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 anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial.

BACKGROUND: Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events. METHODS: This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no). RESULTS: At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events. CONCLUSIONS: LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Annoyed with Haemorrhoids? Risks of the Emborrhoid Technique.

Haemorrhoids, a common ailment afflicting mostly Western patients, can produce bothersome symptoms, in particular pain, pruritus, and bleeding. There is a wide choice of surgical treatment options available for haemorrhoids in patients that cannot be treated with medical therapy, such as those that are prolapsed. Many patients refuse surgery due to the fear of potential complications; to overcome this obstacle, novel alternative techniques have been developed in recent years that are focussed on ligation or occlusion of haemorrhoidal arterial blood flow. We describe a patient who developed recto-sigmoidal ischaemia after embolization of the haemorrhoidal arteries, known as the "emborrhoid" technique, with persistence of rectal bleeding and progressive rectal stenosis.

A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials.

BACKGROUND: There is a lack of standardised outcomes for haemorrhoidal disease making comparison between trials difficult. A need for a very well validated severity score is essential to facilitate meta-analysis of comparative studies, enabling evidence-based clinical practice. METHODS: The Hubble trial provides a large cohort of patients with haemorrhoidal disease randomised to rubber band ligation (RBL) or haemorrhoidal artery ligation. The haemorrhoid severity score (HSS) was collected on each patient at baseline, 6 weeks and 1 year after intervention. This allows for the responsiveness of the HSS instrument to be examined and compared with a more specific instrument, the Vaizey incontinence score (also collected). Responsiveness was tested using four methods (effect size, standardised response means (SRM), significance of change, and responsiveness statistic). RESULTS: The four tests of responsiveness demonstrated that the HSS was more responsive to changes in the patient's health status following both of the interventions compared to the Vaizey questionnaire. For example, between baseline and 6 weeks, the RBL intervention effect size scores and SRM calculations indicated a non-significant small amount of change (0.20 and 0.16 respectively). However, using the HSS, the effect size and SRM demonstrated a large magnitude of change (1.12 and 1.01, respectively) which was significant. Similar results were observed at 1 year. Significance of change scores and the index of responsiveness were also higher for the HSS questionnaire than the Vaizey across both treatment modalities. CONCLUSIONS: The HSS is a highly responsive tool for the detection of changes in haemorrhoid symptoms. It should form an essential patient-reported outcome tool for future studies on haemorrhoidal disease.

Relationship between bidet toilet use and haemorrhoids and urogenital infections: a 3-year follow-up web survey.

Given the growing use of electric bidet toilets in Japan and other countries, we assessed the relationship between bidet toilet use and haemorrhoids or urogenital infections. Data were collected using a web-based longitudinal survey. In total, 10 305 subjects randomly selected from panels of a Japanese website research company for the baseline survey in 2013 were asked about their frequency of bidet toilet use and receipt of a doctor's diagnosis or subjective symptom of haemorrhoids and urogenital infections. One- and three-year follow-up surveys were performed in 2014 and 2016, respectively, and information on newly diagnosed/experienced outcomes occurring during the follow-up period were collected. Cumulative incidence of haemorrhoids and urogenital infections was not significantly increased by habitual use of a bidet toilet. In men, more habitual users reported subjective symptoms of irritated skin around the anus, which were newly experienced during follow-up than non-habitual users (adjusted risk ratio 1.36 (95% confidence interval 1.06-1.75)). Further studies are needed to confirm this relationship. Several of the outcomes were significantly more prevalent in habitual users, but these results were probably explained by reverse causation.

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.

Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief.

AIM: Conventional haemorrhoidectomy is still considered the reference standard for the management of severe or recurrent haemorrhoids. Pain is reported by patients to be the most common postoperative complication. Although the literature lacks a consensus on its effectiveness, metronidazole is often used to reduce postoperative pain. We have performed a meta-analysis of all randomized controlled trials (RCTs) that investigated the use of metronidazole for pain relief after haemorrhoidectomy. METHOD: A systematic review was undertaken in accordance with the PRISMA protocol using the MESH headings 'haemorrhoidectomy', 'hemorhoidectomy', 'hemorrhoidectomy', 'haemorrhoid', 'metronidazole', 'Flagyl® ' 'antibiotic' and 'pain'. The search returned 421 articles of which eight were RCTs suitable for inclusion in the review with a total population of 437 patients. The outcomes of interest were postoperative pain intensity on days 1, 2 and 7 and on first defaecation as measured using a visual analogue scale. RESULTS: The meta-analysis demonstrated a significant reduction in postoperative pain for patients treated with metronidazole with a reduced mean difference for the metronidazole group on day 1 of -1.42 (95% CI: -2.14 to -0.69, P = 0.0001), on day 2 of -1.43 (95% CI: -2.45 to -0.40, P = 0.006) and on day 7 of -2.40 (95% CI: -3.10 to -1.71, P < 0.00001). Pain on first defaecation was likewise reduced with a mean difference of -1.38 (95% CI: -2.15 to -0.60, P = 0.0005). Limitations of this study include variation in the grade of haemorrhoids treated and variability in the quality of included studies. CONCLUSION: Metronidazole is a cheap, safe and effective intervention for reducing postoperative pain following conventional haemorrhoidectomy.

