Fourth-degree Hemorrhoids Research Articles

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020.

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

The Sub-Saharan Experience of Excisional Haemorrhoidectomy with Simultaneous Lateral Internal Sphincterotomy

Milligan-Morgan haemorrhoidectomy (MMH) is still regarded as the standard excisional haemorrhoid procedure. In our centre, prophylactic lateral internal sphincterotomy (LIS) has been routinely performed simultaneously with MMH due to increased incidence of concurrent chronic anal fissure (CAF). We aimed to review our practice, the safety and feasibility of routine MMH+LIS among patients with or without CAF. A prospective observational study was conducted to examine the outcome of MMH + LIS in Kassala, Sudan, from 2015 to 2018. The short-term outcomes of patients undergoing MMH+LIS were compared between patients with or without CAF. There were 252 patients included in the study, with the median age of 33 (ranged 13–80), and 146 (57.94%) were male patients. Of these, 205 patients (81.3%) had third-degree prolapsed haemorrhoids, and 47 patients (18.7%) had fourth-degree prolapsed haemorrhoids, with 73 (29%) patients had a concurrent chronic anal fissure. There were no significant difference (p > 0.05) between the comparing groups with regard to the complications occurred, which were post-operative bleeding (n = 4, 1.6%), anal stenosis (n = 5, 1.98%), faecal incontinence (n = 2, 0.79%), chronic anal pain (n = 5, 1.98%), chronic anal discharge (n = 3, 1.19%), pruritus ani (n = 4, 1.58%) and obstructed defaecation symptoms (n = 4, 1.58%). The overall complication rates were 16/252 (6.3%). Patients without pre-existing CAF were significantly associated with increased post-operative pain (p < 0.0001) after LIS. Prophylactic LIS, along with MMH, is a safe strategy with reasonable desired short-term outcomes and low complication rates. Patients with pre-existing CAF gain better pain control having had concurrent LIS which ultimately justify the procedure.

Impact of post-haemorrhoidectomy pain relief checklists on pain outcomes: a randomized controlled trial.

Haemorrhoidectomy is associated with significant post-operative pain which is primarily managed pharmacologically. Whether a non-pharmacological adjunct such as a checklist can improve pain outcomes after an open haemorrhoidectomy has yet to be studied. The purpose of this study was to determine if a patient-completed checklist of prescribed post-haemorrhoidectomy pain medications would improve pain management after surgery. We conducted a dual-centre randomized controlled trial of patients undergoing a Milligan-Morgan haemorrhoidectomy for symptomatic third or fourth degree haemorrhoids. Thirty-five patients were randomized into either a control group which received post-operative pain medication plus a visual analogue scale (VAS) form, or an intervention group which received a post-operative medication checklist in addition to the items the control group received. Both groups recorded their pain levels on the VAS forms at 10.00, 14.00 and 20.00 hours each day for 14 days post-operatively. Patients in the checklist group reported a significantly greater reduction in mean VAS pain score of 2.51 (95% confidence interval (CI) 1.34-3.68; P < 0.001) between day 1 post-op and day 14 post-op compared to 1.86 (95% CI 0.77-2.95; P = 0.001) for the control group. There was no significant difference between mean pain experienced by patients in either group over each of the 14 days individually or overall (P = 0.07). The pain medication checklist lead to a greater reduction in pain between day 1 and 14 after an open haemorrhoidectomy compared to standard care but did not significantly reduce mean pain across any individual days or overall.

