Hemorrhoid Surgery Research Articles

High risk of complications after a "low risk" procedure: A national study of nursing home residents and older adults undergoing haemorrhoid surgery.

To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery. This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents. A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p < 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p < 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence. This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.

The Clinical Effect and Mechanism of Prostant on Urinary Retention and Anal Pain.

Anal pain and urinary retention are the two most outstanding complications of the procedure for prolapse and hemorrhoids (PPH) surgery. This study intended to assess the clinical effect and mechanism of Prostant on urinary retention and anal pain after the PPH. Here, 30 patients received PPH surgery. The role and mechanism of Prostant in patients and mice with urinary retention and anal pain were evaluated. ANOVA tests were executed and differences between groups were regarded as statistically significant when p < 0.05. Prostant effectively improved the urination status, lower abdomen symptoms, time to urinate and score of VAS, and the reduction of TNF-α and IL-6. Similarly, Prostant can ameliorate the outcome of urodynamics in urinary retention mice. Mechanically, Prostant reversed the urinary retention-elevated the serum level of hs-CRP and TNF-α, reduction of IL-2, imbalance of Treg/Th17, and level of JAK2 and phosphorylated STAT3. Besides, Prostant ameliorated the pain as shown by the reduction of writhing response, and the elevation of threshold of pain and degree of swelling. Moreover, Prostant antagonized the pain-induced dysregulation of Treg/Th17. Therefore, Prostant can treat patients and mice with anal pain and urinary retention by modulating the balance of Th17/Treg to regulate the secretion and production of inflammatory factors. We hope our results can establish a scientific treatment approach for solving anal pain and urinary retention after PPH surgery of mixed hemorrhoids.

Laser Hemorrhoidopexy: An Observational Study of 1088 Patients Treated at Single Center

ABSTRACT Introduction: The present study evaluates the efficacy of laser hemorrhoidopexy, an innovative minimally invasive procedure in 1088 patients. Methods: A hospital based retrospective prospective study planned with the Aim to explore effectiveness and long-term outcomes of Laser Hemorrhoidopexy as the procedure is easy to learn and replicate and will produce similar results. Aim and Objectives: This study aimed to explore the effectiveness and long-term outcomes of laser hemorrhoidopexy as the procedure is easy to learn and replicate and will produce similar results. A retrospective prospective evaluation of preoperative symptoms of hemorrhoids, complications during intra and postoperative period, and healing were recorded. Visual Analog Scale was used to record pain and postoperative patient satisfaction for 6 months, and telephonic follow-up was taken for 48 months, ranging from 24 to 72 months. Results: A total of 1088 patients with a mean age of 39.51 ± 12.52 years were observed. The mean surgery time was 25 min, and the hospitalization duration was 16 h. Mild pain was reported by 23% of subjects postoperatively and 6% of patients at the end of the week. Complications during the early period included minor bleeding (5.88%) and urine retention (4%–5%). Late postoperative complications were bleeding (6.25%), persistent pain (3.03%), hemorrhoid thrombosis (4.59%), and fissure (5.15%). Patient satisfaction at end of a week showed a highly satisfied response by 76.84%, while dissatisfied by 8%. The recurrence rate was 0.55% with a median follow-up of 2 years. Conclusions: Laser hemorrhoidopexy is sphincter saving, simple minimal invasive and safe procedure with less pain, and complications and a high postoperative patient satisfaction rate in Grade II and Grade III hemorrhoids. The recurrence rate in hemorrhoids surgery is negligible if internal mucosal prolapse is corrected with suture mucopexy in two layers.

