Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study

Aim We report a multicentric prospective study which aimed to evaluate Doppler‐assisted ligation of the terminal haemorrhoidal arteries (THD) for II and III degree haemorrhoids. Method A total of 112 patients from five colorectal units, including 81 men, mean age 48 ± 13 years, with II degree (39) and III degree (73) haemorrhoids were treated by Doppler‐guided transanal de‐arterialization and anopexy using a new device (THD). Results The mean operative time was 33.9 ± 8.8 minutes, and the mean number of ligatures applied was 7.2 ± 1.5. Postoperatively, 72% of patients did not need analgesics and the other 28% used nonsteroidal anti‐inflammatory drugs 1–3 times/day for less than 2 days. All the patients were operated as a day case. Early postoperative complications included haemorrhoidal thrombosis (2 patients), bleeding (1) treated by haemostatic suture, dysuria (6) and acute urinary retention (1). After a mean follow‐up of 15.6 ± 6.5 months (range 6–32), 2/105 (20.9%) patients complained of minor bleeding, while mild pain was still present in 4/51 patients (7.8%). There were no statistically significant differences in the sample population regarding the gender or stage of the disease. Tenesmus was cured in 15/17 patients, dyschaezia in 20/22 patients and mucous soiling in 10/10 patients. No new cases of altered defaecation or faecal incontinence were recorded. Overall, 85.7% of patients were cured and 7.1% improved. Residual haemorrhoids were treated by elastic band ligation in nine (8%) patients and by surgical excision in further five patients (4.5%). Conclusion Doppler‐assisted ligation of the terminal branches of the haemorrhoidal arteries for II and III degree haemorrhoids is highly effective and painless. Complications are few and the technique can be performed as a day case.     

‘Distal Doppler‐guided dearterialization’ is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization

Aim Transanal haemorrhoidal dearterialization (THD® Doppler) is a surgical procedure involving Doppler‐guided ligation of haemorrhoidal arteries to reduce arterial flow. With proximal Doppler‐guided dearterialization, arterial ligation is achieved by introducing the proctoscope completely into the anal canal and lower rectum. In the present study, distal Doppler‐guided dearterialization (DDD) is performed in the distal 2 cm of the lower rectum. Immediate and short‐term results were evaluated. Method One hundred patients with bleeding haemorrhoids, with or without muco‐haemorrhoidal prolapse, underwent THD® Doppler procedure, using DDD of the haemorrhoidal arteries 2 cm above the anorectal junction. Mucopexy was performed in patients with haemorrhoidal prolapse. Results The operation time was 20 ± 7 min for dearterialization alone (10 patients), and 30 ± 10 min when mucopexy was added (90 patients). Morbidity included: transient haemorrhoidal thrombosis (two patients); urinary retention (five patients); submucosal abscess (one patient). No patient complained of faecal incontinence. At a median follow‐up of 7.3 (3–17) months, all patients reported an improvement in symptoms. No patients reported bleeding. Conclusion DDD of the haemorrhoidal arteries could be a simplified and more effective method of applying THD.     

Doppler‐guided haemorrhoidal artery ligation,rectoanal repair,sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III–IV haemorrhoids: a multicenter prospective study of safety and efficacy

Objective The isolated use of Doppler‐guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures. Method The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%). Results More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1–4 positions were deemed necessary in 46 (31%) patients. Minimal (muco‐)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1–3 days, 4–7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow‐up of 15 months, 96% of patients were asymptomatic and 95% were satisfied. Conclusions DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.     

Anal duplex fails to show changes in vascular anatomy after the haemorrhoidal artery ligation procedure

Aim The aim of this prospective study was to evaluate whether the beneficial effect of haemorrhoidal artery ligation/transanal haemorrhoidal dearterialization (HAL/THD) is attributable to a change in the vascular anatomy at the level of the corpus cavernosum recti. Method Patients treated by HAL/THD for Grade II or Grade III haemorrhoids were scanned by anal colour Doppler endosonography before treatment and 6 weeks postoperatively. As part of a randomized controlled trial, patients were treated either with or without the Doppler scan. The number and diameter of vascular structures were measured at the distal, mid and proximal levels in the anal canal. Results There were 30 patients in the non‐Doppler group and 34 in the Doppler group. The postoperative measurements of the anal colour Doppler endosonography did not show any significant differences in vascular anatomy compared with the preoperative measurements, regardless of whether the Doppler probe was used (P > 0.05). Conclusion This study failed to show that the effect of HAL/THD is caused by alteration of the macroscopic vascular anatomy in the corpus cavernosum recti.     