A prospective randomized controlled trial comparing the immediate post-operative complications between open and semi-open hemorrhoidectomy

Introduction: Hemorrhoids are one of the most common anorectal pathologies encountered by general surgeons during their practice. Open technique as described by Milligan and Morgan and closed technique as described by Ferguson are the most widely used. A semi-open technique that has lesser complications than the conventional open hemorrhoidectomy has been described. This study aims to compare the immediate postoperative complications between open and semi-open hemorrhoidectomy.&#x0D; Methods: A prospective randomized study, where patients with third and fourth-degree hemorrhoids undergoing hemorrhoidectomy, were taken for the study. The subjects were randomized into two groups, where they underwent either open or semi-open hemorrhoidectomy. Both groups received standard postoperative care and were evaluated after 24 hours after surgery for pain and urine retention and were then discharged with the same treatment plan for both groups. First, follow up was done in one week and the second was done in two weeks after discharge, where pain score, bleeding, wound healing, use of narcotic analgesics and patient discomfort were recorded.&#x0D; Results: A total of 44 patients were divided into two groups, where the age, sex, and grade of hemorrhoids were matched. The pain score using VAS in the first week was compared and it showed that the pain perceived by the patients in the open hemorrhoidectomy was greater than in the semi-open method ((p=0.06, 95% CI= 0.22 to 1.23). Bleeding rate after the surgeries were not different between the two groups (p=0.43) and the urinary retention between them was also not significant (p=0.47). The use of breakthrough narcotic analgesics was more in the open hemorrhoidectomy group (p=0.01). On the fourteenth day follow up, the wound of those who underwent semi-open hemorrhoidectomy, had significantly healed as compared to those who had undergone the open procedure (p= 0.04, 95% CI=0.23 to 0.76), and the patients who had semi-open hemorrhoidectomy had lesser discomfort as compared to the open technique (p=0.02).&#x0D; Conclusion: Semi-open hemorrhoidectomy has fewer post-operative complication rates as compared to open hemorrhoidectomy with decreased pain, faster wound healing rates, and lesser patient discomfort.

Effect of Topical Baclofen 5% on Post-Hemorrhoidectomy Pain: Randomized Double Blind Placebo-Controlled Clinical Trial

BackgroundBaclofen is an agonist for a subtype of gamma-amino butyric acid (GABA-B) receptors and traditionally been used for the systemic treatment of spasticity. Topical application of baclofen has been shown to reduce pain in patients with localized neuropathic pain. ObjectivesIn this study, we investigate the efficacy of baclofen cream (5%) in reducing postoperative pain and analgesic requirement after open hemorrhoidectomy. DesignThe patients were randomly assigned to either baclofen (5%) cream or placebo immediately after surgery and then every 12 h for 14 days. PatientsA total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were randomly assigned to this trial. SettingThis study was conducted at a single educational hospital. Primary and Secondary Outcome MeasuresThe primary outcomes were intensity of pain, measured with a visual analog scale, and the analgesic requirement, measured by the amount of the acetaminophen consumption. ResultsNo significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the baclofen group was significantly lower on week 1 (P = 0.01) and week 2 (P = 0.02) than the placebo group. Similarly, patients in the baclofen group consumed significantly less analgesic medication on week 1 (P = 0.025) and week 2 (P = 0.024) than the control group. ConclusionTopical application of baclofen effectively relieves pain after hemorrhoidectomy with minimal side effects.

A comparative study of open and closed hemorrhoidectomy

Background: Hemorrhoidectomy is the treatment of choice for patients with third-degree or fourth-degree haemorrhoids. This prospective randomized clinical study compared the outcome of surgical haemorrhoidectomy by open and closed techniques in terms of postoperative pain, wound healing, and morbidity.Methods: All consecutive patients with Grade III internal haemorrhoids or Grade IV haemorrhoids were randomly allocated to one of two groups. The entire wound was left open in the open group and completely closed using 2-0 chromic sutures in the closed group. Postoperative pain was assessed by a linear analog scale. Additional consumption of analgesics on the day of surgery and at defecation during the first week was recorded. Patients were followed up 1, 2, and 3 weeks after the procedure.Results: There were 30 patients in each group. No statistically significant differences were found between the two methods regarding complications, pain, or postoperative stay. There were four reoperations for bleeding, all after Milligan-Morgan operations. At follow-up after three weeks 78 percent of the Ferguson patients had completely healed wounds, and none had signs of infection. Of the Milligan-Morgan patients, only 26 percent had completely healed wounds, and symptoms of delayed wound healing were significantly more frequent.Conclusions: Both methods are fairly efficient treatment for third and fourth degree hemorrhoids, without serious drawbacks. The closed method has no advantage in postoperative pain reduction but is more advantageous with respect to faster wound healing.

