Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy

BACKGROUND: Haemorrhoidectomy is frequently associated with postoperative pain and prolonged hospital stay. A new technique of haemorrhoidectomy using the Ligasure device suited to day-case surgery is described. This technique was compared with conventional open diathermy haemorrhoidectomy. METHODS: Forty patients with grade III or IV haemorrhoids were randomized to Ligasure (group 1) or conventional diathermy (group 2) haemorrhoidectomy. Operative details were recorded and patients recorded daily pain scores on a linear analogue scale. Follow-up was at 1, 3, 6 and 12 weeks to evaluate complications, return to normal activity, ongoing symptoms and patient satisfaction. RESULTS: Reduced intraoperative blood loss (median (range) 0 (0-5) ml versus 20 (12-22) ml; P < 0.001) and a shorter operating time (10 (8-11) versus 20 (18-25) min; P < 0.001) was observed in group 1 compared with group 2. More patients in group 1 were discharged on the day of operation (18 of 20 versus 11 of 20; P < 0.05) and there was a trend towards lower postoperative pain scores on day 1 (group 1 median 5 (95 per cent confidence interval (c.i.) 2.6 to 6.8) versus group 2 7 (95 per cent c.i. 4.2 to 7.7); P = 0.36). There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications. CONCLUSION: Ligasure diathermy may be used safely in the treatment of patients with grade III or IV haemorrhoids. It reduces intraoperative blood loss and operating time, and facilitates same-day discharge.     

Meta-analysis of flavonoids for the treatment of haemorrhoids

BACKGROUND: The aim of the study was to evaluate the impact of flavonoids on those symptoms important to patients with symptomatic haemorrhoids. METHODS: A comprehensive search strategy was used. All published and unpublished randomized controlled trials comparing any type of flavonoid to placebo or no therapy in patients with symptomatic haemorrhoids were included. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies and extracted data. RESULTS: Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality and showed variability in the results with potential publication bias. Meta-analyses using random-effects models suggested that flavonoids decrease the risk of not improving or persisting symptoms by 58 per cent (relative risk (RR) 0.42 (95 per cent confidence interval (c.i.) 0.28 to 0.61)) and showed an apparent reduction in the risk of bleeding (RR 0.33 (95 per cent c.i. 0.19 to 0.57)), persistent pain (RR 0.35 (95 per cent c.i. 0.18 to 0.69)), itching (RR 0.65 (95 per cent c.i. 0.44 to 0.97)) and recurrence (RR 0.53 (95 per cent c.i. 0.41 to 0.69)). CONCLUSION: Limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids.     

Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

BACKGROUND: A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective. METHODS: Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols. RESULTS: Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation. CONCLUSION: The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.     

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.     

Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy

BACKGROUND: Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy. METHODS: A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990. RESULTS: Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2.62 (95 per cent confidence interval (c.i.) 1.91 to 3.60)). A higher overall morbidity rate was also demonstrated in this group (RR 1.43 (95 per cent c.i. 1.26 to 1.61)), as was a higher mortality rate (RR 2.51 (95 per cent c.i. 1.61 to 3.91)). CONCLUSION: Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.     

Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy

BACKGROUND: Open haemorrhoidectomy is associated with considerable postoperative pain and discomfort. This study assessed whether glyceryl trinitrate (GTN) ointment promotes wound healing and reduces pain after open haemorrhoidectomy. METHODS: A randomized prospective double-blind placebo-controlled trial was conducted. Patients were randomized to either 0.2 per cent GTN ointment or placebo ointment (petroleum jelly). Patients were asked to fill in a pain diary. Complete healing was defined as complete epithelialization. RESULTS: There were 40 patients in the GTN group and 42 in the placebo group. There were no statistically significant differences in sex, weight, type of haemorrhoid, type of surgery (emergency or elective), number of haemorrhoids excised, duration of surgery, hospital stay and complication rate between the groups. Pain scores and analgesic use were not significantly different. By week 3, however, 17 patients in the GTN group had completely epithelialized wounds compared with eight patients in the placebo group (P = 0.021). Only one patient who received GTN experienced headache requiring discontinuation of the ointment. CONCLUSION: TGN 0.2 per cent ointment improved wound healing rates, but did not reduce pain in this study.     

