Hemorrhoid Surgery Research Articles

Postoperative Complications in Hemorrhoidal Disease and Special Conditions

Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications. To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease. During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE. Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Comparison of outcome between traditional open haemorrhoidectomy and stapled haemorrhoidectomy operation

Background: Haemorrhoidectomy is a surgical excision and removal of the hemorrhoid used primarily only in severe cases. There are many different types of haemorrhoidectomy like open haemorrhoidectomy and stapled haemorrhoidectomy.
 Objective: To compare the outcome of stapled haemorrhoidectomy and traditional open haemorrhoidectomy. Methods: This is a cross sectional study of 72 cases who underwent open and stapled haemorrhoidectomy operation for symptomatic 2nd, 3rd and 4th degree hemorrhoids. Binomial probability pre-posttest were used for statistical analysis, p value less than 0.05 was taken as significant.
 Results: : Among 72 patients, 34 patients of conventional haemorrhoidectomy and 38 of stapled haemorrhoidectomy at 3 months post-surgery in conventional group 1 patient was unsatisfied, 12 patients were satisfied and 4 patients stated their condition good. In stapled group 14 patients stated their condition excellent and 5 patients stated their condition good. Statistical analysis shows that level of satisfaction at 3 months post-surgery in conventional group and stapled group was statistically significant(p-value<.001).
 Conclusion: Stapled haemorrhoidectomy is a relatively new procedure. Stapled haemorrhoidectomy is a safe procedure, less pain and disabled than the conventional haemorrhoidectomy.
 Journal of Surgical Sciences (2017) Vol. 21 (2): 99-104

Efficacy of Doppler-guided hemorrhoidal artery ligation with mucopexy, in the short and long terms for patients with hemorrhoidal disease.

Several studies comparing Doppler-guided hemorrhoidal artery ligation (DG HAL) with or without mucopexy with hemorrhoidopexy and hemorrhoidectomy techniques show no difference in short-term efficacy. The aim of this study was to evaluate efficacy of DG HAL with mucopexy (DG HAL+m) in the long term (beyond 5years) for patients with hemorrhoidal disease. A retrospective observational study was conducted on patients with symptomatic hemorrhoidal disease of any stage treated with DG HAL m at our outpatient colorectal surgery unit in April 2009-April 2013. Patients were followed clinically for 1month and with a questionnaire until 5years after surgery or until they underwent a second surgery for recurrent hemorrhoids. Of 150 patients who underwent DG HALm during the study period 50 (33.3%) were lost to follow-up. A total of 100 patients (47 women, 53 men) were analysed. The average age was 50 (± 12) years. Twenty-six patients (17.3%) had had one or more prior procedures. The mean length of hospital stay was 2.2days (median = 2days; range = 1-8days). No major complications were described. There were no deaths. At 5years the mean bleeding, local discomfort and pain scores were significantly improved. Thirty-six patients (35.6%) had a recurrence during the follow-up period, and 20 (19.8%) of them underwent reoperation. The mean time between the operation and the second procedure was 36months (median 27.4months). The majority (61.4%) of patients were satisfied with the procedure. Despite the low invasiveness of DG HALm the low morbidity associated with the procedure and the satisfactory functional outcomes, the long-term recurrence rate can be very high. However, only about half of the patients who experienced a recurrence needed a second operation.

Nalbuphine versus neostigmine as an adjuvant to intrathecal hyperbaric bupivacaine-induced postoperative analgesia

Introduction Pain remains one of the most important patient complaints after hemorrhoid surgery; most anal surgical procedures are done as a day-case procedure, so medication to relieve or stop pain and provide analgesia should be administered preoperatively to provide postoperative analgesia. Aim The aim of the study is to evaluate the effect of nalbuphine versus neostigmine as an adjuvant to intrathecal hyperbaric bupivacaine on duration of motor block and postoperative analgesia. Patients and methods A total of 40 adult patients of both sexes, with American Society of Anesthetists status I–II, aged between 21 and 60 years, enlisted to undergo hemorrhoidectomy under spinal anesthesia were included. Patients were randomly divided into two groups. Group I was the nalbuphine group (n=20), which received 15 mg (3 ml) of 0.5% hyperbaric bupivacaine+2 mg (0.1 ml) of nalbuphine HCl. Group II was the neostigmine group (n=20), which received 15 mg (3 ml) of 0.5% hyperbaric bupivacaine+50 μg (0.1 ml) of neostigmine. The total volume administered in each group was 3.1 ml. Results The onset of sensory block was significantly faster in nalbuphine group than neostigmine group, whereas onset of motor block was significant faster in neostigmine group than in nalbuphine group (P=0.0001). The time to two-segment sensory regression was significantly longer in nalbuphine group than in neostigmine group (P Conclusion Addition of either nalbuphine or neostigmine to intrathecal hyperbaric bupivacaine induces postoperative analgesia with no significant adverse effect. However, nalbuphine was superior to neostigmine in prolongation of duration of motor block and postoperative analgesia, with decreased postoperative analgesic requirement.

