Randomized controlled study between suture ligation and radio wave ablation and suture ligation of grade III symptomatic hemorrhoidal disease

Purpose  Suture ligation is a simple method to curb the hemorrhoids. The present study was conducted to determine the usefulness of suture ligation in third-degree hemorrhoids and to compare it with author’s procedure of suture ligation coupled with hemorrhoidal ablation through radiowave. Materials and methods  One hundred and twenty-four consecutive patients with grade III hemorrhoids requiring surgery were randomized into two groups. Half of them were treated by suture ligation, while the remaining patients underwent a radiowave ablation of hemorrhoids using a Ellman radiowave generator followed by suture ligation. A blinded observer evaluated postoperative pain scores, amount of analgesics consumed, and complications encountered. He also assessed recurrence of hemorrhoids after 1 year. Results  The postoperative pain score was significantly higher in the suture ligation group (3.4 ± 0.2 vs. 2.2 ± 0.1, p < 0.005). The mean total analgesic dose and duration of pain control using analgesics were greater and longer for suture ligation group than radiowave group (29 ± 4 vs. 23 ± 3 tablets, and 15 ± 3 days vs. 12 ± 4 days, respectively; p < 0.001). Complications were seen more frequently in radiowave group (22% vs.18%). At 1 year follow-up, the recurrence of hemorrhoids was more significant with the suture ligation group (five patients vs. one patient, p < 0.05). Conclusion  Suture ligation of hemorrhoids is a simple, cost-effective, and a convenient modality in treating third-degree hemorrhoids. The efficacy and postoperative comfort is further enhanced if the hemorrhoids are ablated with radiowave prior to ligating them.     

Stapled mucosectomy: an alternative technique for the removal of retained rectal mucosa after ileal pouch-anal anastomosis

Restorative proctocolectomy (RPC), when performed with a stapled ileal pouch-anal anastomosis (IPAA), allows the retention of the rectal mucosa above the dentate line and can result in disease persistence or recurrence, as well as neoplastic lesions in patients with ulcerative colitis (UC). We report the case of a patient with chronic UC who underwent staple mucosectomy, which is an alternative technique that evolved from stapled hemorrhoidopexy, rather than more traditional procedures. The patient had undergone laparoscopic RPC with a stapled IPAA 2 cm above the dentate line and a temporary loop ileostomy. Because the histopathology showed low-grade dysplasia in the proximal rectum, stapled mucosectomy with a 33-mm circular stapler kit at the time of ileostomy closure was scheduled. Following the application of a purse-string suture 1 cm above the dentate line, the stapler was inserted with its anvil beyond the purse-string and was fired. The excised rectal tissue was checked to ensure that it was a complete cylindrical doughnut. Histopathology of the excised tissue showed chronic inflammation. There were no complications during a follow-up period of 5 months. Because it preserves the normal rectal mucosal architecture and avoids a complex mucosectomy surgery, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative to the removal of rectal mucosa retained after RPC.     

Stapled Hemorrhoidopexy vs. Harmonic Scalpel™ Hemorrhoidectomy: A Randomized Trial

PURPOSE A randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpel™ was used.METHODS Patients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpel™ hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions.RESULTS Over a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpel™ (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpel™ hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001).CONCLUSION Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.Presented at the free paper session of the Royal Australasian College of Surgeons Congress, Adelaide, May 13 to 15, 2002.     

Low hemorrhoidopexy staple line does not improve results and increases risk for incontinence

