Hemorrhoidectomy In Patients Research Articles

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.

Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re‐examined

Haemorrhoidectomy and removal of anal skin tags in inflammatory bowel disease (IBD) have been considered to be potentially harmful, but the evidence for this is poor. A review of the literature was undertaken to determine the complications rate after haemorrhoidectomy in patients with IBD. A Medline, PubMed and Cochrane Library search was performed to retrieve studies reporting the surgical treatment of haemorrhoids in patients with IBD. All studies that investigated the complications of haemorrhoidectomy and skin tag removal in patients with IBD were included. Complications included local sepsis, fissure, ulcer, stenosis, faecal incontinence and the direct need for proctectomy or a stoma. Eleven retrospective studies including 135 patients were identified. Most series were small and lacked information on the interval between surgery and the onset of complications. The range of complications ranged from 0% to 100%. Taking the studies together, complications occurred more frequently in Crohn's disease (CD) (17.1%) than in ulcerative colitis (UC) (5.5%). The risk of complication was much higher in patients with unknown than in those with known diagnosis of IBD (50% vs 9.8% in CD; 9.1% vs 4% in UC). There is great variation in the incidence of complications reported after haemorrhoidectomy or removal of skin tags in patients with IBD and it is not possible to draw a firm conclusion. Nevertheless the incidence of complications is high in patients with CD.

A Prospective, Randomized Trial Comparing the Short- and Long-term Results of Doppler-Guided Transanal Hemorrhoid Dearterialization With Mucopexy Versus Excision Hemorrhoidectomy for Grade III Hemorrhoids

Few randomized trials have compared the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy and excisional open hemorrhoidectomy. Few studies have reported long-term results. The aim of this study is to evaluate the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy compared with excisional open hemorrhoidectomy in patients with grade III hemorrhoids. This is a prospective randomized study registered at clinicaltrials.gov (NCT01263431). A power analysis assessed the study's sample size. Patients were randomly assigned to undergo either hemorrhoidectomy or Doppler-guided hemorrhoid dearterialization plus mucopexy. The χ test, Mann-Whitney U test, Student t test, and a regression model were used, as appropriate. This study was conducted at the Department of Surgery, San Raffaele Scientific Institute, Milan, Italy. Fifty consecutive patients were treated for grade III hemorrhoids from July to November 2010. The primary outcome was postoperative pain. The secondary outcomes included postoperative morbidity, the resumption of social and/or working activity, patient satisfaction, and the relapse of symptoms at 1 and 24 months. No major complications occurred in either group. The median visual analog scale scores for pain in the hemorrhoidectomy and Doppler-guided dearterialization plus mucopexy groups on days 1, 7, 14, and 30 were 7 vs 5.5, 3 vs 2.5, 1 vs 0, and 0 vs 0 (p> 0.05). The median work resumption day was the 22nd in the hemorrhoidectomy group and the 10th in the Doppler-guided dearterialization plus mucopexy group (p = 0.09). Patient satisfaction at 1 and 24 postoperative months, with the use of a 4-point scale, was 3 vs 4 and 4 vs 4 (p > 0.05). During the follow-up, 2 patients in the dearterialization group required ambulatory treatment, and 1 patient in each group required further surgery for symptom relapse. Nonvalidated questionnaires were used in the follow-up. Cost analysis was not performed. Compared with hemorrhoidectomy, dearterialization with mucopexy resulted in similar postoperative pain and morbidity, and a similar long-term cure rate.

Longterm effects of compression method in the surgical treatment of bleeding haemorrhoids

Objective: Present study was undertaken to find out the long term effect of application of compression probe after haemorrhoidectomy in the treatment of bleeding haemorrhoids. Materials and methods: They study was carried out in the Department of Clinical Surgery, Russian People's Friendship University, Moscow, Russia, from January 1992 to December 2001, on 80 patients, equally divided into two groups, case (haemorrhoidectomy plus application of compression probe) and control (haemorrhoidectomy only). Results: Long term follow up showed higher good outcome in case group (82.1%) compared to control (53.8%) (P<0.05), satisfactory and unsatisfactory outcome was higher in control group (17.9% and 28.2%) compared to case group (12.8% and 5.1%). Conclusion: Application of compression problem after haemorrhoidectomy in patients with bleeding haemorrhoids gives better long term results. Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13 Page 129-132 DOI: http://dx.doi.org/10.3329/bjms.v12i2.14939