Effectivity of injection sclerotherapy with sodium tetra decyl sulphate in the management of first and second-degree hemorrhoids

Background: Haemorrhoids are one of the common surgical conditions affecting anorectal region with prevalence of 4% of the population. It is usually defined as increase in size as well as downward disruption of normal functional architecture known as anal cushions. Injection sclerotherapy is time honoured outpatient’s procedure that is widely practised globally to treat first and second-degree haemorrhoids.Methods: This prospective study includes 52 patients who were underwent injection sclerotherapy at Bundelkhand Medical College and Associated Hospital Sagar from August 2015 to September 2016. Patients above the age of 18 years of both sexes with Ist and IInd degree hemorrhoids were included in the study. Pregnant patients, patients with diabetes mellitus and with third and fourth degree hemorrhoids were excluded from the study. A detailed history, clinical presentation, digital rectal examination, proctoscopy and routine investigation were done in all cases.Results: In the present study most of the patients were male. Patients with age group ranging from 20-40 year were found of high incidence of haemorrhoids (86.53%). In present study after three doses of injection 94.23% had satisfactory result. After the first dose injection 71.15% patients had satisfactory results rest 15 patients were given second dose of injection of which 60% patients had satisfactory results. Third dose of injection given to the remaining 06 patients proved satisfactory results in only 03 cases. After three doses of injection 03 cases (5.76%) failed to show any response.Conclusions: Sclerotherapy as a safe, easy, cheap and effective method of treatment of 1st and 2nd degree haemorrhoid devoid of any significant complication.

A comparative study of short term results of open haemorrhoidectomy and stapler haemorrhoidopexy

Background: Haemorrhoids are the most common benign anorectal problems worldwide. Treatments of third and fourth degree hemorrhoids include surgical haemorrhoidectomy. Milligan Morgan haemorrhoidectomy (MMH) as described in 1937 has remained the most popular among many techniques proposed. In order to avoid the postoperative drawbacks of Milligan Morgan haemorrhoidectomy, a new surgical treatment for prolapsing haemorrhoids has been described by Longo in 1995, procedure called stapled haemorrhoidopexy which is associated with less postoperative pain and a quicker recovery. The objective of this study was to compare the short-term outcome between stapled hemorrhoidopexy and Milligan-Morgan hemorrhoidectomy.Methods: Prospective randomized study of 120 patients with grade 3 and grade 4 haemorrhoids requiring surgical treatment either MMH or SH, 60 in each group for the period of 18 months from June 2014 to November 2015. Post-operative pain, duration of surgery, duration of hospital stays, post-operative complications and time taken to return to work were compared with mean follow up period of 6 months.Results: Duration of surgery is significantly low in stapled group with P &lt;0.001, duration of hospital stay is significantly low in stapled group with P &lt;0.001, post-operative pain low in staple group with P &lt;0.05, time taken to return to work is significantly early in stapled group with P &lt;0.001. Post-operative complications incontinence not found in the present study but recurrence of two cases in each group noted.Conclusion: Stapled hemorrhoidopexy is associated with less postoperative pain, shorter duration of surgery and hospital stay, earlier return to work as compared with Milligan-Morgan open hemorrhoidectomy. The procedure is not associated with major post-operative complications.