Surgical outcome and ethics in adopting new surgical technique in low resource settings: A case study in haemorrhoid surgery

Introduction: Our aim was to evaluate the surgical outcome and ethical considerations in adopting stapled hemorrhoidopexy (SH) in low-resource settings. Methods: This prospective comparative study of patients with Grade III hemorrhoids was conducted at our institute from December 2017 to July 2019. Short-term surgical outcome and the results of a short questionnaire associated with ethics were evaluated. Results: Sixty patients were operated on for third-degree hemorrhoids, thirty each in Group conventional hemorrhoidectomy (CH) and Group SH. The SH group had better postoperative pain control at 0, 1, and 4 weeks (P = 0.001), but this difference became insignificant at 12 weeks. Overall recurrence was more in SH group (11.37%) as compared to CH group (2.7%), and it was statistically significant (P = 0.01). The mean operative time was significantly less in the SH group (43 min vs. 50 min, P = 0.006). Similarly, the mean hospital stay was significantly less in the SH group as compared to the CH group (2.27 days vs. 3.83 days, P = 0.001). Survey of the operating surgeons revealed that all the three surgeons involved assessed the effectiveness and safety of SH through literature; the main motivation behind performing new technique in resource-poor settings was learning a new technique and teaching purpose. Conclusion: The main value of this research is to describe the adoption of surgical stapler into clinical practice in low-resource settings. Our analysis suggests that, in a rapidly developing area of surgical innovation, adoption of SH in resource-poor settings can give the same outcome as in expert hands.

Infiltracija hirurške rane hronični neuropatski bol kao posledica epiziotomije - postporođajni hronični neuropatski bol

Introduction: Chronic postsurgical pain has an estimated mean incidence of 30% and varies according to the type of surgery and patient characteristics. The pain can be severe and result in clinically relevant functional impairment reported by 5-10% of patients. Epidemiological surveys have shown that many patients with neuropathic pain do not receive appropriate treatment. Bio-psycho-social model of chronic pain is highly expressive in neuropathic pain management and requires the adjustment of the therapeutic approach. Case Report: A 37-year-old female complained of numbness, burning, and discomfort of the perineum. In 2016, after the vaginal baby delivery followed by episiotomy, she experienced discomfort and variety of painful sensations in the episiotomy incision region. A year later, after a hemorrhoid surgery followed by episiotomy scar reconstruction symptoms intensified with a strong influence on the patient's psychosocial condition. Consultation of obstetrician, psychiatrist and neurologist took part. Nevertheless, after two years had passed without significant clinical improvement, the patient was referred to a pain specialist. The pain specialist noticed inconsistency in the current treatment and the pain assessment was done only by one specialist. Testing revealed severe symptoms of hyperalgesia and allodynia, impaired psychosocial functioning related to chronic postsurgical pain. Pregabalin and duloxetine were introduced into the therapy and significantly improved pain relief and psychosocial functioning. Conclusion: Chronic postsurgical neuropathic pain is a complex syndrome which is not necessarily related to extensive surgical stimulus. The multidisciplinary therapy approach is crucial. Health providers who understand bio-psycho-social origin of chronic pain should be members of a multidisciplinary team.