Comparative Study of Infra-red Coagulation vs Haemorrhoidectomy in Patients of Haemorrhoids

Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or as day care procedures. Even though Milligan Morgan Hemorrhoidectomy(MMH) & Minimal Invasive Procedure for Hemorrhoid (MIPH) is the gold standard for hemorrhoids, but newer techniques like INFRA-RED Coagulation(IRC) for 1st, 2nd & 3rd degree hemorrhoids are showing promising results because of minimal complications, ease of procedure and a day care procedure most of the time. Besides that many patients are not ready for a definite surgical procedure and they can be benefitted by IRC.

Milligan–Morgan hemorrhoidectomy under local anesthesia — an old operation that stood the test of time

This study was carried out to evaluate the morbidity and efficacy of Milligan-Morgan (M&M) hemorrhoidectomy in comparison to novel techniques (e.g., hemorrhoidal artery ligation [HAL], stapler hemorrhoidopexy [PPH]). This is a retrospective review of a single-team experience with 2,280 M&M hemorrhoidectomy patients, with 1-12 years follow-up. All patients were operated upon in jack-knife position, using local anesthesia under light sedation in an ambulatory facility. This method allowed us to operate on 40 pregnant women. All operations were performed using simple, commercially available instruments. We found negligible morbidity, no mortality and a very efficient operation on long-term follow-up. The surgical literature is littered with dreadful complications and even mortality from stapled hemorrhoidopexy (Giordano et al., Dis Colon Rectum 51:1574-1576, 2008; Brown et al., Tech Coloproctol 11:357-358, 2007; Cipriani and Pescatori, Colorectal Dis 4:367-370, 2002; Mongardini et al., G Chir 26:275-277, 2005) and the inefficiency of Doppler HAL (Faucheron and Gangner, Dis Colon Rectum 51:945-949, 2008; Scheyer et al., Am J Surg, 191:89-93, 2006). In days of soaring medical expenditures, nobody will argue about the superiority of M&M hemorrhoidectomy as the cheapest operation available. In all aspects, M&M hemorrhoidectomy under local anesthesia beats its competitors in terms of morbidity, mortality, long-term efficiency and low cost.

Aloe vera for treating acute and chronic wounds

Aloe vera is a cactus-like perennial succulent belonging to the Liliaceae Family that is commonly grown in tropical climates. Animal studies have suggested that Aloe vera may help accelerate the wound healing process. To determine the effects of Aloe vera-derived products (for example dressings and topical gels) on the healing of acute wounds (for example lacerations, surgical incisions and burns) and chronic wounds (for example infected wounds, arterial and venous ulcers). We searched the Cochrane Wounds Group Specialised Register (9 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), Ovid MEDLINE (2005 to August Week 5 2011), Ovid MEDLINE (In-Process & Other Non-Indexed Citations 8 September 2011), Ovid EMBASE (2007 to 2010 Week 35), Ovid AMED (1985 to September 2011) and EBSCO CINAHL (1982 to 9 September 2011). We did not apply date or language restrictions. We included all randomised controlled trials that evaluated the effectiveness of Aloe vera, aloe-derived products and a combination of Aloe vera and other dressings as a treatment for acute or chronic wounds. There was no restriction in terms of source, date of publication or language. An objective measure of wound healing (either proportion of completely healed wounds or time to complete healing) was the primary endpoint. Two review authors independently carried out trial selection, data extraction and risk of bias assessment, checked by a third review author. Seven trials were eligible for inclusion, comprising a total of 347 participants. Five trials in people with acute wounds evaluated the effects of Aloe vera on burns, haemorrhoidectomy patients and skin biopsies. Aloe vera mucilage did not increase burn healing compared with silver sulfadiazine (risk ratio (RR) 1.41, 95% confidence interval (CI) 0.70 to 2.85). A reduction in healing time with Aloe vera was noted after haemorrhoidectomy (RR 16.33 days, 95% CI 3.46 to 77.15) and there was no difference in the proportion of patients completely healed at follow up after skin biopsies. In people with chronic wounds, one trial found no statistically significant difference in pressure ulcer healing with Aloe vera (RR 0.10, 95% CI -1.59 to 1.79) and in a trial of surgical wounds healing by secondary intention Aloe vera significantly delayed healing (mean difference 30 days, 95% CI 7.59 to 52.41). Clinical heterogeneity precluded meta-analysis. The poor quality of the included trials indicates that the trial results must be viewed with extreme caution as they have a high risk of bias. There is currently an absence of high quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds.