Development and validation of a symptom-based severity score for haemorrhoidal disease: the Sodergren score.

AIM: One major obstacle in assessing the efficacy of treatment of haemorrhoids and the comparison of trials has been the lack of a standardized, validated symptom severity score. This study aimed to develop an objective, validated symptom-based score of severity for haemorrhoids that can be used to compare treatments, monitor disease and assist in surgical decisions. METHOD: A symptom and quality-of-life questionnaire was developed from the literature in conjunction with expert surgical opinion. The questionnaire was circulated to patients with confirmed haemorrhoids. A statistical model was used to derive a weighted score of symptoms most affecting patients' quality of life. Patients who were offered operative treatment were independently judged by specialists to have more severe symptoms, with further validation of the scoring system against treatment. RESULTS: Forty-five patients were included in final validation analysis, of whom 44 (98%) reported multiple symptoms, the most common being rectal bleeding. Patient-reported effects on quality of life were 47.5 ± 36.3 (1-100 visual analogue scale). Calculated symptom severity scores were used to compare patients receiving operative or ambulatory care, with significant difference in the scores (7.7 ± 3.9 vs 2.8 ± 3.5, P = 0.002) and a receiver operating characteristic area under the curve of 0.842. CONCLUSION: A novel validated score for the assessment of haemorrhoidal disease adopting a standardized global score for symptom severity may have important implications in future for research, assessment and the management of this common pathology.

Visualization and hypervascularization of the haemorrhoidal plexus in vivo using power Doppler imaging transanal ultrasonography and three-dimensional power Doppler angiography.

AIM: The purpose of this study was to demonstrate the distribution of haemorrhoidal arteries and the relationship between vascularity and growth of haemorrhoids. METHOD: One-hundred and three patients with haemorrhoids were studied. Using power Doppler imaging (PDI) transanal ultrasound and three-dimensional power Doppler angiography (3D-PDA), the course of the arteries supplying the haemorrhoids was identified. Measurement of the PDI area was made using the cursor to outline the power Doppler signal of the haemorrhoid, approximately 1 cm above the dentate line. RESULTS: The haemorrhoidal arteries were seen as branches of the superior rectal artery and were detected in 75.7, 71.8, 68.0 and 62.1% of the 11, 7, 3 and 1 o'clock positions in the lithotomy position. The median number of haemorrhoidal arteries significantly increased from three to six with progression of the Goligher classification from Grade 1 to Grade 4 (P < 0.0001). The PDI areas in Grades 1, 2, 3 and 4 were 0.04 ± 0.03, 0.18 ± 0.07, 0.38 ± 0.18 and 0.96 ± 0.32 cm(2) (P < 0.05). CONCLUSION: The distribution of haemorrhoidal arteries varies widely in both number and position. Using PDI transanal ultrasonography and 3D-PDA it was possible to visualize the haemorrhoid plexus and the course of the haemorrhoidal artery in vivo.

Efficacy of Harmonic Scalpel Versus Bipolar Diathermy in Hemorrhoidectomy: A Systematic Review and Meta-Analysis of Nine Randomized Controlled Trials.

Hemorrhoidectomy is one of the most common surgical interventions to remove the third and fourth degrees of prolapse hemorrhoid. We carried out this systematic review and meta-analysis of the randomized controlled trials (RCTs) to comprehensively evaluate the efficacy of harmonic scalpel (HS) versus bipolar diathermy (BD) methods in terms of decreasing intraoperative and postoperative morbidities among patients undergoing hemorrhoidectomy. Suitable citations were found utilizing digital medical sources, including the CENTRAL, Web of Science, PubMed, Scopus, and Google Scholar, from inception until December 2022. Only RCTs that matched the inclusion requirements were selected. We used the updated Cochrane risk of bias (ROB) tool (version 2) to assess the quality of the involved citations. The Review Manager (version 5.4 for Windows) was used to perform the pooled analysis. Data were pooled and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in random-effects models. Overall, there was no significant difference between HS and BD in terms of decreasing intraoperative morbidities like operative time, intraoperative blood loss, mean duration of hospital stay, and mean duration of first bowel movement (P>0.05). Similarly, the rate of postoperative complications like pain, bleeding, urinary retention, anal stenosis, flatus incontinence, and wound edema; was similar in both groups with no significant difference (P>0.05). In conclusion, our pooled analysis revealed there was no substantial difference between HS and BD in terms of intraoperative and postoperative endpoints. Additional RCTs with larger sample sizes are needed to consolidate the power and quality of the presented evidence.