Youtube as a Source of Patients’ and Specialists’ Information on Hemorrhoids and Hemorrhoid Surgery

Youtube as a Source of Patients’ and Specialists’ Information on Hemorrhoids and Hemorrhoid Surgery

Effect of moxibustion combined with five-element music therapy on postoperative pain relief after mixed hemorrhoid operation

Objective: To investigate the effect of moxibustion combined with five-element music therapy on the postoperative pain relief of patients undergoing surgical operation for mixed hemorrhoid with damp-heat syndrome. Methods: Totally, 159 patients meeting the inclusion criteria were assigned to the control group, study group 1, and study group 2, with 53 cases in each group. All patients received routine care after surgical treatment, including acupoint application and Chinese herbal fumigation. In addition, patients in the study group 1 received moxibustion, and those in the study group 2 were given moxibustion combined with five-element music therapy. The degree of postoperative pain was evaluated using visual analog scale (VAS). Results: There was no significant difference in VAS score on pain during dressing changes among three groups (P > 0.05). After 3, 5, and 7 days of intervention, there was a significant difference in VAS score on pain at rest among three groups (P < 0.001), and VAS score in the study group 2 was lower than that in the study group 1 and the control group after 3 and 5 days of intervention, respectively (P < 0.05). Conclusion: Moxibustion combined with five-element music therapy is effective to relieve the postoperative pain of patients undergoing a surgical operation for mixed hemorrhoids with damp-heat syndrome.

Role of local infiltration of methylene blue as an analgesic in stapled hemorrhoidopexy: A prospective study

Background: Stapled hemorrhoidopexy gained popularity due to low postoperative pain. Few patients still complain of postoperative anal pain. Methylene blue (MB) in caudal and epidural anesthesia gives long-term pain relief and has also been used to treat intractable pruritus ani. Objective: Evaluate the role of local infiltration of the MB as an analgesic in the procedure for prolapse and hemorrhoids (PPH) surgery. Design: Prospective observational study. Setting: Tertiary health care center. Patients and Methods: Patients with grade-III hemorrhoids were included and were divided into two groups: A and B. Group A received a perianal injection of 2 mL of 1% MB with 10 mL of 25% bupivacaine. Group B received a perianal injection of 2 mL of normal saline with 10 mL of 25% bupivacaine. Main Outcome Measures: Patients were followed up prospectively for pain, hospital stay, and complications. Results were noted and compared between the two groups. Sample Size: 50 patients. Results: Group A had significantly lower pain scores on day 3 (mean ± SD 2.08 ± 1.08) and day 7 (mean ± SD 0.64 ± 0.95) as compared to the pain scores on day 3 (mean ± SD 3.92 ± 1.35) (P-value = 0.000) and day 7 (mean ± SD 2.40 ± 1.0) (P-value = 0.000) in group B. Pain scores within first 24 h and day 21 post-surgery were not statistically significant between groups A and B (P-value = 0.286 and 0.19, respectively). Group B required a significantly higher number of both injectable and oral analgesics (mean + SD 4.03 + 0.94) as compared to group A patients (mean + SD 1.97 + 0.81) (P-value = 0.001). 4% of the patients in group B had prolonged hospital stay due to severe pain. Patients in group A also had a significant reduction in their requirement of analgesics. None of the patients who received MB had any local or systemic allergic reactions. Conclusion: Local infiltration of MB may be used as an effective analgesic in PPH patients without any increase in morbidity. Limitations: Single-center study with a small sample size. Conflict of Interest: None.

Influence of Titanoreine on Wound Healing and Postoperative Defecation Difficulty in Circular Mixed Hemorrhoids Patients

This study was designed to investigate the application of titanoreine after circular mixed hemorrhoids operation and its influence on wound healing and postoperative defecation difficulty. 46 cases of circular mixed hemorrhoids patients were selected and divided into two groups by random number table. The control group was treated with routine intervention after operation and the study group was treated with titanoreine. The difference of wound healing degree quantitative score before and after the intervention, the effective rate, the average healing days of wound, the first defecation time and the quantitative score of constipation symptoms were compared between the two groups. After the intervention, the quantitative scores of wound healing degree at different time points in the study group were lower than those in the control group (p<0.05, respectively), The effective rate of the study group was significantly higher than that of the control group (p<0.05). The average wound healing days in the study group were 4.1±0.6 d and 5.4±1.5 d in the control group. The average wound healing days in the study group were significantly shorter than those in the control group (t=15.021, p<0.05). The first defecation time of the study group was significantly (p<0.05) earlier than control group. The quantitative scores of constipation at different time points in the study group were significantly lower than those in the control group (p<0.05, respectively). The application of titanoreine after circular mixed hemorrhoids surgery can significantly shorten the time of wound healing, promote the wound healing faster and better, and reduce the risk of defecation difficulty.