Stapled haemorrhoidopexy: 6 years’ experience of a referral centre

Aim To prospectively evaluate the long‐term results and assess patient satisfaction after stapled haemorrhoidopexy (HS). Method A total of 150 patients (121 male patients) with symptomatic grade II (n = 50) or III (n = 100) haemorrhoids underwent stapled HS. Patients were followed up during consultations at regular intervals, allowing prospective data collection. A final telephone follow up was also undertaken. Results Follow up data were obtained for 130 of 150 patients (86.6%). After a median follow up of 39 months (range, 12‐72), 90% of the patients were fully satisfied and 92% were free of haemorrhoidal symptoms. There were no intraoperative complications. Postoperative bleeding that required operation was observed in five patients (3.3%). Most late postoperative complications were benign and easily resolved: unexplained pain for over a month (n = 1), external haemorrhoidal thrombosis (n = 2), anal fissure (n = 6) one with hypertrophic papilla, anal fistula (n = 1), rectal stenosis (n = 1), anal incontinence for (n = 1). Eight patients needed rubber band ligation to treat persistent or recurrent symptomatic prolapse. Four patients (2.6%) were reoperated on during the follow up period but none for haemorrhoidal pathology. Conclusion Stapled HS procedure is effective and has low morbidity, high patient satisfaction and provided good long‐term control of haemorrhoidal symptoms in the treatment of second and third‐degree haemorrhoids.     

Doppler-guided transanal haemorrhoidal dearterialisation

The usual surgical treatment for haemorrhoids consists in excision of the piles and ligation of the hemorrhoidal plexus, with considerable postoperative pain. A new, less invasive technique has been introduced, called transanal haemorrhoidal dearterialisation. This technique consists in Doppler-guided ligation of the distal branches of the superior rectal arteries (3 to 6) 2-3 cm above the pectinate line. Arterial ligation causes reduction of blood flow to, and decongestion of, the haemorrhoidal plexus. From January 2000 to September 2003, we performed transanal haemorrhoidal dearterialisation in 138 patients. Patients experienced no pain in the immediate postoperative period. The follow-up revealed good outcomes. The transanal haemorrhoidal dearterialisation procedure can be considered a safe, effective, painless and quick method of curing haemorrhoidal disease. Its indications are extensive. The success rate is approximately 90%, but may be lower for grade 4 haemorrhoids.     

Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.     

Three‐dimensional power Doppler transanal ultrasonography,to monitor haemorrhoidal blood flow after Doppler‐guided ALTA sclerosing therapy

Aim The study aimed to use power Doppler imaging (PDI) transanal ultrasonography to produce three‐dimensional power Doppler angiography images of haemorrhoidal tissue and to monitor the effects of Doppler‐guided aluminium potassium sulfate and tannic acid (DGALTA) sclerotherapy. Method Ninety‐six haemorrhoids in 43 patients were examined using PDI transanal ultrasonography, and DGALTA sclerotherapy was performed from April 2011 to April 2012. DGALTA sclerotherapy was conducted using a four‐step injection process with pulse wave Doppler ultrasound under perianal local anaesthesia. Results A three‐dimensional power Doppler angiography image of the blood flow in haemorrhoidal tissue was produced using PDI transanal ultrasonography. The cross‐sectional area of blood flow in the haemorrhoidal tissue (PDI area) significantly decreased after DGALTA sclerotherapy. The PDI areas in the preoperative state and 1 and 3 months after treatment were 0.35 ± 0.27, 0.03 ± 0.05 and 0.04 ± 0.05 cm² (P < 0.0001). Conclusion A three‐dimensional power Doppler angiography image of the haemorrhoidal tissue was technically possible and showed blood flow in the haemorrhoidal tissue to be significantly decreased after DGALTA sclerotherapy.     

Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy

BACKGROUND AND METHOD: This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random-effects model for dichotomous and continuous outcomes respectively. RESULTS: Three trials met the inclusion criteria and all were of poor methodological quality. Complete remission of haemorrhoidal symptoms was better after haemorrhoidectomy (RR 1.68 (95 per cent c.i 1.00 to 2.83)). There was significant heterogeneity between the studies (I(2) = 90.5 per cent; P < 0.001). Fewer patients required retreatment after haemorrhoidectomy (RR 0.20 (95 per cent c.i 0.09 to 0.40)), but anal stenosis, postoperative haemorrhage and incontinence to flatus were more common with this operation. CONCLUSIONS: Haemorrhoidectomy produced better long-term symptom control in patients with grade III haemorrhoids, but was associated with more postoperative complications than RBL.     

Doppler-guided haemorrhoidal artery ligation: long-term outcome and patient satisfaction

Objective  Conventional Milligan–Morgan haemorrhoidectomy is associated with significant pain and potentially hazardous complications. Doppler-Guided Haemorrhoidal Artery Ligation (DGHAL) may offer a lower risk, pain-free alternative. We present our early and long-term outcome experience with DGHAL, combined with patient views and satisfaction with the procedure.
Method  One hundred and thirteen DGHALs were performed over a 13 month period by two surgeons in a single centre. Patients graded the severity of postoperative pain on visual-analogue scales. Clinical follow-up was at 6 weeks ( n  = 103), with long-term follow-up ( n  = 90) by postal questionnaire at median of 30 months.
Results  Seven out of one hundred and three (6%) patients reported postoperative discomfort requiring analgesia. Ninety-three out of one hundred and three (90%) patients reported complete relief or significant improvement in their symptoms at 6 weeks, dropping to 77/90 (86%) at 30 months. Anal fissures developed in 2/103 (2%) patients, both treated with Diltiazem ointment. Further surgery was required in 8/90 (9%) patients. Eighty-two out of ninety (91%) patients said they would undergo DGHAL again.
Conclusion  DGHAL is a relatively painless, safe, and effective procedure for symptomatic stage I–III haemorrhoids, for which we have demonstrated long-term durability and acceptability. Its role lies between office based procedures and more invasive operative interventions.     

Surgical treatment of haemorrhoids by stapled mucosaresection in the lower rectum: Indication, results, side-effects

Summary   Background:A. Longo’s circular staple procedure for the treatment of haemorrhoidal disease has given rise to controversies around the globe. The circular staple procedure enables patients to return to normal activity fairly quickly and is, as far as postoperative pain is concerned, superior to conventional procedures. However, long-term results are missing and possible complications remain under scrutiny. A study of this new operative procedure goes hand in hand with a critical evaluation of all surgical procedures for the treatment of haemorrhoidal disease. Methods: We operated on noduli haemorrhoidales interni (NHI) of all degrees. By means of a circular stapler, a mucosal cuff in the distal rectum is excised and prolapsed haemorrhoids are lifted into the proximal anal canal where they regress. No further operating step is required for additional noduli haemorrhoidales externi and fissures. Marisks and skin tags are ablated separately. Surgery is performed under general anaesthesia, only in rare cases under spinal anaesthesia. Postoperative wound care is not performed. Symptoms and findings were documented in linear, analogue charts and patients were interviewed preoperatively, on the day of surgery, as well as postoperatively on the second and eighth day and after 1, 6 and 12 months. Results: We operated on 258 patients with an age of 51.2 ± 13.3 years. The average length of surgery amounted to 28 (range: 15–55) minutes, patients were admitted as in-patients for 5.7 ± 2.35 days and the median recovery-phase lasted 7 (IQR: 4–10) days. Analgesia was standardised. All patients were given intravenous Tramadolhydrochloride (100–200 mg) postoperatively. 56.3% did not require additional analgesia and the remaining patients were given Tramadol (4.5 ± 2.0 capsules of 50 mg per patient) orally. 11.0% of the patients required additional strong analgesia parenterally. 13.6% developed urinary retention that required to be catheterized. 42 patients (16.6%) developed secondary bleeding and 10 patients (3.8%) required surgery for haemostasis. Urgent bowel movement was encountered as the most common side-effect with 30.0% of the cases. Major complications did not occur. The downstaging of the haemorrhoidal degree was satisfactory. 5 patients underwent postoperative rubber-band ligation for small remaining nodules and one patient required corretive Milligan haemorrhoidectomy. Conclusions:A. Longo’s stapler resection is a reliable therapy for haemorrhoidal disease causing minimal operative strain. It leads to immediate manageability of symptoms and initiates a healing process of the pathological anatomy of haemorrhoids. Rare cases with patients experiencing considerable pain are documented. Secondary bleeding may occur, but is easily suppressed. Urgent bowel movement is the most common and lengthy side-effect, but generally speaking, patients do not consider it impairing. With rare cases, remaining internal nodules have to be corrected by rubber-band ligation. External haemorrhoids regress spontaneously. If considered impairing, marisks and skin tags are ablated separately.      