Is Hemorrhoidectomy Safe in Patients with Crohnʼs Disease?

Purpose: Optimal management of symptomatic hemorrhoids in patients with Crohn's disease (CD) remains unclear. Current practice guidelines recommending against hemorrhoidectomy in patients with CD are based on a small case series with high proctectomy rate after hemorrhoidectomy in Crohn's patients. In an effort to further clarify this issue, we reviewed our experience with CD patients who had undergone hemorrhoidectomy to determine if there was an increase rate of complications or proctectomy. Methods: A retrospective review was performed on CD patients with symptomatic hemorrhoids requiring surgery during a 10 year period beginning in March 2001 at a single institution. All CD patients who underwent hemorrhoidectomy by a board certified colorectal surgeon were included in this study. Clinical data was obtained from a combination of chart review and patient telephone interview, including patient demographics and preoperative factors. Results: Seven CD patients undergoing hemorrhoidectomy for symptomatic hemorrhoids were identified. Five patients were male and mean age was 45.1 years (range 23 to 77 years) (table). At the time of the hemorrhoidectomy, 3 (43%) patients had active CD and the remaining 4 (57%) patients were in clinical remission. Three (43%) patients with active Crohn's disease also had other perianal disease at the time of hemorrhoidectomy including anal fissure, anal fistula and perirectal abscess. All 7 CD patients failed medical therapy including a combination of dietary management with high fiber and fluids, laxatives, topical ointments and office based hemorrhoid sclerotherapy. None of the patients had wound complications or other complications related to the hemorrhoidectomy. After a mean follow-up time of 28 months after surgery, none of the patients required additional treatment for hemorrhoids, including proctectomy.Table: Demographics and preoperative Crohn's disease featuresConclusion: Hemorrhoidectomy in select CD patients not responding to nonoperative measures may be safe. A prospective study further examining this issue is underway.

Hemorojinių mazgų chirurginio gydymo rezultatų palyginimas

Valery Larionovich Denisenko 2nd Vitebsk regional clinical hospital, Nekrasova 10, Vitebsk 211000, BelarusEl. paštas: boln_priem@vitebsk.by Tikslas: Palyginti prieširdžių pertvaros defekto chirurginio ir perkateterinio gydymo metodų ankstyvuosius rezultatus ir komplikacijas. Comparative analysis of chronic hemorrhoids surgical treatment Valery Larionovich Denisenko 2nd Vitebsk regional clinical hospital, Nekrasova 10, Vitebsk 211000, BelarusE-mail: boln_priem@vitebsk.by Abstract. The problem of hemorrhoids treatment has been important for more then two thousand years. After the standard closed hemmorroidectomy in the postoperative period pain syndrome long-term rehabilitation of patients, a large number of relapses, can be observed. Implementation method of rubber band ligation, as well as the trans anal doppler-guided hemorrhoidal artery ligation, are an alternative to hemorrhoidectomy in patients with hemorrhoids stage III. The analysis of treatment result was in 75 patients with chronic hemorrhoids treated at proctologic ward in the station Vitebsk (since 2008 II Vitebsk Regional Clinical Hospital) from 2002 to 2009. Accordiny to method of treatment for chronic hemorrhoids three groups of patients. Application were distinguished of trans-anal disarterization of internal hemorrhoids under doppler control with mucopexy and lifting and rubber band ligation gives positive results. In reduction of patients disability from 18,4 ± 0,5 days to 1,3 ± 0,3 days (p < 0,05) rehabilitation of the patients on faster than rehabilitation after using traditional techniques. Key words: hemorrhoids, Doppler, lifting, mucopexy.