Clinical analysis of 36 cases of idiopathic intracranial hypertension complicated with iron deficiency anemia

Objective: To investigate the clinical features, imaging findings and prognosis of idiopathic intracranial hypertension (IIH) patients complicated with iron deficiency anemia (IDA). Methods: A total of 307 cases of IIH patients hospitalized in Beijing Tongren Hospital were retrospectively screened between January 1, 2011 and February 28, 2018. There were 49 anemia cases (15.96%) and 45 IDA cases (14.66%), respectively. Finally, 36 IDA patients were enrolled. The clinical characteristics, imaging findings, treatment and prognosis of these patients were analyzed. Results: IIH combined with IDA was more common in women of childbearing age (34/36). There were 30 obese and overweight cases (83.33%), with multiple subacute or chronic course of disease. The visual symptoms in the early IIH patients were first diagnosed in the Department of Ophthalmology. The first symptom was headache with/without visual symptoms (27 cases (75%)). Head MRI detected empty sella or partial empty sella, and 2 cases of venous sinus thrombosis were found in DSA examination. Of the 34 female patients, 24 had simple menometrorrhagia or menstrual disorder. All patients were given methyl acetate to reduce the intracranial pressure and iron therapy. Five patients received low molecular weight heparin-warfarin sequential treatment, 5 cases underwent gynecologic surgery and 2 male cases received hemorrhoid operation. There were 7 cases underwent lumbar cisterna-peritoneal shunt for visual impairment. During the follow-up, intracranial pressure decreased and visual function of patients improved significantly. Conclusions: IIH is frequently found in obese or overweight women at childbearing age and IDA may be an important cause of IIH. IIH can cause serious irreversible visual impairment. Therefore, early identification and active treatment should be performed. Correction of anemia can significantly improve the clinical symptoms of IIH. Operation should be employed for IIH patients with poor visual function or rapid progress, in order to reduce intracranial pressure and improve prognosis as soon as possible.

Virtual reality distraction decreases pain during daily dressing changes following haemorrhoid surgery.

ObjectiveTo investigate whether immersive virtual reality (VR) distraction could decrease pain during postoperative dressing changes.MethodsThis was a prospective, open-label randomized clinical trial that enrolled patients that had undergone haemorrhoidectomy. Patients were randomly assigned to one of two groups: a control group that received the standard pharmacological analgesic intervention during dressing change and a VR group that received VR distraction during dressing change plus standard pharmacological analgesic intervention. Pain scores and physiological measurements were collected before, during and after the first postoperative dressing change.ResultsA total of 182 patients were randomly assigned to the control and VR groups. The baseline characteristics of the VR and control groups were comparable. There was no significant difference in mean pain scores prior to and after the dressing change procedure between the two groups. The mean pain scores at the 5-, 10-, 15- and 20-min time-points during the first dressing change were significantly lower in the VR group compared with the control group. Heart rates and oxygen saturation were not significantly different between the two groups.ConclusionImmersive VR was effective as a pain distraction tool in combination with standard pharmacological analgesia during dressing change in patients that had undergone haemorrhoidectomy.

Association Between Hemorrhoids and Lower Extremity Chronic Venous Insufficiency.

AimThe aim of the present study was to evaluate the incidence of varicose veins among patients with hemorrhoidal disease and to compare its incidence reported in various community-based studies.MethodThe study group comprised of 100 patients who underwent surgery for symptomatic internal or external hemorrhoids; the control group consisted of 100 volunteers who received no prior therapy for hemorrhoidal disease and lacked any symptoms or findings suggestive of this condition. Subjects in both the groups were inquired with respect to their demographic data and risk factors. Both groups were asked to stand for two minutes before performing leg examinations while still in the standing position. The findings were recorded for both the groups. Varicose veins were classified according to the clinical appearance section of the Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classification that was developed by the 1994 American Venous Forum.ResultsThere was no significant difference between the two groups with respect to age and body mass index (BMI). Significant relationships were identified between the groups with respect to the incidence of varicose veins and chronic constipation. The incidence of C1 and C2 varicose veins observed in the study group was higher than that observed in the control group. The incidence of chronic constipation was higher in the study group than that in the control group.DiscussionLower extremity chronic venous insufficiency is more common in patients with hemorrhoidal disease which increases intra-abdominal pressure. A chronic increase in this pressure causes conditions, such as constipation, which trigger both lower extremity chronic venous insufficiency and hemorrhoidal disease.

