM hemorrhoidectomy, both in terms of patient comfort and cost-effectiveness, since postoperative pain, which is shown as the most important advantage of LH over conventional hemorrhoidectomy methods in the literature, can be relieved with simple NSA-I rescue analgesia in patients undergoing MM. Trial Registration: 03.06.2021/21-63.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance.

INTRODUCTION: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. METHODS: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. RESULTS: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. CONCLUSIONS: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.

Role of antibiotics in Milligan-Morgan hemorrhoidectomy for Grade III to IV Hemorrhoids: A randomized clinical trial.

PURPOSE: This study was mainly to compare the safety and long-term clinical efficacy of using intravenous antibiotics in Milligan Morgan hemorrhoidectomy for Grade III to IV Prolapsing Hemorrhoids. METHODS: This was a parallel group, 3-arm, randomized clinical trial to evaluate the efficacy of intravenous prophylactic antibiotics. A total of 150 consecutive patients undergoing Milligan Morgan hemorrhoidectomy (MMH) in a tertiary hospital for grade III/IV hemorrhoids from January 2020 to August 2022 were enrolled. Patients were randomly assigned to three groups using a computer-generated table. Group A did not receive any prophylactic antibiotic, group B received 2 g I/V Cefoxitin Sodium before the induction of anesthesia, and group C received 2 g I/V Cefoxitin Sodium before the induction of anesthesia and 6 h after operation. RESULTS: There was no significant difference in measured VAS values on the 1st day,3rd day and 7th day after surgery (p> 0.05). Compared with VAS values on the 1st day postoperatively, these values got decreased on the 3rd day and 7th day after surgery (p< 0.05). In addition, there was no significant difference among the first defecation time, wound edema, bleeding, urinary retention after surgery (p> 0.05). There was no significant difference in the outcome comparison between all 3 groups' basal and the 3rd day postoperatively no matter in WBC, NUET% or CRP (p> 0.05). However, compared with basal, the WBC, NUET%,CRP(p< 0.05) of group A and group B on the 3rd day postoperatively got rised, the rate of recurrence of hemorrhoids follow-up for 1 year was 1.4%. CONCLUSIONS: Our results suggest that there is no efficacy on intravenous prophylactic antibiotics in Milligan Morgan hemorrhoidectomy.

Transanal open haemorrhoidopexy: a well-tolerated, minimally invasive surgical method for haemorrhoids grade II to IV.

BACKGROUND: To determine 1-year postoperative recurrence rates, postoperative pain and complication rates of transanal open haemorrhoidopexy applied also in grade IV haemorrhoids. METHODS: Single-centre retrospective observational study without control group. The primary outcome was recurrence rate after 1 year postoperatively. Secondary outcomes were length of postoperative pain, use of opiates and postoperative complications. The recurrence rate was assessed with the Sodergren haemorrhoid symptom severity score questionnaire. For information on the early postoperative period, a retrospective chart review based on the routine 3-month clinical follow-up was done. RESULTS: 135 consecutive patients with haemorrhoids Goligher grades II-IV were operated with transanal open haemorrhoidopexy. 88 patients (65%) consented to participate in the study when approached later via mail. 23% of patients had haemorrhoids Goligher grade IV. 15 patients (17%) needed a second transanal open haemorrhoidopexy for residual haemorrhoidal prolapse. The recurrence rate of prolapsing haemorrhoids was 15% (13 patients) 1 year postoperatively. 21% of patients reported no postoperative pain, 54% described pain for a duration of up to 1 week and 22% for up to 2 weeks. Two patients reported a longer duration of pain of 3 and 4 weeks, respectively. No complications grade Clavien-Dindo III or higher were detected. CONCLUSION: The results of our study indicate that transanal open haemorrhoidopexy has a recurrence rate comparable to traditional haemorrhoidectomy including grade IV haemorrhoids and is associated with less pain and tissue damage. A randomized controlled trial may provide further support for the routine application of this method, but may pose challenges.

Thrombosed external hemorrhoids during pregnancy: surgery versus conservative treatment.

The management of thrombosed external hemorrhoids (TEH) during pregnancy is still under debate because of the fear of potential adverse effects on the fetus. This study aims to compare efficacy and safety of conservative versus surgical treatment of acute TEH in pregnant women. Furthermore, the outcome of two different surgical approaches was evaluated. This is a prospective observational study including a sub-analysis on two randomized groups of pregnant women affected by TEH. The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire. In a randomized sub-analysis of the surgical treatment, the outcome of local excision (LE) versus thrombectomy (TE) was compared. Fifty-three patients entered the study. Twenty-six patients had conservative treatment and 22 underwent surgery. Within the surgical group, 8 were randomized for TE and 14 for LE. VAS, SF-12 and CPGAS improved in both groups after 3 and 10 days from the treatment. However, physical (PCS) and mental health (MCS) domains of the SF-12 and CPGAS showed a significant difference in favor of surgery on the 10th day (PCS: p < 0.002 and MCS: p = 0.03; CPGAS: p = 0.002). The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004). In the surgical group, randomization was halted due to ethical concerns arising from a notable difference in the primary end point between subgroups during interim analysis. Specifically, the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE. No complications occurred for either mothers or fetuses. Both surgical and conservative treatments are safe and effective. However, surgery allows a faster relief of anal pain. Thrombectomy is associated with higher risk of re-thrombosis when compared to local excision (clinicaltrials.gov ID number NCT04588467).