Background The ability of stapled hemorrhoidopexy (SH) to cure hemorrhoidal symptoms appears to depend on patient characteristics and operative technique. We assessed the association between outcome of SH and patients’ characteristics and procedure parameters (associated procedure, suture line height, doughnut size, presence of malpighian tissue or smooth muscle in specimen). Methods A total of 68 consecutive patients (56 males) were prospectively operated by 3 different surgeons. Hemorrhoids were grade II (6%), grade III (76%) or grade IV (18%). Results At a mean 32-week follow-up (range, 9–77), symptoms had resolved in 77% of patients, independently of any operative or clinical parameter. New onset anal incontinence occurred in 11 men (17%): all had urgency, with flatus and liquid stool incontinence in two, and flatus incontinence and mucus soiling in one. Univariate analysis revealed that persistent incontinence was associated with a staple line <6.5 mm from the dentate line, doughnut height <22 mm, and congestive external hemorrhoids; it was also operator dependent (p<0.05). At the 4-week follow-up, 19% of patients had persisting symptoms but only 8% had a demonstrable mucosal prolapse. Conclusion Although the success rate of SH may not be influenced by technical variations, risk for moderate incontinence is elevated when the stapled line is low. An erratum to this article is available at .     

A comparative study between radiofrequency ablation with plication and Milligan-Morgan hemorrhoidectomy for grade III hemorrhoids

Abstract Background Milligan-Morgan (MM) hemorrhoidectomy is the most favored treatment for prolapsed hemorrhoids. However, it may be associated with severe postoperative pain, long periods of convalescence and other complications. In alternative, I use a procedure of radiofrequency ablation and plication (RAP) of hemorrhoids. The present study compared the two procedures in terms of surgical parameters, postoperative pain and complications. Patients and methods A total of 60 patients with grade III hemorrhoids were randomized to undergo radiofrequency ablation and plication (31 patients) or MM hemorrhoidectomy (29 patients). The patients were followed up to 2 years. Results Duration of surgery was significantly longer in the MM group as was postoperative hospitalization (p<0.05). Post-defecation pain and pain at rest were much less in the RAP group (p<0.05). Wound healing period (17 vs. 38 days) and time to return to work (7 vs. 17 days) were the other significant findings favoring RAP procedure. Early complications occurred more frequently in MM group, but late complications like external skin tags (4 vs. 2 patients) were more common in RAP group. One asymptomatic recurrence was noted in RAP group. Conclusions Radiofrequency ablation and plication of hemorrhoids is associated with significantly less postoperative pain, shorter hospital stay and earlier return to normal activity. It can be considered as an alternative to the Milligan-Morgan hemorrhoidectomy.     

Stapled Technique for Acute Thrombosed Hemorrhoids: A Randomized,Controlled Trial with Long-Term Results

Purpose This study was designed to compare stapled vs. conventional hemorrhoidectomy for patients with acute thrombosed hemorrhoids. Methods Forty-one patients with acute thrombosed hemorrhoids were randomized into: 1) stapled hemorrhoidectomy (PPH group; n = 21), and 2) open hemorrhoidectomy (open group; n = 20). Emergency surgery was performed with perioperative data and complications were recorded. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals. Results The median follow-up for the PPH group and open group were 59 and 56 weeks, respectively. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P < 0.01), time to become pain-free (9 vs. 20.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01). On long-term follow-up, significantly fewer patients in the PPH group complained of recurrent symptoms (0 vs. 5, P = 0.02). The overall symptom improvement and patients’ satisfaction were significantly better in the PPH group (90 vs. 80 percent, P = 0.03 and +3 vs. +2, P < 0.01 respectively). Conclusions Stapled hemorrhoidectomy is safe and effective for acute thrombosed hemorrhoids. Similar to elective stapled procedure, emergency stapled excision has greater short-term benefits compared with conventional excision: diminished pain, faster recovery, and earlier return to work. Long-term results and satisfaction were excellent. Presented at the Annual Scientific Meeting of Hong Kong Society for Coloproctology, Hong Kong, January 14, 2006, at the Conjoined Annual Scientific Meeting of Royal College of Surgeon of Edinburg and The College of Surgeons of Hong Kong, Hong Kong, October 10 to 13, 2006, and at Annual Scientific Meeting of the Society of Endoscopic and Laparoscopic Surgeons of Asia, Seoul, Korea, October 18 to 21, 2006.     