Comparison of Early Clinical Outcomes Between ALTA (Aluminum Potassium Sulfate and Tannic Acid, Ziohn®) Injection Therapy and a Submucosal Hemorrhoidectomy in Patients with Internal Hemorrhoids

Purpose: The purpose of this study was to evaluate early outcomes of ALTA (aluminum potassium sulfate and tannic acid, ) injection compared with those of a submucosal hemorrhoidectomy for the treatment of internal hemorrhoids. Methods: From September 2008 to April 2009, a total of 50 patients who had internal hemorrhoids (Golliger grade II to IV) were treated by using either ALTA injection (n=25) or a submucosal hemorrhoidectomy (n=25). Outcomes with respect to pain scores, analgesics use, and satisfaction levels of the patients, and complications were compared. Results: The mean number of hemorrhoidal piles was 3.52 in the ALTA injection group and 3.56 in the operation group. The average amount of ALTA injection was 27.34 cc. Pain scores measured at one day and 7 days after the treatment, and the number of analgesics used in the injection group were significantly lower than those in the operation group (P

Randomized placebo-controlled trial on local applications of opioids after hemorrhoidectomy

Hemorrhoidectomy is associated with considerable postoperative pain. This study assessed whether a small dose of morphine or oxycodone administered in the embedded sponge set in the anus at the end of a hemorrhoidectomy intervention reduced postoperative pain. The presence of opioid receptors was assessed in the anal mucosa excised from ten patients with perianal condyloma acuminata and 19 patients with symptomatic third-fourth degree hemorrhoids. A double-blind prospective randomized placebo-controlled trial was then conducted in 135 patients with hemorrhoids. Hemorrhoidectomy patients were randomized to morphine (MG), oxycodone (OG), or control (CG) groups, each patient having an absorbable sponge dressing left in the anus embedded with 1 mg of morphine, 1 mg oxycodone, or vehicle, respectively. The mean time for the first dose of analgesic drugs, the use of analgesics, and the mean time to void bladder was evaluated. The presence of kappa- and delta-opioid receptor immunoreactivity was detected in the anal mucosa excised from patients with perianal condyloma acuminata and hemorrhoids. Furthermore, there was a significant (P < 0.001) upregulation of kappa receptor immunoreactive-like material in hemorrhoidectomy patients. The mean time for the first analgesic administration was significantly increased (P < 0.001) in MG versus CG. A further significant increase (P < 0.001) was observed in the OG patient group. The mean time for voiding was significantly higher in CG when compared to the MG and OG patient groups. The local administration of very low doses of kappa-opioid agonist decreased hemorrhoidectomy postoperative pain through the interaction with specific opioid receptors located on anal mucosa.

Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids

Hemorrhoidectomy is a frequently performed surgical procedure and associated with postprocedural pain. The use of the Ligasure could result in a decreased incidence of pain as coagulation with high frequency currency and active feedback control over the power output has minimal thermal spread and limited tissue charring. To compare patient tolerance focussing on pain following Ligasure and conventional hemorrhoidectomy in patients with symptomatic hemorrhoids. A multi-database (MEDLINE, EMBASE, CENTRAL and CINAHL) systematic search was conducted. Key journals were handsearched. There was no restriction on language. Randomized controlled trials comparing hemorroidectomy using the Ligasure-technique with conventional diathermy techniques for symptomatic hemorrhoids in adult patients were included. Two reviewers independently extracted data, assessed trial quality and resolved discrepancies together with a third party. Odd Ratios were generated for dichotomous variables. Weight Mean Differences were used for analysing continuous variables. Only random effects models were used. Heterogeneity was explored by sensitvity analysis. Twelve studies with 1142 patients met the inclusion criteria. The pain score at the first day following surgery was significantly less in the Ligasure group (10 studies, 835 patients, WMD -2.07 CI -2.77 to -1.38). Most outcomes concerning analgesics used (7 studies) and pain scores up to 7 days (5 studies) favoured the Ligasure-technique. The benefit was diminished at day 14 (VAS pain score, 4 studies, 183 patients, WMD -0.12 CI -0.37 to 0.12). The conventional technique took significantly longer to complete (11 trials, 9.15 minutes, CI 3.21 to 15.09). There was no relevant difference in postoperative complications, symptoms of recurrent bleeding or incontinence at final follow-up. Hospital stay was similar for both groups (6 reports, 525 patients, WMD -0.19 CI -0.63 to 0.24). Patients treated with the Ligasure-technique returned to work significantly earlier (4 studies, 451 patients, 4.88 days, CI 2.18 to 7.59). Sensitivity analysis on high quality studies, fixed effects models, open or closed conventional techniques revealed no clinical relevant different results. Since the usage of the Ligasure technique results in significantly less immediate postoperative pain after hemoroidectomy without any adverse effect on postoperative complications, convalescence and incontinence-rate, this technique is superior in terms of patient tolerance. Although there was a tendency for equal efficacy, more evaluation of the long-term risk of recurrent hemorrhoidal disease is required.

