Common Anorectal Disorders Research Articles

Ligasure Hemorrhoidectomy: Updates on Complications After an 18-Year Experience.

Hemorrhoidal disease represents one of the most common anorectal disorders in the general population. Energy devices, such as LigaSureTM scalpel, have reshaped the concept of hemorrhoid surgery and in turn, have improved patient outcomes and simplified the work of surgeon. The study aims to evaluate the outcomes of LigaSureTM hemorrhoidectomy (LH) analyzing main post-operative complications rate, length of stay, operating time, and time to return to work. In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed. Complications were classified in early, late, and long-term if they occurred within 1 month, between 1 and 2 months or after 2 months, respectively. 90.2% of patients were treated in day surgery regimen and the mean operating time was 14.3 minutes. The post-operative pain decreased from 3.7 mean VAS on the 1st postoperative day to 0.1 mean VAS on 30th post-operative day. Early complications rate was 2.1%: urinary retention accounted for 1.8% of patients. 0.3%-of patients experienced postoperative bleeding and only one required reoperation. Late complications rate was 5.8%: anal stenosis, incomplete healing, and anal fissure were detected in 3.6%, 1.2%, and 1% of patients, respectively. The long term complications rate was 5.3%: anal fistula, soiling, perianal abscess, and recurrence were identified in 0.2%, 0.1%, 0.3%, and 4.8% of patients, respectively. LH is a safe and fast procedure with a proven minimal complication rate.

A clinical study of anorectal disorders in southern east (Rural) Rajasthan

Anorectal disorders include a diverse group of pathological disorders that generate significant patient discomfort and disability. Its prevalence in general population is much higher than seen in clinical practice. Since most patients with symptoms referred to anorectal disorders do not seek medical attention. Of these symptoms, most patients with anorectal disease present with bleeding PR, pain during defecation, protrusion or itching. Anorectal disorders include hemorrhoids, fissures in ano, fistulas in ano, perianal abscesses, pruritis ani and ano rectal growth. In this study, most common anorectal disorders seen, are hemorrhoids in 50% cases followed by fissure in ano 31.36%. Most cases seen in the age group of 21-40years (55.45%). The most common presenting symptom was bleeding per rectum seen in 122 (55.45%) cases followed by pain during defecation 96(43.63%). Constipation and poor hygiene were the most common predisposing factors seen in most anorectal disorders. Most of the patients were treated with the surgical management in 92% cases with minimal recurrence without any mortality. All patients were discharged within 3 - 5 post operative days.

Safety and Efficacy of Proctosoll Allevia in the Management of Haemorrhoidal Disease in Adults: A Prospective Randomized Clinical Trial.

Hemorrhoidal Disease (HD) is a very common anorectal disorder that affects millions of people around the world and represents a major medical and socioeconomic problem. The aim of the present study was to assess the safety and efficacy of Proctosoll Allevia® in patients affected by symptomatic HD in comparison with the results obtained from a control group. From January to February 2019, all the patients referred to the outpatient clinic of Rajalakshmi Hospital, who were complaining of first or second degree hemorrhoidal symptoms, were enrolled in the study. They were randomly assigned to either of the 2 arms. Group 1: patients were treated with the Proctosoll Allevia® and were under a controlled diet. Group 2: patients were only under a controlled diet without any treatment - control group. A total of 51 subjects were screened and 45 (13 F- 32 M) enrolled in the study. All the patients treated with topical application of the cream showed a statistically significant improvement of symptoms within 14 days from the beginning of the therapy if compared to patients who were treated only with a controlled diet. No major adverse events associated with the use of the new product were recorded. The treatment of I-II degree symptomatic HD with Proctosoll Allevia® has demonstrated to be promising with a good profile of tolerability, safety and efficacy.