Hemoroidlerin Cerrahi Tedavisinde Ferguson Hemoroidektomi

Aim: To assess the outcome of the conventional Ferguson approach in the surgery of our patients who were operated on for prolapsed internal hemorrhoid.Method: 769 patients who were treated with the Ferguson technique between March 2007 and January 2017 were included in the study. Patients' medical files were assessed and, the complaints at presentation, anorectal comorbidities, operation findings and postoperative early and late complication data were recorded.Results: 65% of the patients were male and the mean age was 39 years (18 -81). The durations of complaints varied between one week and 5 years. In the order of higher to lower frequency the complaints were palpable pakers, bleeding and pain respectively. The pakers were at classical locations (3,5,7,11 o’clock) in 69 % of patients. Most of the cases (65%) were grade 4 hemorroid. 19 % of patients had anal fissures as anorectal comorbidity. All patients were operated on at the lithotomy position under spinal anaesthesia. Operation time for ferguson technique was on average 20 minutes and postoperative stay in hospital was one day on average. During the postoperative period, 55 patients developed early complications. These included severe abdominal pain in 25 patients (3-25%), bleeding in 3 (0,4%) and urine retention in 28 (3.60%). Late complications developed in 7 patients. There developed anal stenosis in one patient, anal fissure in 3 and fistula with an abscess in 2. Incontinence and recurrence were not observed in any patient.Conclusion: Ferguson technique is still employed for hemorrhoid surgery. The results of our study support the Ferguson hemorrhoidectomy as a reliable method of preference.

Revisiting imaging features of rectosigmoid vascular malformation with emphasis on multiparametric MRI: a case report

BackgroundGastrointestinal vascular malformations are rare benign vascular neoplasms of the gastrointestinal tract, with the rectosigmoid region being the most frequently involved site. Patients often manifest with recurrent, intermittent rectal bleeding, which might occasionally be life-threatening.Case presentationA 39-year-old man with a history of hemorrhoid operations twice was presented to our gastroenterology department with blood in the stool and abdominal pain. After the colonoscopy, multiparametric MRI, and CT examinations, robotic low anterior resection was performed with the diagnosis of rectosigmoid venous malformation. The histopathological examination confirmed the diagnosis.ConclusionColonoscopy is the preferred method in diagnosing rectosigmoid vascular malformation, but wrong and delayed diagnoses are common. Thus, imaging modalities might add to colonoscopy in equivocal cases.

The Safety, Efficacy, Patient Satisfaction and the Outcome of the Stapled Hemorrhoidectomy in the Bangabandhu Sheikh Mujib Medical University, Bangladesh

Background: Hemorrhoid is a common disease in our country. But its conventional surgical treatment is associated with severe pain and open wound for a long time. Patients are very much frightened to undergo this kind of operation. A new method of hemorrhoid operation i.e. stapled Hemorrhoidectomy does not involve excision of the hemorrhoid and is thereby expected to have less pain and no open wound. Aim of the study: The aim of the study is to investigate the safety, efficacy, patient satisfaction, and outcome of the stapled hemorrhoidectomy operation in the Bangabandhu Sheikh Mujib Medical University, Bangladesh, and different private hospitals in Dhaka city. Methods: 50 patients were selected randomly who were admitted to Bangabandhu Sheikh Mujib Medical University, Bangladesh, and different private hospitals in Dhaka city. They were evaluated by short history, clinical examination, and appropriate investigations. With adequate preoperative preparation, they underwent Stapled Hemorrhoidectomy. They were followed up postoperatively and for 2 months after the operation. Results: 38 patients left the hospital within 36 hours of operation, 6 patients stayed for 4 days, 4 patients for 6 days, and only 2 patients stayed for more than 5 days. 1 patient had 2nd-degree hemorrhoid, 44 had 3rd hemorrhoid and 5 had 4th-degree hemorrhoid the average operating time was 25.30 minutes. The highest time required was 45 minutes and the slowest time was 20 minutes. Initial postoperative pain was common but it didn’t continue for more than 24 hours, only 3 patients complained of occasional pain after discharge. 48 patients had complete relief of symptoms and 2 had a small residual lump. The urgency of defecation was complained about by 5, which subsided with time. No other serious complications like infection or sphincter damage were seen. 49 patients had full satisfaction during follow-up. Conclusion: Stapled Hemorrhoidectomy is associated with significantly less pain immediate ....

Treatment Result of the Mucopexy-Recto Anal Lifting Method for Hemorrhoids in Comparison with Ligation and Excision, and Aluminum Potassium Sulfate and Tannic Acid Sclerotherapy.