Surgical treatment of haemorrhoids with the use of the circular stapler and open haemorrhoidectomy. A comparative study

The surgical treatment of haemorrhoids with the use of a circular stapler is a novel method. A comparative retrospective study of two groups of patients treated surgically for third- and fourth-degree haemorrhoids was conducted. Fifty patients (group A) underwent a surgical intervention with the circular stapler in the rectal mucosa 4 cm above the dentate line. In another group of 50 patients (group B), the standard open haemorrhoidectomy (Milligan-Morgan) was carried out. The new method (group A) compared with the standard haemorrhoidectomy (group B) was found to be less time consuming (mean time, 10±2 minutes vs. 35±5 minutes, p<0.001). The majority of patients (28) in group A experienced mild pain (VAS, 3–5) while pain for the majority of patients in group B was 5–7 on the VAS scale (p<0.01). The duration of postoperative hospitalisation was 1±1 days for the patients of group A and 5±2 days for the patients of group B (p<0.05). The early postoperative bleeding rate was 6% in group A and 12% in group B (p<0.01). None of the patients of group A developed incontinence and 6 (12%) patients in group B developed mild liquid incontinence during the first postoperative month. During the period of follow-up (12 months to 3 years, median length 18 months in outpatient visits), no patient in either group developed recurrence of haemorrhoids or rectal prolapse. In conclusion, the surgical treatment of haemorrhoids with the circular stapler seems to be an efficient alternative to the standard open haemorrhoidectomy when this is indicated. Received: 28 April 2000 / Accepted in revised form: 18 October 2000     

The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the 'STOMA' trial

Background

Ileostomy reversal is associated with surgical site infection (SSI) rates as high as 37%. Recent literature suggests that employing a purse-string approximation (PSA) of the reversal wound reduces this rate of SSI. Thus we wished to perform a randomised controlled trial to compare SSI rates in purse-string versus linear closure (PLC) wounds following ileostomy reversal.

Methods

A randomised, controlled trial was conducted at University Hospital Limerick. Sixty-one patients undergoing ileostomy reversal were included. Thirty-four patients were randomised to PSA and 27 patients to linear closure. The primary endpoint was incidence of SSI and secondary endpoints measured were quality of life and satisfaction with cosmesis. Statistical analysis was performed on a per protocol basis using SPSS version 22.0.

Results

Three patients in the PSA group developed an SSI compared to 8 in the PLC group at 30 days (8 vs 30%, p = 0.03). The mean time to SSI diagnosis was faster in the PSA group (3 vs 12.3 days, p = 0.08). Patients who developed SSI experienced a longer mean length of stay (6.8 vs 11.4 days, p = 0.012). On multivariate analysis, PLC was the only predictive factor of SSI formation (p < 0.001). There was no difference in patient satisfaction between the two study groups (p = 0.14).

Conclusions

PSA of wounds following ileostomy reversal significantly reduces SSI formation compared to linear approximation without any effect on patient satisfaction.

     

Intravenous Thrombolytic Treatment for Acute Myocardial Infarction

Abstract. Intravenous thrombolytic treatment (streptokinase or anisoylated plasminogen streptokinase activator complex (APSAC) was given to 50 consecutive patients within 3 hours after onset of symptoms of acute myocardial infarction. Left heart catheterisation with coronary angiography and simultaneous double view left ventriculography were performed approximately 4 hours after start of thrombolytic treatment. This examination showed that the acute infarct-related coronary artery was open in 36 patients (72%) and closed in 14 patients (28%). A higher left ventricular ejection fraction was found among patients with open, than among patients with closed infarct-related artery (58.8% vs. 48.4%, p=0.05). The group with open artery also had a lower score of regional left ventricular dysfunction (1.7 vs. 2.4, p<0.05, on a scale from 0–3). Single, double and triple vessel coronary heart disease was found in 22, 14 and 13 patients respectively. Mean age was lower in the group with single vessel disease as compared to double and triple vessel disease (48.4 years vs. 53.4 and 55.4 years, p<0.05 and p<0.005). Independently of whether the infarct-related artery was open or closed, there tended to be an inverse correlation between number of diseased vessels and preservation of left ventricular function (statistical significance only for single vessel versus triple vessel disease with respect to score of regional left ventricular dysfunction, 1.8 vs. 2.4, p<0.05). These findings suggest that early thrombolytic treatment within 3 hours of onset of symptoms may preserve myocardial tissue during the evolution of acute infarction. Furthermore, a presumably better collateralisation from adjacent coronary arteries without stenoses may be important for myocardial preservation. Finally, early angiographic examination can be performed safely and is a good support for determination of further treatment, which in the actual patients was coronary bypass surgery in 8 cases, transluminal angioplasty, PTCA, in 20 cases, and medical treatment alone in 22 cases.     