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair

BACKGROUND: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials that compared OIHR and LIHR and were published in the English language between January 1990 and the end of October 2000. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, time to discharge from hospital, return to normal activity and return to work, postoperative complications and recurrence rate. Random effects meta-analyses were performed using odds ratios and weighted mean differences. RESULTS: Twenty-nine trials were considered suitable for meta-analysis. Some 3017 hernias were repaired laparoscopically and 2972 hernias were repaired using an open method in 5588 patients. For four of the six outcomes the summary point estimates favoured LIHR over OIHR; there was a significant reduction of 38 per cent in the relative odds of postoperative complications (odds ratio 0.62 (95 per cent confidence interval (c.i.) 0.46 to 0.84); P = 0.002), 4.73 (95 per cent c.i. 3.51 to 5.96) days in time to return to normal activity (P < 0.001), 6.96 (95 per cent c.i. 5.34 to 8.58) days in time to return to work (P < 0.001) and 3.43 (95 per cent c.i. 0.35 to 6.50) h in time to discharge from hospital (P = 0.029). There was a significant increase of 15.20 (95 per cent c.i. 7.78 to 22.63) min in the mean operating time for LIHR (P < 0.001). The relative odds of short-term recurrence were increased by 50 per cent for LIHR compared with OIHR, although this result was not statistically significant (odds ratio 1.51 (95 per cent c.i. 0.81 to 2.79); P = 0.194). CONCLUSION: LIHR was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than OIHR. However, the operating time was significantly longer and there was a trend towards an increase in the relative odds of recurrence after laparoscopic repair.     

Prospective randomized study of bacteraemia in diathermy and stapled haemorrhoidectomy

BACKGROUND: The incidence and consequences of bacteraemia associated with diathermy and stapled haemorrhoidectomy have not been studied previously. METHODS: Two hundred and five healthy patients randomized to stapled haemorrhoidectomy or diathermy haemorrhoidectomy had perioperative blood cultures taken. The clinical sequelae of bacteraemia and complications of surgery were assessed prospectively. RESULTS: Six patients were excluded for protocol violations. Eleven (11 per cent) of 101 patients with stapled and five (5 per cent) of 98 who had diathermy haemorrhoidectomy had positive blood cultures for organisms after haemorrhoidectomy, predominantly anaerobes commonly found within the bacterial flora of the anorectum (P = 0.19). Transient postoperative pyrexia in several patients did not correlate with detected bacteraemia and settled spontaneously without treatment. There were no serious complications from either operative technique, and no clinical consequences from proven bacteraemia. CONCLUSION: Transient bacteraemia may complicate surgical haemorrhoidectomy but has no serious clinical consequences for healthy adults.     

Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis

BACKGROUND: Death from infected necrosis in acute pancreatitis is common and prevention has focused on prophylactic antibiotics. This study assesses whether intravenous prophylactic antibiotic use reduces infected necrosis and death in acute necrotizing pancreatitis. METHODS: A meta-analysis of randomized controlled trials was carried out. Medline, Web of Science, the Cochrane controlled trials register and international conference proceedings were searched, with a citation review of relevant primary and review articles. RESULTS: Six of 328 studies assessed were included in data extraction. Primary outcome measures were infected necrosis and death. Secondary outcome measures were non-pancreatic infections, surgical intervention and length of hospital stay. Prophylactic antibiotic use was not associated with a statistically significant reduction in infected necrosis (relative risk (RR) 0.77 (95 per cent confidence interval (c.i.) 0.54 to 1.12); P = 0.173), mortality (RR 0.78 (95 per cent c.i. 0.44 to 1.39); P = 0.404), non-pancreatic infections (RR 0.71 (95 per cent c.i. 0.32 to 1.58); P = 0.402) and surgical intervention (RR 0.78 (95 per cent c.i. 0.55 to 1.11); P = 0.167). It was, however, associated with a statistically significant reduction in hospital stay (P = 0.040). CONCLUSION: Prophylactic antibiotics do not prevent infected necrosis or death in acute necrotizing pancreatitis.     

Randomized clinical trial of LigaSure and conventional diathermy haemorrhoidectomy

BACKGROUND: The aim of this randomized prospective trial was to compare LigaSure and conventional diathermy haemorrhoidectomy. METHODS: Two hundred and eighty-four patients with grade III or IV haemorrhoids were randomized to LigaSure or diathermy (Milligan-Morgan) haemorrhoidectomy as a day-case procedure. Operating time, postoperative pain score, hospital stay, postoperative complications, wound healing time and time to return to normal activities were assessed. Thirty-four patients were lost to follow-up. RESULTS: The mean operating time for LigaSure haemorrhoidectomy was significantly shorter than that for diathermy (P = 0.011). Patients treated with LigaSure had significantly less postoperative pain (measured on a visual analogue scale; P = 0.010), a shorter wound healing time (defined as time to absence of swelling; P = 0.012) and less time off work (P = 0.010) than patients who had diathermy. Neither postoperative complications nor mean hospital stay (day-case surgery) were significantly different. CONCLUSION: LigaSure haemorrhoidectomy demonstrates simplicity, reproducibility, a low complication rate, fast wound healing, a quick return to work and reduced postoperative pain.     

Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ

BACKGROUND: There is no clear consensus on the better therapeutic approach (endoscopic versus surgical) to choledocholithiasis. This study is a meta-analysis of the available evidence. METHODS: A search of the Medline and ISI databases identified 12 studies that met the inclusion criteria for data extraction. The analysis was performed using a random-effects model. The outcome was calculated as an odds ratio (OR) or relative risk (RR) with 95 per cent confidence intervals (c.i.). RESULTS: Outcomes of 1357 patients were studied. There was no significant difference in successful duct clearance (OR 0.85 (95 per cent c.i. 0.64 to 1.12); P = 0.250), mortality (RR 1.79 (95 per cent c.i. 0.66 to 4.83); P = 0.250), total morbidity (RR 0.89 (95 per cent 0.71 c.i. to 1.13); P = 0.350), major morbidity (RR 1.34 (95 per cent c.i. 0.92 to 1.97); P = 0.130) or need for additional procedures (OR 1.37 (95 per cent c.i. 0.82 to 2.29); P = 0.230) between the endoscopic and surgical groups. There was also no significant difference between the endoscopic and laparoscopic surgery groups. CONCLUSION: Both approaches have similar outcomes, and treatment should be determined by local resources and expertise.     

French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease

BACKGROUND: The aim of this study was to compare in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD). METHODS: This prospective national multicentre observational study included all consecutive patients undergoing open or laparoscopic elective colectomy for SDD in a 4-month period between June and September 2002. Postoperative in-hospital mortality and morbidity in the two groups were compared. RESULTS: Three hundred and thirty-two consecutive patients undergoing either laparoscopic (163 patients) or open (169 patients) colectomy for SDD were analysed. Overall postoperative mortality and morbidity rates were 0.3 and 23.8 per cent respectively. The morbidity rate was significantly higher in the open than in the laparoscopic group (P < 0.001), leading to a significantly longer hospital stay (P < 0.001). The morbidity rate remained significantly higher in the open group when the patients were matched for age (P = 0.015) or American Society of Anesthesiologists score (P = 0.028). An open procedure (relative risk (RR) 2.13 (95 per cent confidence interval (c.i.) 1.29 to 3.45)), age over 70 years (RR 1.62 (95 per cent c.i. 1.14 to 2.30)) and intraperitoneal contamination (RR 2.54 (95 per cent c.i. 1.18 to 5.50)) were identified as independent risk factors for morbidity. CONCLUSION: A laparoscopic approach to elective treatment of SDD may be associated with reduced postoperative morbidity and hospital stay. A randomized study is required to confirm these results.     

Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm

BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.     

Meta‐analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Background:

In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.

Methods:

A systematic review was performed with meta‐analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Risk ratio (RR) or mean difference was calculated with 95 per cent confidence intervals (c.i.) based on intention‐to‐treat analysis.

Results:

Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury (RR 0·64 (95 per cent c.i. 0·15 to 2·65)) or conversion to open cholecystectomy (RR 0·88 (95 per cent c.i. 0·62 to 1·25)). The total hospital stay was shorter by 4 days for ELC (mean difference ?4·12 (95 per cent c.i. ?5·22 to ?3·03) days).

Conclusion:

ELC during acute cholecystitis appears safe and shortens the total hospital stay. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligation with phenol injection

A prospective randomized clinical trial comparing rubber band ligation (RBL) with phenol injection in 269 patients with symptomatic haemorrhoids presenting to one surgical clinic over a 6 year period, has been carried out. Questionnaires were completed by 215 patients (106 RBL and 109 injection) with an average follow up of 2.75 years. A successful outcome was achieved in 89 per cent of those receiving RBL compared with 70 per cent for injection (P less than 0.001). All symptoms tended to respond more favourably to RBL, the results achieving statistical significance in patients complaining of bleeding and prolapse (P less than 0.01 and P less than 0.05 respectively). Complications from either technique were minimal. It is concluded that RBL is superior to phenol injection in the out-patient treatment of haemorrhoids.     

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA). METHODS: Between 1991 and 1999, 836 patients underwent surgery for ruptured AAA. Their operative risk at presentation was evaluated retrospectively using the Glasgow Aneurysm Score, based on data from the nationwide Finnvasc registry. RESULTS: The operative mortality rate was 47.2 per cent (395 of 836); 164 patients (19.6 per cent) had cardiac complications and 164 (19.6 per cent) required intensive care treatment for more than 5 days. Predictors of postoperative death in univariate analysis were: coronary artery disease (P = 0.005), preoperative shock (P < 0.001), age (P < 0.001), and the Glasgow Aneurysm Score (P < 0.001). In multivariate analysis the predictors were: preoperative shock (odds ratio (OR) 2.13 (95 per cent confidence interval (c.i.) 1.45 to 3.11); P < 0.001) and the Glasgow Aneurysm Score (for an increase of ten units: OR 1.81 (95 per cent c.i. 1.54 to 2.12); P < 0.001). Receiver-operator characteristic (ROC) curves showed that the best cut-off value of the Glasgow Aneurysm Score in predicting postoperative death was 84 (area under the curve 0.75 (95 per cent c.i. 0.72 to 0.78), standard error 0.17; P < 0.001). The operative mortality rate was 28.2 per cent (114 of 404) in patients with a Glasgow Aneurysm Score of 84 or less, compared with 65.0 per cent (281 of 432) in those with a score greater than 84 (P < 0.001). CONCLUSION: The Glasgow Aneurysm Score predicted postoperative death after repair of ruptured AAA in this series.     

Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer

BACKGROUND: The appropriate extent of lymph node clearance during gastrectomy for cancer remains controversial. METHODS: Medline, Embase, the Cochrane register and other databases were searched for studies reporting node dissection technique, 5 year survival and mortality after gastrectomy. Comparisons with systematic bias in treatment allocation and patients who received perioperative chemotherapy were excluded. Meta-analysis was performed separately for randomized and non-randomized comparisons. RESULTS: Two randomized and two non-randomized comparisons of limited (D1) versus extended (D2) node dissection and 11 reports of one dissection type were analysed. For D2 the randomised trials showed no overall survival benefit (Risk ratio (RR) = 0.95, 95 per cent c.i. 0.83-1.09) and an increased postoperative mortality (RR = 2.23, c.i. 1.45-3.45), apparently related to pancreatico-splenectomy and surgical inexperience. A trend towards survival benefit for D2 was observed for T3+ tumours (RR = 0.68, c.i. 0.42-1.10). Non-randomized comparisons found no survival benefit for D2 (RR = 0.92, c.i. 0.83-1.02), but decreased postoperative mortality (RR = 0.65, c.i. 0.45-0.93). Nine observational studies of D2 reported better results than two studies of D1 surgery, but in very different settings. CONCLUSIONS: Evidence for D2 dissection is inconclusive. No overall survival advantage has emerged, but some patients with intermediate stage disease may benefit. Excess operative mortality appears to be associated with pancreatico-splenectomy, low case volume and lack of specialist training.     

Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy

BACKGROUND: The introduction of a stapling technique for the treatment of haemorrhoids has the potential for less postoperative pain, a short operating time and an early return to full activity. The outcome of stapled haemorrhoidectomy was compared with that of current standard surgery in a randomized controlled study. METHODS: Two hundred patients were randomized to either stapled haemorrhoidectomy (n = 100) or Milligan-Morgan haemorrhoidectomy (n = 100) between March 1997 and December 1998. Each patient received standardized postoperative analgesic and laxative regimens, and completed a linear analogue pain score every 6 h during the first day after operation, after the first motion and daily until the end of the first week. Operating time, frequency of postoperative analgesic intake, hospital stay, time to return to normal activity and postoperative complications were also recorded. RESULTS: The mean(s.d.) age of patients in the stapled and surgical groups was 44.1(3.2) and 49.1(12.2) years respectively. The stapled group had a shorter operating time, less frequent postoperative analgesia intake, shorter hospital stay and earlier return to normal activity. Early and late complications, and functional outcome were better in the stapled group. CONCLUSION: Use of a circular stapler in the treatment of haemorrhoidal disease was safe, and was associated with fewer complications than conventional haemorrhoidectomy.     

Survey of methods of treatment of haemorrhoids and complications of injection sclerotherapy.

INTRODUCTION: This study was conducted to survey current practices in the treatment of haemorrhoids (Hs), prevalence of complications associated with injection sclerotherapy (IS) and attitudes to its use to treat anterior Hs. METHODS: Postal questionnaires were sent to 92 consultant surgeons in the South East Thames Region. They were returned anonymously. RESULTS: Seventy questionnaires were returned (76% response rate) and 61 questionnaires were used in the data analysis; 18 from coloproctologists and 43 from non-coloproctologists who treated Hs. First degree Hs were mostly treated with IS alone (76%). Second degree Hs were treated with rubber band ligation (RBL) alone (36%) or a combination of IS and RBL (36%). Third degree Hs were mostly treated with haemorrhoidectomy (76%). Nineteen surgeons (31%) reported complications using IS; 82% of these were urological. Nine surgeons (15%) did not use IS to treat anterior Hs and 10 (16%) advised their trainees not to inject anteriorly. CONCLUSIONS: IS is a common treatment of Hs. Nearly one-third of consultants reported complications, the majority of which were urological and likely to be secondary to IS of anterior Hs. It may be safer to avoid IS of anterior haemorrhoids.     

Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy

BACKGROUND: Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy. METHODS: A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale. RESULTS: Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047). CONCLUSION: Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.