The outcomes of Mucopexy-Recto Anal Lifting (MuRAL) in hemorrhoid surgery were compared with ligation and excision (LE), and aluminum potassium sulfate and tannic acid sclerotherapy (ALTA). In this study, we conducted a 3-year follow-up study of MuRAL (380 cases) and compared it with LE (1417 cases) and ALTA (541 cases) performed at the same period. Operative time, mean hospital stay, postoperative pain, postoperative complications, and recurrence were compared and examined retrospectively. The mean operative time was the longest for MuRAL, followed by LE, and then ALTA at 29.1, 21.5, and 12.4 minutes, and the mean length of hospital stay was 6.2, 10.6, and 1.3, days, respectively. Based on the frequency of injectable analgesic use, postoperative pain was clearly milder in MuRAL and ALTA than in LE. The recurrence rates were 3.2% with MuRAL, 1.1% with LE, and 12.4% with ALTA. Early postoperative low-grade fever and bowel movement urgency were observed in all surgeries, but these were minor and did not pose a safety problem. LE is painful and requires prolonged hospitalization but is the most curative; ALTA is simple and can be performed as a day surgery but has a high recurrence rate. MuRAL was less painful than LE and had a lower recurrence rate than ALTA. In recent years, there have been various innovations in the surgical treatment of hemorrhoids, and choosing a technique that is appropriate for the condition of the hemorrhoid and patient's needs is necessary. MuRAL can be one of the options for hemorrhoid treatment as a “cure without cutting” method.

Pain at the First Post-hemorrhoidectomy Defecation Is Associated with Stool Form.

Objectives: Post-hemorrhoidectomy defecation pain is problematic, and pain associated with the first defecation is particularly important for patients. The present study aimed to investigate whether stool form consistency affected defecation pain after hemorrhoidectomy. Methods: A prospective, cohort, observational study where patients scheduled for hemorrhoidal surgery were analyzed. This study used two patient-reported scales to study parameters based on the first postoperative defecation. The Bristol Stool Form Scale (BSFS) and visual analog scale (VAS) assessed stool consistency and defecation pain. The association between stool consistency and defecation pain intensity was assessed using multiple linear regression analysis. Where there was evidence of non-linearity, we applied a restricted cubic spline with three knots to explore the non-linear association. We performed a non-linear regression analysis to estimate the association. Results: A total of 179 patients were analyzed. The regression model results demonstrated that these scales negatively correlated with statistical significance (p = 0.003). Conclusions: This study showed that the softer the stool, the less painful the defecation. Surgeons should attempt to induce a patient to avoid hard stool after surgery. Trial registration: The Ethics Review Committee of the Japan Medical Association approved the study. The study was registered with the Japan Registry of Clinical Trials (jRCT1030190224, https://jrct.niph.go.jp/latest-detail/jRCT1030190224).

Comparison of Milligan Morgan Versus Stapled Hemorrhoidectomy in Patients Attending Tertiary Care Hospital

Background and Aim: Hemorrhoids are common anorectal problems that cause fear by bleeding, pruritus burden, and thrombosis pain. Prolapse and hemorrhoids are managed by stapled hemorrhoidectomy (SH). Initially, Stapled hemorrhoidectomy seemed to be a good alternative for Milligan Morgan (MM) hemorrhoidectomy verified by various studies. However, recent studies found that long-term assessment of stapled hemorrhoidectomy gives poor outcomes in terms of postoperative complications and patient’s satisfaction. Therefore, the present study aimed to compare the Milligan Morgan versus stapled Hemorrhoidectomy in patients attending Tertiary Care Hospital. Methodology: This prospective study was carried out on 120 patients at the Department of Surgery Unit-I Sheikh Zayed Medical College Rahim Yar Khan from 1st May 2021 to 31th April 2022. All the patients of either gender with an age range from 18 years to 60 years after 2nd degree hemorrhoids failure of multiple rubber band ligations and 3rd and 4th degree hemorrhoids were enrolled. Concomitant anal disease patients such as ano-rectal cancer, fissure, fistula, and abscess were excluded. Patients were divided into two categories: Group-I Stapled Hemorrhoidectomy and Group-II Milligan Morgan. Post-operative complications such as stenosis and urinary retention during hospitalization were recorded. All the data were entered and analyzed using SPSS version 25. Results: The overall mean age of Group-I and Group-II was 46.78±12.66 years and 48.91±14.82 years respectively. Each group comprised 60 patients. Out of the SH group, 35 (58.3%) were males and 25 (41.7%) were females. Of the MM Group-II, male and females were 44 (73.3%) and 16 (26.7%) respectively. About 53 (88.3%) patients in Group-I and 32 (53.3%) patients in Group-II had relief from bleeding and other symptoms. The surgical duration in Group-I and Group-II was 22.9 ± 12.9 minutes and 34.8 ± 9 minutes with statistical significance (p=0.000) respectively. The vessel spurting ligation and postoperative hemorrhage was developed in 5 (8.3%) in SH group patients. Post-operative bleeding and intervention was found in 26 (43.3%) patients in Group-II. The prevalence of postoperative pain requiring analgesia was found in 20 (33.3%) in Group-I and34 (56.7%) in Group-II respectively. After treatment, fecal incontinence was developed in none of the patients in both groups. The postoperative complications such as anal tag, tenderness, bleeding, urinary retention, and wound discharge were higher in Group-II as compared to Group-I with statistical insignificance (p&lt; 0.05). Conclusion: The present study found that hemorrhoids could be effectively treated by Stapled hemorrhoidectomy compared to Milligan-Morgan procedure in terms of postoperative pain, hospital stay, and usage of analgesics, reduced postoperative complications, patient’s satisfaction, and time taken for operation. Beside lesser complications, fecal incontinent, severe pain, and other complications could result from stapling technique. Post-operative pain and complete pain relief was significantly lower in MM group. Hospitalization in the SH group was shorter than the MM group. Hemorrhoid recurrence was null in both SH and MM group. Keywords: Hemorrhoid Surgery, Stapled Hemorrhoidectomy, Milligan-Morgan