A study on outcome of primary closure versus open fistulectomy in low level fistula in ano

Background: Fistula-in-ano is one of the common ano-rectal disorder which causes appreciable morbidity and inconvenience to the patient. Different surgical techniques have been described in literature from time to time. Open fistulectomy though considered as the standard treatment for fistula in-ano, fistulectomy with primary closure has its merits of short hospital stay, early wound healing and lower costs. The objectives of this study was to compare the period of stay, period of healing, time period to return to daily activities and cost factor between open fistulectomy and primary closure technique.Methods: Patients admitted in all surgical units of NIMRA Hospital, were included in the study without bias on a serial basis. This is a study comprising 50 patients over a period of 12 months from Febrauary 2019 to January 2020.Results: The patients were divided into two equal and comparable groups. Patients who underwent open fistulectomy were classified under Group I and those who underwent fistulectomy with primary closure were classified as Group II. The patient’s characteristics of the two groups were well matched.Conclusions: In patients treated by classical method because of long time taken to heal, number of hospital visits for dressings were more and more antibiotics were prescribed when compared to cases treated by excision of fistula tract and primary closure. From this study it can be concluded that fistulectomy with primary closure is ideal for low anal fistulaures.

Thrombectomy for Acute Treatment of Trombosed Hemorrhoids

Hemorrhoidal disease is a common anorectal disorder characterized by the symptomatic enlargement and distal displacement of the hemorrhoids, which are the normal anal cushions. The main symptoms of hemorrhoidal disease include rectal bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Hemorrhoids are classified based on their location and the degree of prolapse. Clinical management of hemorrhoidal disease is based on severity. While conservative strategies are used for Patients with grades I or II disease, radical surgery is recommended for patients with grades III or IV hemorrhoids. Hereby we present our results of thrombectomy on acute treatment in patients with acute thrombosed hemorrhoids. 54 consecutive cases included this study. The mean age of the Patients was 38.5(+/-4.1), 22 patients were male, 32 patients were female. All patients underwent thrombectomy procedure and 8th hour 12th hour, 24th hour and 3rd day VAS scores were (4.1; 3.4; 5.8; 2.1) consecutively. 1 patient had developed intraoperative bleeding which controlled with monopolar electrocautery application, no postoperative bleeding has seen. 1 patient developed slight infection which controlled with simple antibiotics. No other complication has seen after procedure. Our study’s the results were similar with literature and as conclusion we believe thrombectomy is a very safe and effective method of management of acute hemorrhoidal crisis in patients with thrombosed hemorrhoids.

Comparative study of efficacy of Khanduchakka (Ehretia laevis) Ghrit and cow ghee in the management of Parikartika (fissure in ano)

Background: Fissure in ano a very common anorectal disorder can be compared with Parikartika as per Ayurveda. Khanduchakka (Ehertia laevis) has Vraņashodhana and Ropaņa (wound-healing) properties that can help to heal the Vraņa (ulcer) rapidly. Its base is ghee, which itself has Samskaranuvarti (i.e., enhancing the properties of a drug) and healing properties. Khanduchakka Ghrita is beneficial by virtue of easily available ingredients and a time-tested classical formulation. Hence, it was compared with cow ghee in this study. Aim: Evaluation of the efficacy of Khanduchakka Ghrita, compared with cow ghee, in the management of Parikartika.Materials and Methods: Diagnosed cases of fissure in ano as per the inclusion and exclusion criteria were selected and divided into two groups. For patients in group A, Khanduchakka Ghrita was applied; and in group B, cow ghee was applied. Assessment of each patient was carried out on 0, 15th, and 30th day and a follow-up on 45th day. Data were collected and a statistical analysis was done using appropriate tests. Results: The present study found that pain, itching, bleeding, and tenderness were significantly reduced and healing was significantly faster in group A (n = 15) compared to group B (n = 15). Conclusions: Based upon the results it can be concluded that Khanduchakka Ghrita is more significant than cow ghee in managing Parikartika.

Preoperative MRI of perianal fistula evaluation and its impact on surgical outcome

BackgroundPerianal fistula (PAF) is an abnormal tract communicating an external cutaneous opening in the perianal region to the anal canal. PAF is one of the common anorectal disorders in surgical practice with high prevalence. The current study aimed to determine the ability of preoperative MRI for preoperative evaluation of perianal fistula.ResultsThis is a retrospective evaluation of 65 patients with perianal fistula. MRI fistula imaging-related data were revised, and fistula severity was scored using criteria of both local extension of fistulas and active inflammation for a total maximum score of 22. Preoperative MRI could predict the severity of perianal disease with sensitivity, specificity, and accuracy rates of 75%, 92%, and 84.6%, respectively. Surgical findings concerning PAF severity correlated significantly with MRI findings. Diffusion-weighted magnetic resonance imaging (DW-MRI) provided high sensitivity and accuracy with 100% specificity for fistula visualization and highest sensitivity, specificity, and accuracy for detection of cavities > 3 mm in diameter. DW-MRI provided the highest specificity rate on ROC curve analysis among the three MRI pulse sequences (DW-MRI, short tau inversion recovery (STIR), and T1 post-contrast).ConclusionMRI is valuable and accurate for preoperative investigation for PAF evaluation and abscess localization. MRI allowed accurate detection of internal fistula opening and its relation to sphincters. DW-MRI is a valuable sequence with highest diagnostic yield, and its addition to STIR WI improves sensitivity and specificity for determination of fistula activity and extension.

Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand.

BACKGROUNDHemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention.AIMTo determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand.METHODSAn online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios.RESULTSThere were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain.CONCLUSIONAlthough there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.

Treatment for Anal Fissure: Where do we stand in 2020?

Anal fissure is arguably the most painful common anorectal disorder. The severity of pain is disproportionate to the size of the lesion (often 8–10 mm located in the posterior midline of the anal canal). Numerous surgical procedures have been advocated but Lateral Internal Sphincterotomy (LIS) has become the standard of care and the procedure of choice. Due to concerns regarding fecal incontinence (FI) following LIS various chemicals have been applied to the anal canal in hope of finding an alternative “chemical” or “pharmacological sphincterotomy”. Large numbers of studies in the literature suffer from being non-randomized case series with short follow-ups and with variable outcome measures. In 2020, LIS is the most reliable treatment for chronic anal fissure associated with almost immediate pain relief, lasting results, a very low recurrence rate, and a very small rate of postoperative FI.

A comparative study between open haemorrhoidectomy and minimal invasive procedure for haemorrhoids (MIPH) in cases of grade III and IV haemorrhoids

Haemorrhoid is a common anorectal disorder which usually requires surgical intervention. Conventional haemorrhoidectomy had been practiced for long time but in 1993 Longo introduced a newer minimally invasive procedure for haemorrhoids. In this study we have compared the post-operative results of MIPH with conventional open haemorrhoidectomy. To analyze and compare various Pre and post-operative factors such as duration of surgery, post-operative pain and analgesia, duration of hospital stay, post- operative complications, recurrence and early return to work in the patients suffering from Grade III and IV Haemorrhoids undergoing Open Miligan-Morgan’s haemorrhoidectomy and Minimal Invasive Procedure for Haemorrhoids(MIPH). In this prospective study a total of sixty patients underwent surgery for grade III and IV haemorrhoids at Santosh Medical College and Hospital, Ghaziabad from April 2017 to October 2018. Thirty patients in group A underwent Milligan Morgan technique of open haemorrhoidectomy and thirty patients in group Bunderwent Longo’s technique of MIPH (Minimal Invasive Procedure for Haemorrhoids). The average duration of surgery was significantly less in MIPH group as compared to open haemorrhoidectomy group. Only 6.6% of MIPH developed early post-operative complications whereas atleast 25% of open haemorrhoidectomy developed early complications such as pain, bleeding per rectum and wound infection. Early return to work was significantly better in MIPH group. MIPH is safe with a low recurrence rate and complications. It is a nobel technique and has emerged as an alternative to open haemorrhoidectomy. Only limitation is the cost of the MIPH stapler device. Keywords: Haemorrhoids; MIPH, Open Haemorrhoidectomy; Stapled Haemorrhoidopexy.

Tamponade dressings versus no tamponade after hemorrhoidectomy: study protocol for a randomized controlled trial