Haemorrhoids – a collagen disease?

Objective The cause of haemorrhoidal disease is unknown, epidemiological data and histopathological findings support the hypothesis that reduced connective tissue stability is associated with the incidence of haemorrhoids. Therefore the aim of this study was to analyse the quantity and quality of collagen formation in the corpus cavernosum recti in patients with III°/IV° haemorrhoids in comparison with persons without haemorrhoids. Method Haemorrhoidectomy specimens of 31 patients with III°/IV° haemorrhoids were examined. The specimens of 20 persons who died a natural death and who had no haemorrhoidal disease served as the controls. The amount of collagen was estimated photometrically by calculating the collagen/protein ratio. The collagen I/III ratio served as parameter for the quality of collagen formation and was calculated using cross polarization spectroscopy. Results Patients with haemorrhoids had a significantly reduced collagen/protein ratio (42.2 ± 16.2 μg/mg vs 72.5 ± 31.0 μg/mg; P = 0.02) and a significantly reduced collagen I/III ratio (2.0 ± 0.1 vs 4.6 ± 0.3; P < 0.001) compared with persons without haemorrhoidal disease. There was no correlation with patients’ age or gender. Conclusions There is a fundamental disorder of collagen metabolism in patients with haemorrhoidal disease. It remains unclear whether this is due to exogenous or endogenous influences.     

Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler‐guided transanal haemorrhoid dearterialization for third‐degree haemorrhoids

Aim Doppler‐guided transanal haemorrhoid dearterialization (THD) and stapler haemorrhoidopexy (SH) have been demonstrated to be less painful than the Milligan–Morgan procedure. The aim of this study was to compare the effectiveness of THD vs SH in the treatment of third‐degree haemorrhoids in an equivalent trial. Method One hundred and sixty‐nine patients with third‐degree haemorrhoids were randomized online to receive THD (n = 85) or SH (n = 84) in 10 Colorectal Units in which the staff were well trained in both techniques. The mean follow‐up period was 17 (range 15–20) months. Results Early minor postoperative complications occurred in 30.6% of patients in the THD group and in 32.1% of patients in the SH group. Milder spontaneous pain and pain on defecation were reported in the THD group in the first postoperative week, but this was not statistically significant. Late complications were significantly higher (P = 0.028) in the SH group. Residual haemorrhoids persisted in 12 patients in the THD group and in six patients in the SH group (P = 0.14). Six patients in the SH group and 10 in the THD group underwent further treatment of haemorrhoids (P = 0.34). No differences were found in postoperative incontinence. The obstructed defecation score (ODS) was significantly higher in the SH group (P < 0.02). Improvement in quality of life was similar in both groups. Postoperative in‐hospital stay was 1.14 days in the THD group and 1.31 days in the SH group (P = 0.03). Conclusion Both THD and SH techniques are effective for the treatment of third‐degree haemorrhoids in the medium term. THD has a better cost‐effective ratio and lower (not significant) pain compared with SH. Postoperative pain and recurrence did not differ significantly between the two groups.     

Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?

INTRODUCTION: Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse. MATERIALS AND METHODS: One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease. RESULTS: There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence. CONCLUSION: Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.     