Sitz bath for pain reliever in patient with hemoroidectomy

Hemorrhoids are diseases affecting the rectum and anus caused by damage to the hemorrhoidal plexus or blood vessels around the rectum and anus. If hemorrhoids are large lumps, then one of the steps is hemorrhoid surgery. One of the effects of post hemorrhoidectomy is pain felt in post hemorrhoidectomy patients. This study aims to apply the application of sitz bath hydrotherapy to decrease pain intensity in post hemorrhoidectomy patients. The method used for this application is a case study. The length of pain felt was measured using the VAS and NRS pain scales. The results of this study indicate that the application of sitz bath hydrotherapy with the main ingredient of warm water at a temperature of 40-45OC can be applied to post hemorrhoidectomy patients who experience moderate to severe pain.&#x0D;

Experience of transanal hemorrhoidal dearterialization in the surgical treatment of grades II-IV hemorrhoids that bleeding

The aim of the work was to analyze the use of Transanal Hemorrhoidal Dearterialization (THD) in the surgical treatment of hemorrhoids of various degrees. The use of THD for complicated hemorrhoids in 514 patients for the period 2008–2021 was analyzed on the clinical basis of the Department of Surgery No.3 of the Bogomolets National Medical University (Ukraine). The average age of the patients was 39.1 years. 159 (30.9%) patients had grade II hemorrhoid, 299 (58.2%) – grade III, 56 (10.9%) – grade IV. All patients had manifestations of rectal bleeding and periodic prolapse of hemorrhoidal nodes, 75 (14.6%) patients had a pain syndrome associated with anal fissures, 19 (3.7%) patients underwent THD for recurrent (after performing other operations) hemorrhoids. No severe postoperative complications were observed. The average length of stay in the hospital was 1.3 days. The working capacity of the patients was restored after 3–5 days. Since 2015, THD has been performed according to the method updated by the authors, which was called Distal Doppler-controlled Dearterialization (DDD). We compared the results of performed THD before and after supplementing her DDD. When comparing THD before and after supplementing its DDD, a significant (p=0.00007) increase in the specific gravity of surgical interventions in stage III hemorrhoids while preserving the quality and duration of the postoperative course was revealed. Also, the number of THD in combination with surgery for chronic anal fissure, the number of operations for recurrent hemorrhoids increased significantly (p&lt;0.05), which indicates the validity and effectiveness of the technique as an operation of choice in the surgical treatment of stage II–IV hemorrhoids. Application of the updated technique using DDD facilitates the performance of mucopexy, allows performing operations at later stages of complicated hemorrhoids. Keywords: proctology, THD, DDD, Doppler-controlled dearterialization.

The necessity of preoperative enema preparation for hemorrhoidal surgery: a single-center comparative study.

Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids. The necessity of preoperative enema preparation (PEP) in hemorrhoidal surgery is inconclusive. This study aims to evaluate the benefit and safety of PEP in hemorrhoidal surgery. This comparative study analyzed data from electronic medical record database and outpatient questionnaire archive. Data of patients who underwent hemorrhoidal surgery from March 2020 to February 2021 were obtained. Patients were allocated to either the PEP or non-PEP group. Primary outcome measurements were postoperative pain and oral analgesic use. Secondary outcomes were the number of days until first defecation, length of hospital stay, time to return to work, incidence of urinary retention, delayed bleeding, and local infection. Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups, respectively, who underwent hemorrhoidal surgery were analyzed. Most patients underwent stapled hemorrhoidopexy, with 106 (81.54%) in PEP group and 113 (80.71%) in non-PEP group. The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups. Our findings revealed that performing PEP before hemorrhoidal surgery produced no benefit when compared with not performing PEP. Typically, the procedure of PEP is inconvenient and discomforting for patients. Therefore, we suggest that it can be omitted in hemorrhoidal surgery.

Fulvestrant, an estrogen receptor inhibitor, relieves postoperative hemorrhoid edema via up-regulation of miR- 424-5p

Purpose: To investigate estrogen receptor (ER) expression in postoperative hemorrhoid edema tissues, and the likely mechanism involved in fulvestrant-mediated reduction of postoperative hemorrhoid edema.Methods: One hundred and eighty-five patients admitted to Jinshan Hospital of Fudan University, Shanghai who accepted hemorrhoidectomy were enrolled in this study. Primary cells were extracted from the anal margin tissues of patients for the determination of changes in ERα and vascular endothelial growth factor (VEGF). In vitro cellular experiments were performed in primary vascular endothelial cells to verify whether ER promoted postoperative perianal edema via the miR-424-5p estrogen receptor α gene (ESR1) axis. The cells were exposed to Fulvestrant, estradiol, and miR-424-5p mimic. Changes in expressions of ERα and VEGF were determined.Results: Fourteen patients (7.57 %), comprising 2 males (2.60 %) and 12 females (11.1 %), developedpostoperative anal margin edema. There was a significant difference in the incidence of postoperative anal edema between males and females (p &lt; 0.05). Both immunohistochemistry and immunoblotting revealed markedly higher ERα levels in postoperative anal edema tissues than in preoperative tissues (p &lt; 0.05). Moreover, ERα level was regulated by estradiol, and miR-424-5p targeted the estrogen receptor α gene (ESR1).Conclusion: Estradiol inhibits miR-424-5p through ERα in perianal tissues after hemorrhoid surgery. It increases VEGF and promotes perianal edema. However, fulvestrant inhibits ERα, thereby reducing VEGF expression and mitigating postoperative hemorrhoid edema, and therefore, has potential application for the management of postoperative hemorrhoid edema.

Comparison between open Haemorrhoidectomy versus closed Haemorrhoidectomy

Objective: The study is about the comparison of open haemorrhoidectomy and closed haemorrhoidectomy. This study is aimed to compare both surgical techniques and to find out the outcomes. Materials and Methods: This study was conducted at sugery department sir Ganga ram hospital Lahore from January 2021 to December 2022. A total of 70 participants were part of the study. The patients of the age group between 20 to 65 years were admitted to the surgery department for planned hemorrhoids surgery. The patients treated with open haemorrhoidectomy were allocated to group 1 while group 2 consists of patients selected for closed haemorrhoidectomy. Before the surgery, consent was signed by the individual patients or their relatives. Exclusion Criteria: The patients suffering from issues like ulcerative colitis, immune deficiency diseases, rectal cancer, Crohns disease, and thrombosed hemorrhoids were omitted from the study. Patients with a previous history of hemorrhoids operation and pregnant women with piles were also excluded from this study. Results: A total of 70 patients were the part of study. 35 of patients for open haemorrhoidectomy considered as group 1 and 35 were the part of close haemorrhoidectomy, considered as group 2. Patients of age 20 to 65 years were included in the study. In group 1, 20 (57.14%) males and 15 (42.85%), females their average age mean was 39. 9 ± 10.11 for both males and females. 27 (77.14%) patients were reported preoperative bleeding, 9(25.71 %) pain and 23 (65.71%) patients had the issue of pruritus. In group 2 the mean age 40 ± 12.2 was reported,22 (62.85%) males and 13 (37.14%) females. Preoperative 25 (71.42%) bleeding cases, 6 (17.14%) with severe pain and 20 (57.14%) had a history of Pruritus. The most common symptom was bleeding. The comparison of open haemorrhoidectomy and closed haemorrhoidectomy is elucidated in Table 2. The operative time for open haemorrhoidectomy was shorter than closed haemorrhoidectomy with a P-value of 0.03. The stay duration at the hospital for the first group was 3 days while 2 days for the second group with non-significant results. The wound healing time was measured less for 2nd group than 1st group. A significant difference was found in wound healing such as for first group,5weeks and for 2nd group,3 weeks. The post-operative pain was observed lesser in group 2 (closed haemorrhoidectomy) than the group 1 (open haemorrhoidectomy). Conclusion: We concluded that a closed haemorrhoidectomy produces less post-operative pain than an open haemorrhoidectomy. Secondly, wound recovery was more quickly in the case of closed haemorrhoidectomy. Keywords: Closed haemorrhoidectomy, open haemorrhoidectomy, haemorrhoids.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation

Study objectiveThe efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DesignA pre- and post-implementation quality improvement evaluation. SettingOperating room and post-anesthesia care unit. PatientsNinety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. InterventionsA preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MeasurementsThe primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. Main resultsPACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0–6] vs. 0 [IQR 0–4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10–23] vs. 15 [IQR 15–25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). ConclusionsLiposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.

Recurrent bleeding after rubber band ligation diagnosed as mild hemophilia B: a case report and literature review

BackgroundHemophilia is a recessive hemorrhagic disease relevant to X chromosome. In mild hemophilia cases, spontaneous bleeding is rare and the blood clotting function is normal, but severe bleeding may occur after trauma or surgery. Therefore, missed diagnosis of hemophilia before operation may contribute to bleeding after hemorrhoid operation.Case presentationA 21-year-old male was hospitalized in the anorectal department because of repeated bleeding after hemorrhoid surgery. Despite several suture hemostasis procedures, the patient still suffered from recurrent bleeding. He had no family history of hemophilia or bleeding tendency, and had not been diagnosed with hemophilia before this admission. The diagnosis of mild hemophilia B was made after further examination of coagulation indexes. By using frozen plasma and coagulation factor complex to supplement coagulation factors, the patient’s bleeding was stopped and he was discharged after 23 days in hospital. During the follow-up, lower-than-normal coagulation factors were still found in him, but no bleeding occurred again.ConclusionsThe undiagnosed patient with mild hemophilia B has an increased risk of bleeding after hemorrhoid surgery because of the consumption of coagulation factors. This case report aims to address the importance of hemophilia screening before operation and reduce the risk of postoperative bleeding. For patients with recurrent bleeding after hemorrhoid surgery, hemophilia should be further excluded. Wound bleeding may recur in hemophilia patients after suture hemostasis. Therefore, prompt supplementation of coagulation factors is needed to help stop bleeding once the diagnosis of hemophilia is made.

Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review.

Background and Objectives: Excisional hemorrhoidectomy is considered as a mainstay operation for high-grade hemorrhoids and complicated hemorrhoids. However, postoperative pain remains a challenging problem after hemorrhoidectomy. This systematic review aims to identify pharmacological and non-pharmacological interventions for reducing post-hemorrhoidectomy pain. Materials and Methods: The databases of Ovid MEDLINE, PubMed and EMBASE were systematically searched for randomized controlled trails (published in English language with full-text from 1981 to 30 September 2021) to include comparative studies examining post-hemorrhoidectomy pain as their primary outcomes between an intervention and another intervention (or a sham or placebo). Results: Some 157 studies were included in this review with additional information from 15 meta-analyses. Fundamentally, strategies to reduce post-hemorrhoidectomy pain were categorized into four groups: anesthetic methods, surgical techniques, intraoperative adjuncts, and postoperative interventions. In brief, local anesthesia-alone or combined with intravenous sedation was the most effective anesthetic method for excisional hemorrhoidectomy. Regarding surgical techniques, closed (Ferguson) hemorrhoidectomy performed with a vascular sealing device or an ultrasonic scalpel was recommended. Lateral internal anal sphincterotomy may be performed as a surgical adjunct to reduce post-hemorrhoidectomy pain, although it increased risks of anal incontinence. Chemical sphincterotomy (botulinum toxin, topical calcium channel blockers, and topical glyceryl trinitrate) was also efficacious in reducing postoperative pain. So were other topical agents such as anesthetic cream, 10% metronidazole ointment, and 10% sucralfate ointment. Postoperative administration of oral metronidazole, flavonoids, and laxatives was associated with a significant reduction in post-hemorrhoidectomy pain. Conclusions: This systematic review comprehensively covers evidence-based strategies to reduce pain after excisional hemorrhoidectomy. Areas for future research on this topic are also addressed at the end of this article.