Modified ultrasound scalpel haemorrhoidectomy versus conventional haemorrhoidectomy for mixed haemorrhoids: a study protocol for a single-blind randomised controlled trial.

BACKGROUND: Haemorrhoids are common and frequently occurring diseases in the clinical setting, and severe haemorrhoids require surgical treatment. There are various surgical methods to treat haemorrhoids, but each has advantages and disadvantages. In recent years, ultrasonic scalpels have been used in haemorrhoid surgery and have achieved good results. Ultrasonic scalpel haemorrhoidectomy is safer and more effective in the surgical treatment of grade III and IV haemorrhoids, with less intraoperative bleeding, less postoperative pain, and fewer complications than diathermic therapy, electrosurgical haemorrhoidectomy, PROXIMATE® PPH haemorrhoidal circular stapler haemorrhoidopexy (PPH), and traditional haemorrhoidectomy. In previous reports, the majority of ultrasonic scalpel haemorrhoidectomies were performed as open procedures, with only the body of the haemorrhoid removed with the ultrasonic scalpel and the wound left open for drainage and natural healing. However, we performed a preliminary experiment with 12 patients who underwent open ultrasonic scalpel haemorrhoidectomy in the early stage. The results showed that 8 patients had different degrees of postoperative bleeding, and 4 of them required a second haemostatic surgery under anaesthesia. Therefore, we modified the open ultrasonic scalpel haemorrhoidectomy procedure by removing the mucosa of the internal haemorrhoid and closing the base of the incision with figure-eight penetrating sutures and designed this study protocol to evaluate its clinical efficacy and safety. METHODS: A randomised single-blind parallel-controlled trial is proposed for this project, and patients who meet the inclusion criteria will be divided into a test group and a control group, with 39 patients in each group. The experimental group will be treated with modified ultrasonic scalpel haemorrhoidectomy, and the control group will be treated with the Milligan-Morgan operation. The effectiveness of modified ultrasonic scalpel haemorrhoidectomy for haemorrhoids will be objectively evaluated, including the incision healing time and the time for patients to return to normal activities, postoperative complications, evaluations of anal function 3 months and 6 months after surgery, an evaluation of quality of life 6 months after surgery, and an evaluation of the patient satisfaction rate 6 months after surgery. The safety assessment will consider all adverse and serious adverse events associated with the study treatment. DISCUSSION: The study was approved by the ethics committee. The first patient was registered on July 1 2021. The purpose of this trial will be to evaluate the clinical efficacy and safety of the modified ultrasonic scalpel haemorrhoidectomy procedure for the treatment of mixed haemorrhoids and to provide an evidence base for the clinical promotion and application of the procedure. A limitation of this study is that only the patients will be single-blinded because the researchers and the patients cannot be blinded at the same time, which may produce certain bias in the results. In addition, the sample size of this study will be small, and the test results will only represent the findings from this clinical trial. In later stages, the sample size needs to be further expanded to improve the level of evidence. Despite its limitations, we hope the present study will help provide a more optimised surgical approach in the selection of haemorrhoid surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry (Registration ID: ChiCTR2100047229). Registered on June 11, 2021.

Sweetening the pain: The role of sugar in acutely prolapsed haemorrhoids.

Abstract: Haemorrhoids are considered among the most frequent proctologi-cal condition at a general practitioner (GP) practice. Acute prolapse of internal haemorrhoids is presented with oedema, inflammation and acute pain. The application of granulated sugar on swollen hae-morrhoids leads to an immediate reduction of their edema and to the patient's relief. After the topical application of sugar, haemorrhoids begin to shrink immediately and edema is drastically reduced, while haemorrhoidal tissue can easily retracted back into the anal canal. The method is a cheap, quick and painless way to control the worsening symptoms such as swelling, bleeding and irritation. In addition, this method can easily be applied in the GP practice without the necessity of any form of anaesthesia.

Surgical technique is the main predictor of recurrence in the management of haemorrhoids.