Topical diltiazem ointment in post-hemorrhoidectomy pain relief: A meta-analysis of randomized controlled trials

Hemorrhoidectomy is commonly associated with postoperative pain. Calcium channel blockers are known to cause relaxation of gastrointestinal smooth muscle and oral diltiazem has also been shown to reduce the resting anal pressure. We attempted to analyze efficacy and side effects of topical diltiazem oint. in post-operative pain control. This is a meta-analysis of patients who underwent hemorrhoidectomy using topical diltiazem oint. versus placebo (Vaseline) for pain control. Patients with third or fourth degree hemorrhoids undergoing traditional hemorrhoidectomy were included. Procedures took place in the colorectal division of a hospital in 5 countries. Five randomized control trials (RCTs) published between 2005 and 2016 including 227 patients were included our meta-analysis (Diltiazem (calcium channel block) group=137; Placebo (Vaseline) group=90). Pain assessment was performed using a standardized Visual Analogue Scale. Any side effects of surgery or medication use, which were noted by the patient or the surgeon, also were recorded. A total of 227 patients were included in the meta-analysis. The results revealed that Diltiazem ointment was statistically significant in reducing pain within 48h, at 72h, and more than 96h after operation compared to the placebo group. Regarding overall complications (including headache), there was no statistical significance between diltiazem and placebo group. Topical application of diltiazem effectively relieves pain after hemorrhoidectomy with minimal side effects. Further large studies are needed to substantiate its value in clinical practice.

Effects of Topical Atorvastatin (2%) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial.

Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2%) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated. A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12h for 14days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing. There was no significant difference in the average postoperative pain scores in the first 48h (P 12h=1, P 24h=0.128 and P 48h=0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P=0.004), which also was the same at the week 2 (P=0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12h and 24h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P=0.04). Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy. IRCT201404013014N8.

Transanal Hemorrhoid Dearterialization and mucopexy: a minimal invasive approach for prolapsed hemorrhoids. Four cases report.

Hemorrhoidal disease is one of the most frequent causes of anal pathology. Surgical therapy is reserved for patients who do not respond to non-operative management and for advanced third and fourth degree hemorrhoids. Milligan-Morgan and Ferguson hemorrhoidectomies are considered the first-choice therapy, but these procedures are associated with postoperative complications including infection, stenosis, pelvic floor dysfunction, rectal bleeding and postoperative pain. In order to minimize postoperative complications, less invasive procedures have been described and two of them are reported with promising results: Stapled hemorrhoidopexy (PPH) and Transanal Hemorrhoid Dearterialization (THD). THD involves ligation of the hemorrhoidal arteries under Doppler guidance resulting reduced inflow that facilitates reduction in size of hemorrhoids, while suture mucopexy addresses the prolapsed mucosa. THD is proven as a reliable technique for third degree hemorrhoids, but its role in fourth degree hemorrhoids is not generally accepted. Herein we report four cases of prolapsed hemorrhoids which were treated with THD and mucopexy. The procedure was successful in all patients. Photographs taken, before and after the procedure, show an impressive reduction of the prolapsed hemorrhoids. THD and mucopexy appears to be an effective technique with the potential of treating not only third degree, but advanced hemorrhoids as a safe one-day procedure with immediate visible results.

A Comparative Study of Open (Milligan-Morgan) Versus Closed (Ferguson) Hemorrhoidectomy

&lt;strong&gt;Introduction&lt;/strong&gt;: Hemorrhoidectomy is an operation for third and fourth degree haemorrhoids. There are two methods by which hemorrhoidectomy can be done -open (Milligan-Morgan) in which the wound is left open and allowed to heal by secondary intension and closed (Ferguson) methods in which the wound is closed with absorbale sutures. &lt;strong&gt;Aim:&lt;/strong&gt; To compare post operative pain and recovery in open (Milligan-Morgan) and closed (Ferguson) methods and evaluate optimum choice of the procedure for third or fourth degree hemorrhoids. Study Design: Prospective randomized study. &lt;strong&gt;Settings:&lt;/strong&gt; Department of Surgery, Dr. Vasantrao Pawar Medical College, Hospital and Research Center. &lt;strong&gt;Duration:&lt;/strong&gt; Two year (August 2010 to August 2012). Sample Size: 70 cases (35 cases in each group). Inclusion Criteria: Patients with third/four degree hemorrhoids. Exclusion Criteria: Patients with associated anal and perianal conditions like fissure in ano, inflammatory bowel diseases and rectal malignancy, portal hypertension were excluded from the study. &lt;strong&gt;Results:&lt;/strong&gt; Mean hospital stay for open group was 5 days and closed group was 3 days. Post operative pain was seen in 77% in open group and 48 % in closed group. Pain was relieved earlier in closed group. 71% patients had completely healed wounds at 3 weeks in closed group in comparision to only 42% in open group. Anal stenosis was seen in 2 patients of open hemorrhoidectomy. &lt;strong&gt;Conclusion:&lt;/strong&gt; Closed hemorrhoidectomy is the procedure of choice for three/four degree hemorrhoids.