Prospective randomized trial of submucosal hemorrhoidectomy with radiofrequency bistoury vs. conventional Parks’ operation

Abstract.Background: Postoperative pain has always been the main adverse effect of the surgical treatment for hemorrhoids. Surgical techniques evolved mainly to solve this problem as well as postoperative bleeding, stenosis and recurrence. This randomized study compared the results obtained using submucosal hemorrhoidectomy with radiofrequency bistoury with those of the conventional Parks operation.Methods: A total of 102 patients were randomized to undergo submucosal hemorrhoidectomy with radiofrequency bistoury (51 patients) or conventional Parks haemorrhoidectomy (51 patients); loss of some patients at follow-up resulted in 49 and 45 patients available for analysis, respectively. The operating time, amount of pain (VAS scale, 1–10), postoperative analgesic requirement, intra- and postoperative complications, length of hospital stay and patient satisfaction were documented.Results: In comparison to Parks technique, use of radiofrequency bistoury reduced mean operating time (61.2 min vs. 37.4 min; p<0.05), first postoperative day pain score (5.9 vs. 4.0; p<0.05), pain score at first evacuation (5.7 vs. 4.2; p>0.05), postoperative stay (2.2 days vs. 1.3 days; p<0.05), and pain score on postoperative day 7 (3.6 vs. 2.8; p>0.05). Fecal incontinence was never observed. Incontinence to flatus with spontaneous resolution within 2–3 weeks was reported by 4 subjects in each surgical group. Urinary retention requiring catheterization occurred in 21 subjects in the radiofrequency bistoury group and in 18 patients in the control group. No complications nor recurrences were reported at the 6-month follow-up in either group.Conclusions: Performing submucosal hemorrhoidectomy with radiofrequency bistoury improves the results obtained with Parks technique, allowing us to simplify the surgical procedure, reduce operating time, postoperative pain and bleeding, and shorten the hospital stay.     

Gabapentin significantly decreases posthemorrhoidectomy pain: a prospective study

Purpose

Surgery for hemorrhoidectomy remains a painful procedure despite advances in pain management. Gabapentin is widely used for control of acute and chronic pain. Our aim was to evaluate the effect of gabapentin on posthemorrhoidectomy pain and opioid use.

Methods

A prospective, open-label study. Patients requiring hemorrhoid surgery were recruited to be in control (standard of care) or treatment group (standard of care plus daily gabapentin).

Results

Twenty-one treatment and 18 control patients were recruited. One patient from study group and two patients from control group were excluded due to failure to follow up. Pain levels for gabapentin group were significantly lower on postoperative days 1, 7, and 14 compared to the standard treatment group (3.68 vs. 6.82 p?p?=?0.02 and 0.75 vs. 3.64 p?Conclusions Daily use of gabapentin in perioperative period significantly decreased reported levels of postoperative pain. This effective, inexpensive addition improves pain after hemorrhoid surgery. Randomized placebo-controlled studies would better define the usefulness of this medication for posthemorrhoidectomy pain.     