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&lt;0.005). The pain experienced in the immediate postoperative period was higher for the open group (p&lt;0.005). Noticeable difference in the hospital stay between the two groups was observed, with stapled group being discharged earlier (p&lt;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&lt;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.

Perioperative Adverse Events in Women Undergoing Concurrent Hemorrhoidectomy at the Time of Urogynecologic Surgery.

The aim of this study was to describe the incidence and trends of outcomes after concurrent surgeries for symptomatic hemorrhoids and pelvic floor disorders. This was a retrospective matched cohort study. Women who underwent concurrent vaginal urogynecologic and hemorrhoid surgery between 2007 and 2017 were identified by their surgical codes and matched to a cohort of women who underwent vaginal urogynecologic surgery only. The medical record was queried for demographic and perioperative data. Thirty-three subjects met the inclusion criteria; 198 subjects were matched accordingly (N = 231). Mean age and body mass index were 57 ± 12 years and 28.9 ± 5.6 kg/m, respectively. Subjects who underwent concurrent hemorrhoidectomy were more likely to have had previous prolapse surgery (27.3% vs 15.2%, P = 0.09) and preoperative fecal incontinence (27.3% vs 13.6%, P = 0.05). Concurrent cases were more likely to have unplanned office visits (27.2% vs 12.6%, P = 0.03) and phone calls (range, 1-7 vs 0-10; P = 0.001), mostly for pain complaints. Reoperation was higher in combined cases (3% vs 0%, P = 0.01); however, the overall rate of serious perioperative adverse events was low and not different between groups. Concurrent cases were more likely to be discharged home with a Foley (42.4% vs 18.2%, P = 0.002) and to have a postoperative urinary tract infection (33.3% vs 10.6%, P = 0.005). In the concurrent group, 33.3% of the patients experienced severe rectal pain. Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery are at higher risk of minor events such as postoperative urinary tract infection and need for discharge home with a Foley, as well as risk of pain that may be greater than urogynecologic surgery alone.

Somatosensory stimulation treatments for postoperative analgesia of mixed hemorrhoids: Protocol for a systematic review and network meta-analysis.

Background:Pain after hemorrhoidal surgery bothers both clinicians and patients. Somatosensory stimulation treatments have shown promising effect on the pain after hemorrhoidal surgery, but the comparative effectiveness between them has not been studied. We aim to determine the relative effectiveness among these treatments on pain relief after hemorrhoidal surgery by using network meta-analysis.Method:We will search the following electronic databases: MEDLINE, EMBASE, the Cochrane library, Chinese Biomedicine database (CBM), China National Knowledge Infrastructure (CNKI). We will include randomized controlled trials (RCTs) that examine the effect of somatosensory stimulation treatments on pain after hemorrhoidal surgery. The primary outcome will be the responder rate after treatment. The secondary outcomes will include the assessments with pain intensity scales (visual analog scale, numeric rating scale, or other scales) on day 1 to 7 after surgery. Two independent reviewers will extract needed information from eligible trials using standardized electronic forms. Network meta-analysis will be performed using a frequentist framework based on electrical network theory. The relative effectiveness of the treatments will be ranked by using P score, which is the mean probability of a treatment ranking the best in all treatments. Meta-regression will be performed to assess the impact of surgery type, anesthesia methods, and funding source on the treatment ranking. The quality of the eligible RCTs will be evaluated by the Cochrane risk of bias tool.Ethics and dissemination:The result of this network meta-analysis will clarify which is the relatively best somatosensory-stimulation treatment in relieving postoperative pain caused by hemorrhoidal surgery, and the review will, therefore, guide the management of postoperative pain after hemorrhoidal surgery for clinicians and patients. This review does not require ethical approval and will be reported in a peer-reviewed journal.Trial registration number:PROSPERO CRD42018115558.