BackgroundSymptomatic hemorrhoids are one of the most common anorectal disorders. Many surgeons use tamponades after open hemorrhoidectomy to manage postoperative bleeding. The question of whether a tamponade is necessary and beneficial after hemorrhoidectomy has not yet been conclusively answered. A previously conducted single-center pilot trial included 100 patients after Milligan–Morgan hemorrhoidectomy. The data indicated that insertion of an anal tamponade after hemorrhoidectomy does not reduce postoperative bleeding but causes significantly more pain. The findings of this pilot trial are now to be verified by means of a multicenter randomized clinical study called NoTamp.MethodsWe plan to include 953 patients after Milligan-Morgan or Parks hemorrhoidectomy in the NoTamp study. The aim is to demonstrate that using no tamponade dressing after open hemorrhoidectomy is not inferior to using tamponades with respect to postoperative bleeding, and that the patients report less pain. Primary endpoints of the trial are the maximum postoperative pain within 48 h and the incidence of severe postoperative bleeding that requires surgical revision within 7 days after the surgical procedure. Secondary endpoints of the study are the use of analgesics in the postoperative course, the lowest hemoglobin documented within 7 days, quality of life and patient satisfaction. Safety analysis includes all adverse and serious adverse events in relation to the study treatment. Further information can be found in the registration at the German Registry of Clinical Studies (DRKS00011590) and on the study webpage (https://notamp.de/en-GB/trial/main/setLocale/en_GB/). The study is financed by the HELIOS research funding.DiscussionThe study received full ethics committee approval. The first patient was enrolled on 3 May 2017. This trial will finally answer the question whether the insertion of a tamponade after open hemorrhoidectomy is necessary and beneficial.Trial registrationGerman Clinical Trials Register (Deutsches Register Klinischer Studien (DRKS), DRKS00011590. Registered on 12 April 2017.

Stapled haemorrhoidopexy vs. open haemorrhoidectomy: a comparative study

Background: Haemorrhoidal disease is one of the most common anorectal disorders. The grading of haemorrhoids depend on their severity and tendency to prolapse. Surgery is essential for grade 3 and 4 haemorrhoids. This study aims to compare the outcomes of the stapled haemorrhoidopexy and open haemorrhoidectomy in terms of intra and postoperative complications in terms of pain, return to activity of daily living (ADL) i.e. return to functional activity.Methods: A single-centred observational follow-up study on patients undergoing surgery for haemorrhoids between 2016-2017. Total number of patients operated were 106. Total cases included in the study are 95, out of which 59 were in open haemorrhoidectomy group and 36 in stapled haemorrhoidopexy group. Data was collected and the various parameters compared between the two groups.Results: The most common symptom found in the study was bleeding per rectum (91%). Intraoperative bleeding was more in open group compared to the stapled group (p<0.005). The pain experienced in the immediate postoperative period was higher for the open group (p<0.005). Noticeable difference in the hospital stay between the two groups was observed, with stapled group being discharged earlier (p<0.005). The immediate postoperative complications were not significantly different in the two groups. The need for postoperative analgesia was seen to be lesser in the stapled group compared to the open group (p<0.005).Conclusions: Our study confirms that stapled haemorrhoidopexy is better than open haemorrhoidectomy in terms of intra operative duration and pain experienced by the patient with an early return to activities of daily living.

Effects of subjective sleep quality on the quality of life in patients with chronic anorectal disorder.

The aim of the present study was to evaluate the subjective sleep quality in patients with anorectal disorder, to determine the factors associated with subjective sleep quality, and to explore the relationship between subjective sleep quality and quality of life. This descriptive study was conducted between April 8, 2015 and April 12, 2016. The research population consisted of 284 patients who attended the general surgery outpatient clinics of Konya Military Hospital and were subsequently diagnosed with one of the four most common anorectal disorders (hemorrhoidal disease, anal fissure, anorectal abscess/fistula, and sacrococcygeal pilonidal disease). Data were collected from 114 patients who volunteered to participate in the study. After establishment of the diagnosis based on proctological anamnesis and physical examination, the Pittsburgh Sleep Quality Index, Short-Form Health Survey, Beck Anxiety Inventory, and Beck Depression Inventory were administered to the patients, along with a questionnaire on sociodemographic data, via a face-to-face interview technique. Ninety-six (84.2%) patients had poor sleep quality, whereas 18 (15.8%) patients had good sleep quality. Among the patients with poor sleep quality, 16 were diagnosed with anorectal abscess and fistula (100.0%), 40 with hemorrhoidal disease (90.9%), 16 with sacrococcygeal pilonidal disease (80.0%), and 24 with anal fissure (70.6%). Overall, all patients with poor sleep quality (n=96) had low scores in all subcomponents of the quality of life scale. The sleep quality in patients with chronic anorectal disorder is significantly impaired, thus negatively affecting quality of life. Therefore, improvement in quality of life by improving sleep quality should be one of the main objectives in treating chronic anorectal disorders.