Establishment and study of a rat internal haemorrhoid model.

To establish a relatively stable internal haemorrhoid model in rats. A total of 48 SPF SD rats were selected and randomly divided into a blank group of 16 and a model group of 32. The model was created by croton oil-mixed liquid stimulation combined with standing and swimming experiments, and the modelling times were 1 week and 2 weeks, respectively. By observing the symptoms and signs of rats, pathological morphology and immunohistochemical staining of anorectal tissue, anorectal laser speckle blood-flow imaging and defecation contrast, etc., the effect of different modelling times was evaluated. The stability of the model was evaluated after feeding for 2 weeks. Both model-formation times caused rats to produce local symptoms of tissue bulging in the haemorrhoid area. Microscopy showed that the rectal submucosal interstitial blood vessels were dilated, and inflammatory cell infiltration and other manifestations were observed. Laser speckle blood-flow imaging revealed increased anorectal blood perfusion and capillary dilatation, and defecography showed a longitudinal and continuous rectal mucosa. After 2 weeks of normal feeding, lifting of the haemorrhoidal tissue was still present. The effect of modelling for 1 week was most in line with the clinical manifestations of internal haemorrhoids. The 1-week modelling scheme in this study can effectively establish a rat internal haemorrhoid model that closely approximates clinical internal haemorrhoid symptoms and pathological manifestations. The operation is simple, the success rate is high, and the model has certain stability. This model can be used as an important basis for studying various treatment methods for internal haemorrhoids.

Development of a low-cost simulator for training in hemorrhoidal ligation

Introduction: Rubber band ligation is a minimally invasive outpatient hemorrhoid treatment with low cost, low complication rates, and rapid realization. It is performed with the aid of an anoscope and uses a rubber ring that surrounds the hemorrhoidal nipple, causing compression of the vascular structures of the tissue, leading to necrosis and remission of the hemorrhoid. No device for training this essential procedure for treating this pathology has been identified in the literature. Therefore, we aim to develop a low-cost simulator for training hemorrhoidal rubber ligation. Methods: The model was constructed using PVC pipe wrapped in neoprene fabric. Hemorrhoidal nipples and the pectineal line were also simulated using fabric and sewing threads. The procedure is performed with conventional anoscope and ligature forceps. Conclusion: The device in question is a low-cost simulation model designed to train the skills required to perform a rubber band ligation and review the basic anatomy of the anal canal during anoscopy. Given these qualities, the model can be used for academic training due to its low cost and simplicity of application. (AU)

The comparison of an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) versus circular stapled hemorrhoidopexy (CSH) in patients with grade IV hemorrhoids: a retrospective cohort study.

OBJECTIVES: The objectives of this study were to present an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) in the treatment of grade IV hemorrhoids and to assess long-term outcomes of this technique compared with circular stapled hemorrhoidopexy (CSH). METHODS: Conventional CSH kits combined with an intestinal spatula were used for performing C-PSH. A total of 256 patients with grade IV hemorrhoids referred to Hangzhou Third People's Hospital between January 2016 and June 2017 were obtained: 122 (47.7%) with C-PSH, and 134 (52.3%) with CSH. After propensity score matching, 222 patients (111 in C-PSH group and 111 in CSH group) were ultimately analyzed. The primary outcome was the five-year recurrence rate of hemorrhoids. Secondary outcomes included intraoperative outcomes, postoperative outcomes and complications. RESULTS: The operative time in the C-PSH group was slightly longer than that in the CSH group (p < 0.01). The vertical length of rectal mucosa specimen in the C-PSH group was shorter than that in the CSH group (p < 0.01). Compared with the CSH group, fecal urgency incidence and numeric rating scale (NRS) score at first defecation were lower in the C-PSH group (p < 0.05). Major complication rate in the CSH group was higher than that in the C-PSH group (p = 0.03). Five-year recurrence rate between the C-PSH group and CSH group was comparable (p > 0.05). Multivariate Cox regression analysis revealed that constipation was an independent prognostic factor for hemorrhoidal recurrence. CONCLUSIONS: The accessible C-PSH seems to be a safe and effective technique in managing grade IV hemorrhoids. It has advantages in alleviating postoperative pain at first defecation, fecal urgency and major complications compared with CSH. It could be an alternative technique in the treatment of grade IV hemorrhoids.

[Chinese expert consensus on the treatment of hemorrhoids by injection(2023 edition)].