Sucralfate ointment reduces pain and improves healing following haemorrhoidectomy: a prospective, randomized, controlled and double-blinded study

Background It has been clinically observed that posthaemorrhoidectomy pain is the most feared symptom by the patient, often leading to avoiding surgery altogether. Opioids and NSAIDs are used to control posthaemorrhoidectomy pain, but they have short duration of action and well-known side effects and may be expensive. These factors justify the need to search for new treatments to decrease posthaemorrhoidectomy pain. Patients and methods A total of 90 patients who had undergone surgery for third-degree and fourth-degree haemorrhoids were included in this prospective, randomized, controlled and double-blinded study. The patients were randomly assigned to two groups. Group A received topical sucralfate in petrolatum base and group B received plain petrolatum base. Patients were evaluated at days 1, 7 and 14 for the severity of pain (using the visual analogue pain scale) and for the amount of analgesia used. On day 28 patients were evaluated for wound healing. Results Patients in the sucralfate group suffered significantly less pain and required less analgesics (narcotic and nonsteroidal) on days 1, 7 and 14 postoperatively (P Conclusion Topical sucralfate ointment significantly decreases pain at days 1, 7 and 14 after haemorrhoidectomy and significantly accelerates wound healing.

Safety of surgical treatment of hemorrhoids in elderly patients

Introduction: The aim of this study was to compare the outcomes following surgical treatment of hemorrhoids between elderly (≥60 years old) and young patients (&lt;60 years old).Methods: A total of 365 patients who underwent surgical procedures for the treatment of third or fourth degree hemorrhoids between January 01, 2009 and January 31, 2014 were retrospectively screened.Results: Among the 365 participants, 316 and 49 patients were younger and older than 60 years of age, respectively. No statistically significant differences with regard to the gender, operative duration, hospitalization time, incapacity to work, hemoglobin levels at admission or discharge, number of hemorrhoid packages, presence of thrombosis prior to the surgery, reoperation requirement, or the number of patients complaining of long-term pain were observed between the groups. Moreover, there was no statistically significant difference in the rate of early or late postoperative complications between the groups.Conclusions: In conclusion, we found that the surgical treatment of hemorrhoids is equally safe in the younger and elderly patients. Therefore, surgeons can be confident in performing surgical treatment of hemorrhoids in elderly patients.

What is the Technique without a Proper Classification?