Comparison between stapler hemorrhoidectomy and open hemorrhoidectomy in the management of grade III and IV hemorrhoids: a prospective randomized study

Background: Haemorrhoids are one of the most common anorectal disorders. Haemorrhoids or piles are dilated veins of the anal canal and are more common in obesity, constipation and pregnancy. Classically they occur in the 3, 7 and 11 o'clock position with the patient in lithotomy position. Symptoms of haemorrhoids are per rectal bleeding and prolapse. Bleeding is bright red in colour and which is painless. The aim of the study was to compare the early results in 60 patients randomly allocated to undergo either stapled or open hemorrhoidectomy.Methods: Out of 60 patients, 30 (50.0%) patients underwent hemorrhoidectomy by Open Milligan-Morgan’s method were classified as Group A while rest 30 (50.0%) patients underwent hemorroidectomy by Stapler method after anal stretching, these patients were classified as Group B.Results: Pain score of majority of patients of Group A was ≥7 (76.7%), only 6.7% had pain score <3 and rest 16.7% had pain score 3 to 6. On comparing the difference of pain in passage of first stool among patients of Group A and Group B statistically was found to be highly significant. Pain in follow up at 3, 7 and 15th day was also significantly higher in group A in comparison to group B.Conclusions: Of the 60 patients in the current study, 32 are still in the follow up with the maximum follow up period of 11 months. There was no case of recurrence of haemorrhoids in this study. The factor of cost was not evaluated in the study since the hospital stay as well as stapling instrument was totally free in U.P, UMS, Saifai.

Temperament and character traits in patients with anorectal disorder

Aim: The aim of this cross-sectional study is to investigate temperament and character traits in patients with anorectal disorders, considering that temperament and character traits of patients with anorectal disorders will be affected differently from healthy individuals.Methods: We compared 102 patients diagnosed with one of the four most common anorectal disorders (hemorrhoidal disease, anal fissure, anorectal abscess/fistulae, and sacrococcygeal pilonidal disease) who applied to the out-patient clinic and 80 healthy adults without any medical condition. Both groups were administered sociodemographic and descriptive information questionnaire, Temperament and Character Scale (TCS), Beck Depression Scale (BDI), Beck Anxiety Scale (BAI) and State and Trait Anxiety Scale (STAI).Results: According to the control group, the patients with anorectal disorders had higher harm avoidance (HA) scores from temperament dimensions and lower self-directedness (SD) scores from character dimensions. The anxiety and depression rates were higher in the group with anorectal disorders.Conclusions: Anorectal disorders are common diseases in the society. Temperament and character traits are closely related to comorbid psychiatric disorders seen in patients with anorectal region disease. At the same time temperament and character traits can affect compliance with medical and surgical interventions for anorectal disease. Our study has provided important data to encourage clinicians to evaluate patients in a multidisciplinary approach in the treatment of anorectal disorders that are generally predisposed to chronicity.

Outcomes of Management of Anal and Perianal Suppuration at Niamey National Hospital, Niger

Bakground: Anal and perianal sepsis is common anorectal disorders found in surgical practice. This study aims to report epidemiological aspects and outcomes of management of anal and perianal suppuration. Methods: This was a retrospective study from January 2011 to June 2016 at Niamey National Hospital. Patients operated on for anal and perianal suppuration of non-specific anorectal origin were included. Results: During the study period, we collected 141 cases of anal and perianal suppurations. The average age of our patients was 42±8.8 years. The sex ratio was 3.27 in favor of men. The origin of the patients was urban in 73.8% of the cases. The history of diabetes mellitus was found in 14.2% (n=20). Anal fistulas and anal abscesses (n=115) were simple in 46% (n=53) and complex in 54% (n=62). A fistulectomy with the placement of an elastic seton was performed for 41.13% of cases (n=58) and fistulotomy in 29.78%. The evolution of 6 months was marked by a recurrence in 10.63% (n = 15), the anal incontinence of gas at 9.21% (n=13). Deaths (n=4) were recorded in patients with Fournier’s gangrene. Uncomplicated therapeutic success was 80.13% (n=113). Conclusion: The surgical treatment of anal fistula (the main cause of anal and perianal suppuration) aims to eradicate the suppuration and to preserve the anal continence. The fistulotomy done in the context of the management of a simple fistula gives a better outcome. Incontinence-related complications and relapses must impose thoroughness and patience in the surgical treatment of complex fistulas.