Topical Sucralfate Decreases Pain After Hemorrhoidectomy and Improves Healing: A Randomized, Blinded, Controlled Study

Oral and topical sucralfate is regularly used in ulcers of gastrointestinal tract, vaginal and perianal excoriations, and radiation burns. This study was designed to determine whether there was any advantage of topical application of sucralfate in reducing postoperative pain and promoting wound healing after open hemorrhoidectomy in patients with Grades III or IV hemorrhoids. A total of 116 patients were randomly assigned to receive sucralfate cream (sucralfate group) or placebo cream (control group) applied to the surgical site. Weekly pain score was evaluated by using Visual Analog Scale. The amount of analgesic tablets consumed in each week also was assessed. At the end of four weeks, two independent surgeons assessed the wound healing. There was no significant difference in age, gender distribution, and number of excised hemorrhoid piles between the two groups. Patients in the topical sucralfate group experienced significantly less pain at Day 7 (Visual Analog Scale +/- standard error of the mean, 3.7+/-0.3 vs. 6.1+/-0.7; P<0.002) and at Day 14 (1.6+/-0.2 vs. 3.1+/-0.6; P<0.01). Likewise patients who received sucralfate cream used less analgesic tablets compared with the placebo group. In the sucralfate group, the overall wound healing ranked significantly better than in controls (P<0.02). Topical sucralfate significantly reduces pain at Days 7 and 14 after hemorrhoidectomy and promotes faster wound healing compared with that of a placebo.

Stapled Hemorrhoidopexy Is Associated with a Higher Long-Term Recurrence Rate of Internal Hemorrhoids Compared with Conventional Excisional Hemorrhoid Surgery

The purpose of this systematic review was to compare the long-term results of stapled hemorrhoidopexy with conventional excisional hemorrhoidectomy in patients with internal hemorrhoids. A systematic review of all randomized, controlled trials comparing stapled hemorrhoidopexy and conventional hemorrhoidectomy with long-term results was performed by using the Cochrane methodology. The minimum follow-up was six months. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications, and pain. Twelve trials were included. Follow-up varied from six months to four years. Conventional hemorrhoidectomy was more effective in preventing long-term recurrence of hemorrhoids (odds ratio (OR), 3.85; 95 percent confidence interval (CI), 1.47-10.07; P < 0.006). Conventional hemorrhoidectomy also prevents hemorrhoids in studies with follow-up of one year or more (OR, 3.6; 95 percent CI, 1.24-10.49; P < 0.02). Conventional hemorrhoidectomy is superior in preventing the symptom of prolapse (OR, 2.96; 95 percent CI, 1.33-6.58; P < 0.008). Conventional hemorrhoidectomy also is more effective at preventing prolapse in studies with follow-up of one year or more (OR, 2.68; 95 percent CI, 0.98-7.34; P < 0.05). Nonsignificant trends in favor of conventional hemorrhoidectomy were seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, the presence of perianal skin tags, and the need for further surgery. Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and symptoms of anal obstruction/stenosis. Conventional hemorrhoidectomy is superior to stapled hemorrhoidopexy for prevention of postoperative recurrence of internal hemorrhoids. Fewer patients who received conventional hemorrhoidectomy complained of hemorrhoidal prolapse in long-term follow-up compared with stapled hemorrhoidopexy.