Stapled Hemorrhoidopexy and Milligan Morgan Hemorrhoidectomy in the Cure of Fourth-Degree Hemorrhoids: Long-Term Evaluation and Clinical Results

Purpose The long-term results after stapled hemorrhoidopexy compared with Milligan-Morgan procedure are discussed. Methods The clinical data of 100 patients treated by Milligan-Morgan procedure or stapled hemorrhoidopexy for fourth-degree hemorrhoids have been reviewed. All patients were visited and submitted to a questionnaire to evaluate resumption of symptoms, functional results, and recurrence rate. Results The mean follow-up was 54 months for stapled hemorrhoidopexy and 92 months for the Milligan-Morgan procedure. Postoperative pain and return to normal activity were worse in the Milligan-Morgan procedure (Visual Analog Scale 8.56 vs. 5.46, P < 0.001; and 2.4 vs. 2 weeks, P value = 0.018). Eight percent of patients who had stapled hemorrhoidopexy complained of spontaneous pain or pain during defecation vs. 0 percent of patients who underwent the Milligan-Morgan procedure. We noted that there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. The relative risk of recurrence for stapled hemorrhoidopexy compared with Milligan-Morgan procedure was 1.18 (95 percent confidence interval 1< relative risk < 1.4). No statistical difference was noted in patients’ satisfaction after the procedures. Conclusions Long follow-up seems to indicate more favorable results in Milligan-Morgan procedure in terms of resumption of symptoms and risk of recurrence. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Primary and Repeated Stapled Hemorrhoidopexy for Prolapsing Hemorrhoids: Follow-Up to Five Years

Purpose Treating hemorrhoids by stapled hemorrhoidopexy has become increasingly common, because the procedure results in less pain and allows the patient to return to work earlier than with open hemorrhoidectomy. However, the durability of stapled hemorrhoidopexy has not been evaluated. This study was designed to assess initial results, analyze complications and failures, and document both the need for repeated procedures and the outcomes of follow-up to five years. Methods From 1998 to 2004, 258 patients underwent modified stapled hemorrhoidopexy. The appearance of the anus was scored preoperatively, immediately after the procedure, at three months, and at one to five years postoperatively. The anatomy score ranged from 1 (normal anus) to 7 (worst prolapse). We also evaluated operation time, analgesia, staple line position, postoperative pain score, technical failures, postoperative complications, need for repeated procedures, and patient satisfaction. Statistical analyses were used to identify correlations and differences, and the variables were analyzed in relation to the final outcome. Results The patients were observed for a median of 34 (range, 18–78) months. The median postoperative pain score was 4 (Visual Analog Scale 1–10) on the day of stapled hemorrhoidopexy; additional external procedures resulted in significantly higher pain (P < 0.05). Stapled hemorrhoidopexy was repeated in 31 patients (12 percent), and 38 patients (14.7 percent) had subsequent excisions. Technical failures occurred in 18 of 258 patients (7 percent). The median anatomy score decreased from 6 (range, 3–7) preoperatively to 1 (range, 1–6) at last follow-up, irrespective of one or a repeated stapled hemorrhoidopexy, surgical excision, or technical failure. The risk of reintervention was greatest during the first year after a stapled hemorrhoidopexy. Overall, patient satisfaction was high and correlated significantly with the anatomy score (r = 0.46, P < 0.05). Conclusions The pain after stapled hemorrhoidopexy was low, recovery was rapid, complications were few, and patient satisfaction was high. A recurrent (or persistent) prolapse was alleviated by a repeated stapled hemorrhoidopexy for cure. However, there was a high risk of reintervention after a stapled hemorrhoidopexy, and this should be further evaluated.     

Open versus closed day-case haemorrhoidectomy: is there any difference?