Hemorrhoids is a common anorectal disease, usually occurring in middle-aged people aged 25-65 years old, clinical bleeding, swelling, prolapse, pain, itching and anal discomfort, and repeatedly attacks and aggravated gradually, seriously affecting the quality of life of patients. The treatment of hemorrhoids includes conservative, injection, ligation, and various surgical procedures. Injection therapy with a history of more than 150 years is simple to operate, easy to popularize and apply in grass-roots units, causes less intraoperative bleeding and fewer complications, and has reliable efficacy. As a result, it is favored by clinicians and patients. The injection treatment of hemorrhoids has been mentioned in various hemorrhoid treatment guidelines and consensus at home and abroad, but there is no special expert consensus for reference. Led by the Anorectal Physicians Branch of the Chinese Medical Doctor Association and the Colorectal Surgery Group of the Surgery Branch of the Chinese Medical Association, experts in related fields in China were invited to review the latest evidence-based medical evidence at home and abroad and conducted evidence quality assessment and recommendation strength classification according to the GRADE system. This paper attempts to make detailed recommendations on the types and application methods of the preparations commonly used in the injection treatment of hemorrhoids at home and abroad, and form the Chinese Expert Consensus on the Treatment of hemorrhoids by anal injection (2023 edition), aiming to guide the reasonable selection of drugs and dosage forms for hemorrhoidal injection treatment, and to provide reference for standardizing the use of different drugs and dosage forms, so as to improve the effectiveness and safety of clinical application of hemorrhoidal injection treatment.

Stapled hemorrhoidopexy. A single-center study on over 600 patients with long term follow-up.

OBJECTIVE; The aim of this study is to evaluate the results of patients treated by stapler hemorrhoidopexy for hemorrhoidal disease with a long term foloow up. MATERIAL AND METHOD: Patients who were operated with stapled hemorrhoidopexy (SH) technique between 01/01/2009 and 01/01/2019 in the general surgery department were included. Patients with stage 2 and stage 3 hemorrhoidal disease included. All patients were operated by the same surgeon using a 33-mm circular PPH stapler. All patients were evaluated on the 7 th day with physical examination, at the second month with physical exam and flexible rectoscopy and at one year with physical examination or telephone call and then with follow up exams if they had symptoms. RESULTS: 646 patients were included. 581 of them were discharged on the same day of the operation. At 1 week after surgery,78 patients (12 %) reported urgency and occasional gas leakage, and 18 patients (3%) reported liquid leakage. 68 patients ( 11%) developed grade 3 or 4 recurrence 38 (6 %) of these patients were treated with Milligan Morgan hemorroidectomy. 19 patients with bleeding were treated with band ligation . Fourty-five patients (7%) required drug therapy for treating hemorrhoidal bleeding. 42 patients developed anal fissure and three patients had anal stenosis. CONCLUSIONS: SH provides high patient comfort and short hospital stay and is a good surgical alternative providing a low recurrence rate in the long run . This single center study with a long follow up period provides a contribution to literature. KEY WORDS: De Longo, Hemorrhoidal disease, Stapled hemorrhoidopexy.

Parameters predicting postoperative pain and quality of life after hemorrhoidectomy: follow-up results from a prospective multicenter randomized trial.

PURPOSE: Pain and reduced quality of life (QoL) are major subjects of interest after surgery for hemorrhoids. The aim of this study was to find predictive parameters for postoperative pain and QoL after hemorrhoidectomy. METHODS: This is a follow-up analysis of data derived from a multicenter randomized controlled trial including 770 patients, which examines the usefulness of tamponade after hemorrhoidectomy. Different pre-, intra-, and postoperative parameters were correlated with pain level assessed by NRS and QoL by the EuroQuol. RESULTS: At univariate analysis, relevant (NRS > 5/10 pts.) early pain within 48 h after surgery was associated with young age (≤ 40 years, p = 0.0072), use of a tamponade (p < 0.0001), relevant preoperative pain (p = 0.0017), pudendal block (p < 0.0001), and duration of surgery (p = 0.0149). At multivariate analysis, not using a pudendal block (OR 2.64), younger age (OR 1.55), use of a tamponade (OR 1.70), and relevant preoperative pain (OR 1.56) were significantly associated with relevant early postoperative pain. Relevant pain on day 7 was significantly associated only with relevant early pain (OR 3.13, p < 0.001). QoL overall remained at the same level. However, n = 229 (33%) patients presented an improvement of QoL and n = 245 (36%) an aggravation. Improvement was associated with a reduction of pain levels after surgery (p < 0.0001) and analgesia with opioids (p < 0.0001). CONCLUSION: Early relevant pain affects younger patients but can be prevented by avoiding tamponades and using a pudendal block. Relevant pain after 1 week is associated only with early pain. Relief in preexisting pain and opioids improve QoL. TRIAL REGISTRATION: DRKS00011590 12 April 2017.