BACKGROUND: The pursuit of better management for haemorrhoidal disease (HD) is far from over, and even with the latest surgical procedures, none of the treatment options is close to perfect. The aims of this study were to review our experience with patients treated for symptomatic HD, compare the different treatment strategies in terms of complication and recurrence rates and determine predictors of recurrence. METHODS: A total of 1958 patients who underwent a procedure for HD performed by a single colorectal consultant surgeon between 2000 and 2015 were reviewed. RESULTS: The treatment performed was rubber band ligation (RBL) in 73%, excisional haemorrhoidectomy (EH) in 16% and stapled haemorrhoidopexy (SH) in 11%. After a mean follow-up of 42.1 months, 242 patients (12%) developed recurrence. Logistic regression analysis of multiple factors showed that treatment received was a significant predictor of recurrence. RBL had the lowest post-operative complication rate but had the highest recurrence rate. EH had the lowest recurrence rate. SH had the highest complication rate but with similar recurrence rates to EH. Complications included pain, anal fissure, bleeding and urinary retention. CONCLUSION: Low-grade HD can initially be treated with RBL with good results. Although conventional EH remains a mainstay operation for recurrent and complicated HD, SH can also be considered in selected cases particularly when performed by a surgeon with adequate experience. Treatment should be tailored to the individual based on patient preference, suitability, degree of haemorrhoids and symptomatology.

Local anaesthesia for haemorrhoidal rubber band ligation reduces immediate post-operative recovery time and use of opioid analgesia.

BACKGROUND: Haemorrhoidal rubber band ligation (RBL) is a well-established, safe and cost-effective treatment for bleeding haemorrhoids. It is generally well tolerated; however, some patients may require narcotic analgesia or even admission to hospital for pain management. This comparative cohort study reports on the difference in peri-procedural analgesia administration and post-operative recovery time between patients who received local anaesthetic (LA) infiltration in addition to RBL, compared with patients treated only with RBL. METHODS: Consecutive patients with haemorrhoids treated over a 3-month period with LA infiltration in addition to RBL were compared to a consecutive control group who received RBL alone in the preceding 3 months. Clinical data were collected prospectively for LA group and retrospectively for the control group. Data collected included analgesia administered during the procedure and in recovery, as well as the mean time to discharge. RESULTS: A total of 32 patients treated with LA infiltration following RBL for haemorrhoids were compared with 22 patients who were treated with RBL alone. There was a reduction in the administration of intra-procedural parecoxib in the LA group (P < 0.001). Following the procedure, there was a reduction in the administration of both oral and intravenous opioid analgesia (P = 0.009) and reduced mean time to discharge in the LA group (P < 0.001). CONCLUSION: Infiltration of LA proximal to the band following RBL for haemorrhoids reduced the administration of analgesia both during the procedure and in recovery, as well as mean time to discharge following the procedure.

Relationship between anal symptoms and anal findings.

BACKGROUND: The frequencies and types of anal symptoms were compared with the frequencies and types of benign anal diseases (BAD). METHODS: Patients transferred from GPs, physicians or gynaecologists for anal and/or abdominal complaints/signs were enrolled and asked to complete a questionnaire about their symptoms. Proctologic assessment was performed in the knee-chest position. Definitions of BAD were tested in a two year pilot study. Findings were entered into a PC immediately after the assessment of each individual. RESULTS: Eight hundred seven individuals, 539 (66.8%) with and 268 without BAD were analysed. Almost one third (31.2%) of patients with BAD had more than one BAD. Concomitant anal findings such as skin tags were more frequently seen in patients with than without BAD (<0.01). After haemorrhoids (401 patients), pruritus ani (317 patients) was the second most frequently found BAD. The distribution of stages in 317 pruritus ani patients was: mild (91), moderate (178), severe (29), and chronic (19). Anal symptoms in patients with BAD included: bleeding (58.6%), itch (53.7%), pain (33.7%), burning (32.9%), and soreness (26.6%). Anal lesions could be predicted according to patients' answers in the questionnaire: haemorrhoids by anal bleeding (p=0.032), weeping (p=0.017), and non-existence of anal pain (p=0.005); anal fissures by anal pain (p=0.001) and anal bleeding (p=0.006); pruritus ani by anal pain (p=0.001), itching (p=0.001), and soreness (p=0.006). CONCLUSIONS: The knee-chest position may allow for the accumulation of more detailed information about BAD than the left lateral Sims' position, thus enabling physicians to make more reliable anal diagnoses and provide better differentiated therapies.