Update on the Pathophysiology and Management of Anorectal Disorders.

Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.

Randomized Trial of Open Hemorrhoidectomy Versus Stapled Hemorrhoidectomy for Grade II/III Hemorrhoids

Hemorrhoids are one of the most common anorectal disorders. Open hemorrhoidectomy (OH) is the gold standard surgical technique while stapled hemorrhoidopexy (SH) [procedure for prolapsed hemorrhoids (PPH)] is a newly developed method for the surgical management of hemorrhoids. A Medline, PubMed, and Cochrane data base search was performed. Relevant papers, e.g., randomized controlled trials, review, and meta-analysis from different parts of the world have shown stapled hemorrhoidopexy is less painful and it is associated with quicker recovery, but SH is associated with higher rates of skin tags, hemorrhoid recurrence, and prolapse recurrence than conventional hemorrhoidectomy. A randomized trial was conducted from March 2014 to March 2016 at M.Y.H. Hospital Indore tertiary care center. The aim of the study was to compare the early results in 100 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Patients with grade II and III hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open (50 patients) hemorrhoidectomy. Post-operative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (mean 35.8 mins [range 20 to 50] minutes versus 50.2 mins [range 30 to 60] minutes, p < 0.05). Mean (range) VAS scores in the stapled group were significantly lower (VAS score after 7 days: 2.2 [2 to 5] versus 3.3 [2 to 6], p < 0.05). Resumption of routine work was significantly faster in the stapled group (8.08 days versus 16.2 days, p = 0.001). At follow-up, 4 weeks and 4 months recurrence of symptoms and fecal urgency was present in 6/50 (12%) patients in the stapled group and 2/50 (4%) in the OH group (p < 0.05). Our initial results suggest that stapled hemorrhoidectomy is an effective treatment for symptomatic second and third degree hemorrhoids but with significant complication rates on follow-up in patients compared with traditional hemorrhoidectomy.

Benign ano-rectal disorders

Benign ano-rectal disorders are a common adult presentation to primary care; they also generate a significant number of secondary referrals. The exact prevalence of these conditions is difficult to determine, due to under-reporting of symptoms, which patients can find embarrassing and difficult to disclose. It can be challenging to distinguish between different ano-rectal disorders which present with similar symptoms. A high index of suspicion is required to detect serious malignant pathology. The aim of this article is to outline the epidemiology, pathophysiology, diagnosis and management of common benign ano-rectal disorders in primary care. The indications for surgical referral and important cancer referral guidelines are included.

HAEMORRHOIDECTOMY;

Haemorrhoids are one of the most common anorectal disorders. Internalhaemorrhoids are symptomatic anal cushions and characteristically lie in the 3, 7 and 11 o’clockposition whereas external haemorrhoids relate to venous channels of the inferior haemorrhoidalplexus. Objectives: To compare the outcome of haemorrhoidectomy using harmonic scalpelversus conventional closed haemorrhoidectomy. Study Design: Randomized control trial.Setting: Department of Surgical unit II, Jinnah Hospital, Lahore. Period: Six months from 25thDecember 2014 to 24th June 2015. Methodology: A total of 140 patients were included inthis study. Patients were divided in two groups A &amp; B. In Group A, (70 patients) conventionalhaemorrhoidectomy was performed by the Ferguson Technique (closed technique) whereasin Group B, (70 patients) suture less closed haemorrhoidectomy was performed by using theharmonic scalpel. Results: The mean age of the patients in group A was 43.3±8.2 years andin group B was 42.3±7.3 years. The mean time for surgery in group A was 23.8±4.2 minutesand in group B was 8.5±3.6 minutes. The mean pain score in group A was 5.3±1.8 VAS andin group B was 3.9±1.9 VAS. In group A, less than 1 day postoperative hospital stay was in 62(88.6%) patients and in group B, it was in 66 (94.3%) patients. Conclusions: It is concludedfrom this study that haemorrhoidectomy by harmonic scalpel results in decrease in operationtime and less postoperative pain although there is not much significant difference in less than 1day hospital stay as compared to the conventional closed haemorrhidectomy technique.