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse

Aim Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day‐case surgery programme. Method From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third‐ and fourth‐degree haemorrhoids, second‐degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21–85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day‐case rate, postoperative pain (measured by a visual analogic scale, 1–10), admissions, re‐admissions, early postoperative situation and recurrence were evaluated in the study. Results The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty‐five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty‐three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. Conclusion SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day‐cases.     

Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient's degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.     

Radiofrequency haemorrhoid surgery: An alternative to newer treatment of haemorrhoids

Background: The author describes his experience of treatment of advanced haemorrhoidal disease using a technique called radiofrequency ablation and plication of haemorrhoids. Patients and Methods: Both male and female patients presenting with prolapsing haemorrhoids with indications for surgery were enrolled for the study. An Ellman radiofrequency generator was used for ablation of haemorrhoids. The surgical technique and clinical follow up of patients operated by this technique is presented. Patients were initially called at 7, 14 and 30 postoperative days and then at least 2 years after the procedure. Results in terms of mean hospital stay, postoperative pain, postoperative complications, period of incapacity for work and effectiveness of the procedure are presented. Results: 1260 patients operated with this technique were assessed. The average duration of operation was 7 min (range 5–9 min). Mean hospital stay was 11 h (range 6–23 h). The immediate postoperative complication included secondary bleeding, retention of urine and perianal thrombosis. The mean period of incapacity for work was 8 days (range 6–14 days). The mean analgesic requirement was 20 tablets of Tramadol (range 14–33). At the last follow up, 2% of patients had recurrence of bleeding and 6% developed anal skin tags. Conclusion: The procedure of radiofrequency ablation and plication of haemorrhoids shows promising results in patients with advanced haemorrhoidal disease. Being safe, effective, and a swift technique, it can be proposed as an alternative to conventional surgical procedures.     

Proctological diseases in routine urologic practice

Nearly two third of adults will suffer from proctologic complaints. The same symptoms could also indicate or mask an anorectal carcinoma. Therefore, the first priority should be to exclude the possibility of a neoplasm of the colon, rectum and the anal canal. Knowledge of the specific anatomy of the anal canal and the patient's history will lead to an exact proctologic diagnosis: perianal thrombosis, acute thrombosed prolapsed haemorrhoidal plexus, an anal fissure, abscess and fistula are located within the highly sensitive anoderma and are characterized by pain. Perianal thrombosis, chronic fissure, abscess and fistula require surgery. Conservative treatment is the choice for an acute anal fissure, haemorrhoids grade I-II. Haemorrhoids II-III require surgery, e.g. by haemorrhoidal artery ligation, open or closed resection of the haemorrhoidal plexus, reconstruction of the anal canal or stapled mucosectomy. Perianal diseases such as perianal tags, fibroma or condylomata acuminata are easily diagnosed and treated. Secondary perianal eczema requires treatment of the underlying proctologic disease. If it persists, a biopsy is required.     

Tumor vascularity as a prognostic factor for hepatic tumors.

The prognostic and therapeutic significance of tumor vascularity was studied in 36 patients with hepatoma or metastatic colon cancer in the liver. All patients had nonresectable tumor and were treated by hepatic artery ligation and hepatic arterial infusion chemotherapy. Chemotherapy consisted of methotrexate, actinomycin-D, 5-fluorouracil and cyclophosphamide. Hepatic tumors were categorized into Grades I to III in the order of increasing vascularity as determined by preoperative hepatic angiography. Tumor vascularity of 15 patients with hepatoma was Grade III in 11 (73%) and Grade II in 4 (27%). No patient with hepatoma had a Grade I tumor. The median survival of patients was 10 and 6 months for Grade III and II hepatomas, respectively, after hepatic artery ligation, and 18 and 8.5 months for Grade III and II, respectively, from the time of diagnosis of hepatoma. Tumor vascularity of 21 patients with metastatic colon cancer was as follows: Grade III in 3 (14%); Grade II in 10 (48%); and Grade I in 8 (38%). The median survival was 11, 10.5 and 4 months for Grades III, II and I, respectively, after hepatic artery ligation, and 17, 14.5 and 7.2 months for Grades III, II and I, respectively, from the time of diagnosis of hepatic metastases of colon cancer. The results indicate that the more vascular the hepatic tumor on angiogram, the better the prognosis following hepatic artery ligation and infusional chemotherapy.     

Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.