Inferior load generated by preloaded versus manually loaded haemorrhoid banding devices: the effect of 'creep relaxation'.

BACKGROUND: The efficacy of rubber band ligation of haemorrhoids relies on the load generated on haemorrhoidal tissue by bands as they return to their preformed shape after being deployed. 'Preloaded' haemorrhoid banding devices are widely available, but the effect of the resultant prolonged stretch on bands while stored in this manner has never been examined by comparing these to manually loaded devices, which are stretch immediately prior to being deployed. A difference could have clinical relevance, potentially resulting in a higher rate of clinical failure. The present study aimed to investigate any difference in load generated by preloaded versus manually loaded devices. METHODS: A preloaded and a manually loaded device were selected for comparison. Each type was measured on a testing rig. The device type, load generated by each band and the time to expiry were recorded. RESULTS: A total of 137 haemorrhoid bands were tested: 66 preloaded and 71 manually loaded. There was a statistically significant overall reduction in load generated by preloaded versus manually loaded devices (284.0 versus 272.1 g, mean difference -11.9 g, 95% confidence interval -17.5 to -6.3 g, P = 0.0001). Adjusted for time, the load generated by preloaded bands fell 3.7 g (95% confidence interval 2.7-4.8, P < 0.001) for each month closer to the expiry date. CONCLUSIONS: The load generated by haemorrhoid bands from preloaded devices is lower and deteriorates significantly towards their expiry date compared with bands from manually loaded devices. This is mostly likely due to their storage in a stretched state. This should be considered by clinicians when using haemorrhoid banding devices.

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

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

Transanal Hemorrhoidal Dearterialization With Doppler Arterial Identification Versus Classic Hemorrhoidectomy: A Retrospective Analysis of 270 Patients.

PURPOSE: Despite the minimally invasive nature of transanal hemorrhoidal dearterialization (THD) with Doppler arterial identification procedures, hemorrhoidectomy is still considered the gold standard procedure for hemorrhoidal disease. However, the classical techniques of hemorrhoidectomy have a high rate of postoperative complications. The main purpose of this study is to demonstrate the efficacy and complications of these techniques used for grades II and III hemorrhoids. METHODS: A retrospective (case-control) study was carried out from January 2009 to May 2014, and all patients undergoing surgical procedures for hemorrhoidal disease in two French clinics were considered. Application of inclusion and exclusion criteria identified 270 eligible patients (163 undergoing Doppler THD and 107 treated with Milligan Morgan hemorrhoidectomy). Statistical analysis was calculated considering immediate postoperative complications, functional results, chronic complications, and recurrences. RESULTS: Analysis of primary outcomes showed a significant difference between the 2 groups concerning postoperative pain, which had a lower rate in THD (P = 0.0001) and in postoperative bleeding (P = 0.02) than hemorrhoidectomy. However, long-term follow-up at three years showed a superior rate of recurrence in the THD group (P = 0.009). CONCLUSION: The THD technique is a safe and effective procedure for grades II and III hemorrhoids, has lower rates of post-operative pain and bleeding, and allows faster hospital discharge; however, it also shows a higher rate of recurrence at three years of follow-up.

Metronidazole following excisional haemorrhoidectomy: a systematic review and meta-analysis.

BACKGROUND: Post-operative pain is a major issue following excisional haemorrhoidectomy. Although metronidazole by both oral and topical administration routes has been shown to reduce pain after haemorrhoidectomy, its use remains a contentious issue. This systematic review and meta-analysis aims to investigate the effect of metronidazole on post-operative pain after excisional haemorrhoidectomy. METHODS: A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) published in PubMed/MEDLINE, EMBASE, CENTRAL and CINAHL, from inception to December 2016 were retrieved. The primary outcome investigated was post-operative pain reported as visual analogue score (VAS). Secondary outcomes were analgesia use, complications and time to return to normal activity. Meta-analysis was performed using Review Manager version 5.3 software. RESULTS: Nine randomized controlled trials including 523 patients were included in the final analysis. Five studies used oral administration and four used topical. Meta-analysis showed that post-operative VAS of patients receiving metronidazole by either route was significantly less than those in comparison groups. VAS means decreased at all the time points for both oral and topical metronidazole. Topical and oral routes of administration were not compared in any study. There was no increase in complication rates and return to normal activity was significantly earlier for patients receiving metronidazole (-4.49 days; 95% confidence interval [-7.70, -1.28]; P = 0.006). CONCLUSIONS: Both topical and oral metronidazole reduce post-operative pain without an increase in complication rates and result in an earlier return to normal activity. Further work is required to determine which the optimum route of administration is.