A comparative study of open (Milligan-Morgan) versus closed (Ferguson) haemorrhoidectomy with and without internal sphincterotomy

Background: Normal anal canal contains cushion of submucosa with vascular tissues. When cushions become abnormal , cause symptoms. This clinical condition is known as haemorrhoids. Haemorrhoidectomy is surgery for haemorrhoids, which can be performed by Milligan-Morgan (open technique) or Ferguson (close technique) methods. This study is conducted to compare different surgical modalities of treatment for haemorrhoids.Methods: In total, 232 patients suffering from haemorrhoids with or without fissures were included in the study. Patients were categorized into two groups. Patients undergoing open technique were designated as open group, similarly patients undergoing close technique were designated as close group. In both groups for few patients internal sphincterotomy (I.S.) was performed. Post-operative pain was assessed by visual analogue scale in all groups, per operative haemorrhage was assessed by number of swabs used during surgery and VAS estimation, operating time and post-operative hospital stay were recorded.Results: 136 patients were suffering from haemorrhoids with fissures. Of these 84 patients were operated by open technique and 52 patients by close technique. In all 136 patients, internal sphincterotomy was performed. Remaining 96 patients were suffering from only haemorrhoids. Of these 30 patients were treated by open technique with I.S., 30 patients were treated by close technique only. 25 patients were treated by close technique with I.S. and 10 patients were treated by close technique without I.S. Close group and open group with I.S. experienced less pain compared to without I.S. in both groups. Per operative haemorrhage and hospital stay in close group was less . Operative time in open group was less compared to close group.Conclusions: Ferguson procedure is found to cause less post-operative discomfort. Addition of internal sphincterotomy is having a positive effect in reducing post-operative pain.

Outcomes of Advancement Flaps Used in the Treatment of Anal Stenosis Developing After Hemorrhoid Surgery: One Center Experience

Outcomes of Advancement Flaps Used in the Treatment of Anal Stenosis Developing After Hemorrhoid Surgery: One Center Experience

High post-operative pain scores despite multimodal analgesia in ambulatory anorectal surgery: a prospective cohort study

Background: Ambulatory surgery for anorectal procedures has become widely accepted. Recent reviews recommend a multimodal approach to pain management. However, these recommendations are largely based on single intervention studies. Our goal was to evaluate post-operative pain in patients receiving a multimodal analgesic regimen.Methods: All patients undergoing an ambulatory anorectal procedure between December 2015 and September 2016 received a pain diary. Mean pain throughout the day and pain during defecation where recorded on day 0–14 and day 21 postoperatively using a numeric rating scale-11. Use of oral analgesics was also recorded.Results: Forty-two patients completed the pain diary. The use of local anesthetic infiltration did not result in a significant difference in pain scores in this study. Patients who received written information on postoperative pain management and hygienic measures had higher intake of oral analgesics. Despite receiving multimodal analgesic treatment, patients undergoing surgery for hemorrhoids or anal fissures reported pain scores ≥4 and used analgesics longer.Conclusion: A multimodal analgesic approach consisting of local anesthetic infiltration, multiple oral analgesics and written information seems to be insufficient for certain patient groups after ambulatory anorectal surgery. Especially patients undergoing surgery for hemorrhoids or an anal fissure should receive adequate analgesia. Pain during defecation is problematic and finding a solution for this problem remains challenging. Further research into the combined use of different analgesic modalities is recommended.

Open surgery for haemorrhoids in persons with spinal cord injury.

Pilot retrospective study on the outcome of open surgery for grade III and IV haemorrhoids in patients with SCI. Haemorrhoids and anal fissures are common in patients with spinal cord injury (SCI). Grade I to III haemorrhoids are usually managed medically or by surgical ligation. Grade III and IV haemorrhoids are treated with surgical haemorrhoidectomy in the general population, but not in patients with SCI, most probably due to fear of complications. Fondation Hopale, Berck-sur Mer, France. The surgical database was searched for open haemorrhoidectomies performed between 2007 and 2016. Seventeen patients were included. There were mostly males with complete paraplegia, mean age: 50 years and mean time since injury: 15.9 years. Open haemorrhoidectomy (Milligan and Morgan) was performed for isolated haemorrhoids (n = 4), and combined with Leopold Bellan procedure (posterior anoplasty and internal sphincterotomy) for associated anal fissures (n = 13). Short-term follow-up was performed by the surgeon (post-operative weeks 2 and 6), long-term follow-up by telephone interview (mean 5.7 years, SD 1.9). At 6-weeks post-operative, no significant complications had occurred and all wounds had healed, however 1 patient had recurrence of anal fissure. At long-term follow-up, 75% of patients reported a significant improvement in anorectal symptoms. Recurrences were reported by 5 patients: 3 haemorrhoids (18%) and 2 anal fissures (25%). Anal incontinence occurred in 1 patient who required an anal plug. All patients maintained the same bowel programs as pre-operative. Open surgery procedures were well tolerated and should be considered in persons with SCI.