Background and aims Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology.Patients and methods We carried out a randomised prospective study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy (group A) versus 100 patients undergoing Ferguson haemorrhoidectomy (group B) for symptomatic haemorrhoids, in whom medical treatment or rubber band ligation had failed.Results Characteristics of the population were: mean age 43.5 years, with predominance of males, 123 vs. 77; 88% ASA I-II. Clinical presentation: 95% rectal bleeding; 87.5% third-fourth degree. The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients (90%). Length of surgery: 24 min (group A) and 30 min (group B) (p=n.s.). Resection of three haemorrhoidal cushions was done in 87.5% of cases. There were no re-operations or re-admissions after discharge. Symptomatic recurrence, stenosis and incontinence were not found during the follow-up of the first year. Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group, but the difference was statistically significant (p<0.05) only during bowel movements. There was complete healing in 40% of the patients in group A and 90% of those in group B (p<0.05) after 1 month. After 1 year, the results and complications were similar in both groups (p=n.s.).Conclusions Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year.     

Randomised trial comparing LigaSure haemorrhoidectomy with the diathermy dissection operation

The study was designed to compare LigaSure haemorrhoidectomy with open haemorrhoidectomy performed by means of diathermy excision. Fifty-sixty consecutive patients with third- and fourth-degree haemorrhoids were randomly allocated to undergo either LigaSure haemorrhoidectomy (29 patients) or diathermy haemorrhoidectomy (27 patients). All patients were evaluated for operative time, pain, post-operative analgesic requirements, time to first bowel movement, length of hospital stay, wound healing period, time to return to work, and occurrence of early postoperative complications (such as urinary dysfunction, bleeding, soiling, seepage, continence disorders) and late complications (such as stenosis). A statisticallysignificant advantage was observed in the patients who received the LigaSure technique as far as concerns length of operative time (9.2 vs. 12.2 min, p<0.001), post-operative analgesic requirements (14.1 vs. 16.8 administrations, p<0.001), wound healing period (16.3 vs. 37.5 days, p< 0.0001), and time to return to work (8.3 vs. 18.3 days, p<0.01). No significant difference was seen in the postoperative pain score, complications rate, first bowel motion or hospital stay. No recurrence was observed at the 6-month follow-up. In conclusion, our experience shows that the LigaSure haemorrhoidectomy offers definite advantages over the classic diathermy technique. This procedure is easier, safer, and more rapid to perform and is followed by a faster wound healing time, a significantly shorter hospital stay, less postoperative pain and faster wound healing. Received: 18 September 2002 / Accepted: 20 October 2002     

Ligasure? versus diathermy hemorrhoidectomy under spinal anesthesia or pudendal block with ropivacaine: a randomized prospective clinical study with 1-year follow-up

Purpose  We evaluate the safety and efficacy of a spinal anesthesia with lidocaine versus a local anesthesia of pudendal block with ropivacaine combined with intravenous sedation in the hemorrhoidectomy procedure and also we compared the short- and long-term efficacy of conventional diathermy versus Ligasure™ diathermy hemorrhoidectomy. Methods  Seventy-four patients of grade III or IV hemorrhoids were randomized to conventional diathermy hemorrhoidectomy under spinal (n = 19) or local anesthesia (n = 18) and Ligasure™ diathermy hemorrhoidectomy under spinal (n = 17) or local anesthesia (n = 20). Time of follow-up was 12 months. Results  Patients operated under local anesthesia had less pain (p < 0.01), less analgesic requirements (p < 0.001), shorter hospital stay (p < 0.01), and less postoperative complications (p < 0.05). A shorter operating time (p < 0.001) and less complications at 4 months postoperatively (p < 0.05) was observed in the Ligasure™ group, but differences at 12 months were not found. Conclusions  Hemorrhoidectomy under local anesthesia with pudendal block with ropivacaine and sedation reduced postoperative pain, analgesic requirements, and postoperative complications, and can be performed as day-case procedure. Ligasure™ diathermy hemorrhoidectomy reduced operating time and was equally effective than conventional diathermy in long-term symptom control.     

Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair

BACKGROUNDCurrently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIMTo evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODSThis was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed.RESULTSThe direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation).CONCLUSIONStapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.     

Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial

Background Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of “heat”. Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH). Methods Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient’s satisfaction. Results A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC. Conclusions Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period. An erratum to this article is available at .     