Dear Sir, We read with interest the commentary by Morelli [1] and we are in agreement with the need to investigate the classifications evolution in association with the treatment techniques. This is the important conceptual message which is contained within the commentary. In fact, also in our experience [2], the classification has a significant effect on patient selection and choice of treatment.Recently, small randomized-controlled trials comparing stapled haemorrhoidopexy (SH) with traditional excisional surgery have shown it to be less painful and that is associated with quick recovery [3-6]. The reports also suggest a better patient’s acceptance and a higher compliance with day-case procedures potentially making it more economical. At the same time, several studies comparing SH and Milligan-Morgan (M-M) surgery demonstrated that stapled technique, associated with less pain in the immediate postoperative period, presents a higher risk of recurrence and residual prolapse, with necessity of reintervention and some other symptomatic treatment in long term follow-up [7-9]. Recently, several studies reported a higher percentage of haemorrhoid recurrence after SH, especially in patients with fourth degree haemorrhoids. They suggest that the treatment of second, third and fourth degree haemorrhoids by SH technique, gives optimal results in terms of less postoperative pain, faster return to work and shorter hospital stay, indicating a higher recurrence rate in fourth-degree haemorrhoids patients when the long-term evaluation is considered [8,10,11]. Therefore even if the SH is a safe and effective treatment for haemorrhoids, needs a rigorous patients selection. Furthermore, by applying the SH technique, there is the risk of intraoperative and immediate postoperative complications, such as closing or perforation of rectum, pelvic sepsis and mechanical circular suture dehiscence [10,11].Basing on the clinical evidence and literature revision, the decision to use SH or M-M, should be primarily based on the priorities and preferences of the patient (pain reduction and a rapid return to work / activities in the short-term, or reduction in the risk of recurrence in the long term), and the preference of the surgeon [12].A new technique based on doppler-guided ligation of the terminal branches of the superior haemorrhoidal artery was introduced in 1995 as an alternative to haemorrhoidectomy. Several studies reported that there are some terminal branches from the superior rectal artery-corresponding to the distribution of the anal cushions which varies widely in number and position.The rationale of this treatment was later supported by the findings from vascular studies, which demonstrated that patients with haemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries. Therefore, ligating the arterial supply to haemorrhoidal tissue by suture ligation may improve haemorrhoidal symptoms. DGHAL is most effective for second- or third-degree haemorrhoidsIn a study of Miyamoto et al. [13] is described that there were always more than three (usually six) terminal branches of haemorrhoidal

Stapled hemorrhoidopexy versus Milligan–Morgan hemorrhoidectomy: a short-term follow-up on 640 consecutive patients

Background The aim of the present study is to report our data on the treatment of third-and fourth-degree hemorrhoids with stapled technique and Milligan–Morgan operation in terms of postoperative results, costs, and recurrence.

English

BACKGROUND: This study was carried out to evaluate possible differences of pre and post treatment parameters between patients undergoing injection Sclerotherapy, rubber band ligation and hemorrhoidectomy. METHODS: The prospective study was carried out in 150 patients of haemorrhoids during August 2010 to November 2012. Each group of 50 patients treated with injection sclerotherapy, band ligation and haemorrhoidectomy and followed up for 1 year for complications. RESULTS: In the present study pain, bleeding and urinary retention were common following haemorrhoidectomy. One patient had anal incontinence post sclerotherapy. Anal incontinence was found to be a major problem in post haemorrhoidectomy period. Two patients had anal stenosis after haemorrhoidectomy. Second setting required in 6 patients of sclerotherapy and 4 patients of rubber band ligation. No recurrence noted in haemorrhoidectomy patients. Following sclerotherapy, 35 (70%) patients resolved, 9 (18%) improved and 3 (6%) remained unchanged. Following rubber band ligation, 32 (64%) resolved, 12 (24%) improved and 3 (6%) unchanged, while after haemorrhoidectomy, 37 (74%) resolved and 10 (20%) improved. DISCUSSION: Injection sclerotherapy remains the choice in first degree haemorrhoids. Rubber band ligation can be considered as first line of treatment for second degree haemorrhoids and few cases of third degree haemorrhoid. Conservative methods are acceptable to patients in outcome and in patient compliance, but repetitions of treatment may be needed. Haemorrhoidectomy remains the only form of therapy with lasting results. Thus it should be considered for all cases of third and fourth degree haemorrhoids and for uncontrollable symptomatic recurrences following conservative procedures.

Residual Prolapse in Patients with III-IV Degree Haemorrhoids Undergoing Stapled Haemorrhoidopexy with CPH34 HV: Results of an Italian Multicentric Clinical Study