Effect of Red Chili Consumption on Postoperative Symptoms During the Posthemorrhoidectomy Period: Randomized, Double‐blind, Controlled Study

The aim of this study was to determine whether there was any relation between consumption of chilies and postoperative symptoms after hemorrhoidectomy in patients with grade III or IV hemorrhoidal disease. A total of 60 patients were randomly assigned to receive antibiotics and analgesics alone (control patients) or daily consumption of 3 g of chili powder along with identical antibiotics and analgesics (chili group). The evaluation of symptoms-pain, anal burning, pruritus, bleeding-during the postoperative period was assessed by means of patients' self-questionnaires. A global score for evaluating each postoperative symptom was compared between the two groups at the 1-week follow-up. No significant difference in age, sex distribution, or grade of disease was noted between the two groups at baseline. The incidence of post-hemorrhoidectomy symptoms was higher in the group consuming chilies during the first postoperative week. The global score for postoperative pain (14.60 for the chili group vs. 7.97 for the control group, p < 0.001) and for anal burning (12.90 for the chili group vs. 7.82 for the control group, p < 0.0001) were significant. Although bleeding (6.95 in the control group and 7.57 in the chili group, p < 0.81) and pruritus (8.06 in the control group and 8.75 in the chili group, p < 0.69) were more common in the chili group, the difference did not achieve statistical significance. This study shows that consumption of 3 g of red chilies per day during the postoperative period after hemorrhoidectomy increases the intensity of typical postoperative symptoms, stool frequency, and the consumption of analgesics.

Effects of spinal anesthesia and laryngeal mask anesthesia on mood states during hemorrhoidectomy

The present study was undertaken to compare the effects of laryngeal mask anesthesia (LMA) and spinal anesthesia on mood states in patients undergoing hemorrhoidectomy. A total of 46 patients who underwent hemorrhoidectomy for grade III and IV hemorrhoids were included in this study. LMA with fentanyl plus propofol was given to 23 patients, and spinal anesthesia with bupivacaine was administered to 23 patients. Mood changes were assessed preoperatively and 2 h postoperatively with the Profile of Mood States (POMS), which consists of 65 questions that are designed to measure 6 identifiable mood states (tension, depression, anger, vigor, fatigue, and confusion). No significant differences were noted between the 2 groups in terms of baseline POMS global and subscale scores, except for scores regarding vigor. No significant mood changes were observed after hemorrhoidectomy in patients who were given LMA; however, an increase in total POMS score was reported in patients given spinal anesthesia. These findings suggest that mood score is affected by spinal anesthesia but not by LMA in patients who are about to undergo hemorrhoidectomy.

Management of haemorrhoids – A personal local experience

Background : The aim of the study was to analyze the management of patients presenting with haemorrhoids in the local set up. Methods : The records of all patients treated in the private consulting rooms of the author in Hurlingham in Nairobi for haemorrhoids by the author were reviewed. Results : A total of 300 patients with haemorrhoids were treated of which approximately two thirds were less than 50 years of age. The male to female ratio was 2.15: 1 and the commonest mode of presentation was haematochlesia. Approximate 25% of the patients were diagnosed by anal inspection alone while 75% had internal non-prolapsed haemorrhoids. 96% of the patients had a 60cm colonoscopy at which 2.8% were found to have a rectal malignancy. Seven patients required emergency surgery for their painful thrombosed external haemorrhoids and 21 patients had a haemorrhoidectomy. Band ligation was performed in 181 patients. None of these had any major complications while two of the haemorrhoidectomy patients had major complications. Conclusion : Haemorrhoids are a common problem and should be diagnosed accurately since appropriate management prevents unnecessary morbidity. Haemorrhoids maybe secondary to proximal rectal pathology. Where possible band ligation provides good symptom relief. Recommendation : It is advisable to perform a 60cm colonoscopy before treating haemorrhoids.

The use of Ligasure haemorrhoidectomy in patients taking oral anticoagulation therapy.

To assess the safety of Ligasure haemorrhoidectomy in treating patients on long-term anticoagulation therapy. Three patients taking warfarin underwent Ligasure haemorrhoidectomy for prolapsing haemorrhoids. Each had a successful procedure without complications. Ligasure haemorrhoidectomy can be safely performed in anticoagulated patients and reduces in-patient hospital stay.

A systematic review of stapled hemorrhoidectomy.

Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

A Systematic Review of Stapled Hemorrhoidectomy—Invited Critique

Hypothesis: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. Data Sources: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. Study Selection: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. Data Extraction: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. Data Synthesis: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. Conclusions: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.