Topical Metronidazole (10 Percent) Decreases Posthemorrhoidectomy Pain and Improves Healing

INTRODUCTION Oral metronidazole has been previously demonstrated to decrease postoperative pain after open diathermy hemorrhoidectomy. The current study investigates the efficacy of topical metronidazole (10 percent) in reducing postoperative pain and promoting wound healing after Harmonic Scalpel^® hemorrhoidectomy.METHODS A prospective, randomized trial was conducted to compare posthemorrhoidectomy pain and wound healing with use of topical metronidazole (10 percent) vs. placebo carrier, applied to the surgical site. Surgical indications included grade 3 or 4 internal or external hemorrhoidal disease, with or without a fissure-in-ano. Pain was assessed using a visual analog score (VAS) preoperatively and on postoperative days 1, 2, 7, 14, and 28. Twenty-four-hour narcotic use (hydrocodone 10 mg) was recorded on postoperative days 1, 2, 7, 14, and 28. Digital photographs of the surgical site were taken at 14 days postoperatively. The photographs were independently ranked by three blinded observers according to a) postoperative edema, b) primary vs. secondary healing, and c) overall wound healing.RESULTS Twenty patients were randomized in a prospective manner, ten to the topical 10 percent metronidazole group and ten to the placebo carrier group. Patients in the topical metronidazole group experienced significantly less postoperative pain at day 7 (VAS ± SEM, 3.4 ± 0.4 vs. 6.3 ± 0.5; P = 0.002) and day 14 (1.0 ± 0.4 vs. 3.2 ± 0.7, P = 0.02). There was no statistical difference in narcotic analgesic requirements between groups. In the metronidazole group, postoperative edema was ranked significantly lower (mean score, 3.0 vs. 7.0, P < 0.01) and overall wound healing ranked significantly better (4.0 vs. 7.0, P = 0.03) than in controls.CONCLUSION Topical 10 percent metronidazole significantly reduces posthemorrhoidectomy discomfort at days 7 and 14 postoperatively. Postoperative edema is reduced and overall healing is improved, compared with that of carrier controls.     

Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA)

Background and purpose Assessment of risk factors associated with the use of perioperative allogeneic blood transfusion and the effect of transfusion on infectious complications after ileal pouch-anal anastomosis (IPAA).Methods All patients included had IPAA with ileostomy. They were divided into two groups: transfused (TRAN); nontransfused (NON). Data included age, gender, preoperative anemia (Hgb <9 l g/dl), operative blood loss, transfusion volume, incidence of postoperative infectious or anastomotic complications, and length of stay (LOS).Results The 1,202 patients eligible for the study were divided into: TRAN = 240 patients and NON = 962 patients. The patient age, sex, and preoperative steroid use were similar in both groups. Significantly, more patients in the TRAN group were anemic preoperatively (32 vs 11%; p<0.05) and the preoperative Hgb level was significantly lower in the TRAN (12.07; p<0.05 vs 13.34 g/dl). Transfusion was required more frequently in anemic patients (p<0.001). The overall infection rate was significantly higher in the TRAN (48.75 vs 11.22%, p<0.001), Anastomotic separation (10.83 vs 3.32%, TRAN and NON, respectively; p<0.001) and fistula formation percentage (20.8 vs 4.46%, TRAN and NON, respectively; p<0.001) was significantly higher in the TRAN group. Pelvic sepsis also occurred more frequent in TRAN (22.9 vs 4.2%, TRAN and NON, respectively; p<0.001). The incidence of any infectious complication at any site was higher in anemic patients irrespective of transfusion status (18.2 vs 2.8%, p<0.05). Transfusion was the only significant independent risk factor for postoperative infections. LOS was adversely affected by an infectious complication (9 vs 7 days, p<0.001).Conclusions Preoperative anemia is a significant risk factor for perioperative transfusion with significant increase in postoperative infectious complications and anastomotic complications after IPAA. Strategies to correct preoperative anemia, refine indications for transfusion, and define the use of blood salvage techniques may be helpful in decreasing this risk.