CPH34 HV, a high volume stapler, was tested in order to assess its safety and efficacy in reducing residual/recurrent haemorrhoids. The clinical charts of 430 patients with third- to fourth-degree haemorrhoids undergoing SH in 2012-2013 were consecutively reviewed, excluding those with obstructed defecation (rectocele >2 cm; Wexner's score >15). Follow-up was scheduled at six and 12 months. Rectal prolapse exceeding more than half of CAD was reported in 341 patients (79.3%); one technical failure was reported (0.2%) without any serious untoward effect; and 1.3 stitch/patient (SD, 1.7) was required to achieve complete haemostasis. Doughnuts volume was higher (13.8 mL; SD, 1.5) in patients with a large rectal prolapse than with smaller one (8.9 mL; SD, 0.7) (P value <0.05). Residual and recurrent haemorrhoids occurred in 8 of 430 patients (1.8%) and 5 of 254 patients (1.9%), respectively. A high index of patient satisfaction (visual analogue scale = 8.9; SD, 0.9) coupled with a persistent reduction of constipation scores (CSS = 5.0, SD, 2.2) was observed. The wider prolapse resection well correlated with a clear-cut reduction of haemorrhoidal relapse, a high index of patient satisfaction, and clinically relevant reduction of constipations scores coupled with satisfactory haemostatic properties of CPH34 HV.

Efficacy of Cholestyramine Ointment in Reduction of Postoperative Pain and Pain during Defecation after Open Hemorrhoidectomy: Results of a Prospective, Single‐center, Randomized, Double‐blind, Placebo‐controlled Trial

The aim of the present study was to evaluate the efficacy of cholestyramine ointment (15 %) in reducing postoperative pain at rest and during defecation after open hemorrhoidectomy. A total of 91 patients with third and fourth degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either cholestyramine ointment or placebo immediately after surgery, 12 h after surgery, and then every 8 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of tramadol consumption. The cholestyramine group had less postoperative pain than the placebo group at the 24th hour (1.84 ± 2.54 vs. 4.07 ± 3.35; P = 0.001) and 48th hour (0.18 ± 0.88 vs. 3.57 ± 3.45; P < 0.001) and less pain during defecation starting at the 48th hour (2.28 ± 2.96 vs. 4.77 ± 4.09; P = 0.001). Similarly, the average tramadol consumption at hours 24 and 48 was significantly lower for the cholestyramine group (5.32 ± 21.45 vs. 43.18 ± 61.56 mg at 24 h, and 4.48 ± 16.65 vs. 57.63 ± 65.47 mg at 48 h; P < 0.001). The only adverse event was pruritus, which had a lower frequency in the cholestyramine group but the difference was not significant until postoperative week 4 (P < 0.001). Compared with placebo, cholestyramine ointment (15%) reduced postoperative pain at rest and on defecation, and consequently lowered the analgesic requirement after open hemorrhoidectomy.

EVALUATION OF LONGO’S HEMORRHOIDECTOMY AT HUE UNIVERSITY HOSPITAL

Introduction: Since Longo First described it in 1998, Stapled Hemorrhoidectomy has been emerging as the procedure of choice for symtomatic hemorrhoid. Several studies have shown it to be a safe, effective and relative complication free procedure. The aim of this study was to determine the suitability of (SH) as a day cas procedure at Hue University Hospital. Methods: From Decembre 2009 to April 2012, 384 patients with third- degree and fourth-degree hemorrhoids who underwent Stapled Hemorrhoidectomy were included in this study. Parameters recorded included postoperative complications, analegic requirements, duration of hospital stay and patient satisfaction. Follow-up was performed at 1 month and 3 months post-operative. Results: Of the 384 patients that underwent a Stapled Hemorrhoidectomy 252 (65,7%) were male and 132 (34,3%) were female. The mean age was 47,5 years (range 17-76 years. Duration of hospital stay: The mean day was 2,82 ± 1,15 days (range 1-6 days). There were no perioperative complications. There was one case postoperative complication: hemorrhage; Follow-up after surgery: 286 (74,4%) patients had less anal pain, 78 (20,3%) patients had moderate anal pain, 3 (0,8%) patients had urinary retention; Follow-up after one month: good for 325 (84,6%) patients, average for 59 (15,4%) patients; Follow-up after three months: good for 362 (94,3%) patients, average for 22 (5,7%) patients. Conclusion: Our present study shows that Stapled Hemorrhoidectomy is a safe, reduced postoperative pain, shorter hospital stay and a faster return to unrestricted daily activity