Increased Risk of Bleeding with Topical Metronidazole in a Postoperative Wound after Anal Fistula and Hemorrhoid Surgery: A Propensity Score-Matched Case-Control Study.

Background: Topical metronidazole (TM) is commonly used in many infective conditions and postoperative wounds including after anorectal surgery. TM was prescribed in patients operated for benign anorectal conditions (anal fistula and hemorrhoids) to hasten wound healing. After the initiation of this protocol, the incidence of postoperative wound bleeding seemed to increase. There are no data in the literature suggesting that topical metronidazole increases the risk of bleeding. Objective: Analysis of the association of TM with an increased risk of bleeding in postoperative anorectal wounds. Design: This was an observational and a retrospective study. Propensity score matching was performed. Setting: This study was conducted at a specialized center for anorectal disorders in postoperative patients suffering from anal fistula and hemorrhoids. Materials: The incidence of postoperative bleeding in the patients in whom TM was used (study group) was retrospectively compared with the patients operated one year before this period in whom TM was not used (control group). Sample size: There were 35 patients in the study group and 181 patients in the control group. Main outcome measures: The incidence of bleeding and the number of bleeding episodes were evaluated. Results: The incidence of bleeding was significantly higher in the study group as compared to the control group (8/35 (22.8%) vs. 8/181 (4.4%), respectively, p = 0.0011). In most cases, bleeding was controlled with conservative measures. The number of bleeding episodes was also significantly higher in the study group (14 vs. 11, respectively, p = 0.0001). The number of patients requiring operative intervention was also higher in the study group (2/35—5.7%) as compared to the control group (1/181—0.56%), but this was not statistically significant (p = 0.069). Conclusions: The study highlighted that application of topical metronidazole in postoperative anorectal wounds increased the risk of bleeding. Most of the bleeding episodes were controlled with conservative measures but they caused considerable patient anxiety and apprehension.

Analgesic Effect of Ropivacaine Combined with Hydromorphone following Surgery for Mixed Hemorrhoids: A Pilot Study

Background Postoperative pain is a major adverse effect of surgery for mixed hemorrhoids. We evaluated whether spinal anesthesia with ropivacaine and hydromorphone provided safe and effective analgesia after surgery for mixed hemorrhoids. Methods This single-center, double-blind pilot study included patients with mixed hemorrhoids who underwent a procedure for prolapse and hemorrhoids (PPH) and external hemorrhoidectomy under spinal anesthesia at Zhejiang Hospital, China (October 2020 to December 2020). Patients were randomized to a hydromorphone group (spinal anesthesia with 0.5% ropivacaine and 75 μg hydromorphone) or morphine group (spinal anesthesia with 0.5% ropivacaine and 150 μg morphine). Pain scores (numerical rating scale), incidences of vomiting and itching, and length of hospital stay (LoS) were recorded at 6, 12, 18, and 24 hours after surgery. Results The analysis included 40 patients in each group. Median (interquartile range) pain score in the hydromorphone group was higher than that in the morphine group at 12 hours (1 (0–2] vs. 0 (0–2), p=0.044) but not significantly different between groups at 6 hours (0 (0–1) vs. 0 (0-0) p=0.228), 18 hours (2 (2–3) vs. 2 (1–3) p=0.060) or 24 hours (2 (2–3) vs. 2 (1–3) p=0.081). The hydromorphone group had a lower incidence of pruritus than the morphine group (47.5% vs. 67.5%, p=0.018). There were no significant differences between groups in vomiting incidence or LoS. Conclusion In patients with mixed hemorrhoids, spinal anesthesia with ropivacaine/hydromorphone has a comparable analgesic effect and a lower incidence of pruritus during the first 24 hours after surgery than spinal anesthesia with ropivacaine/morphine.

Ligasure™ Hemorrhoidectomy versus Conventional Hemorrhoidectomy: Comparison in Outcome

BACKGROUND: Hemorrhoids are a common problem faced in the surgical practice that cause a variety of symptoms ranging from bleeding per rectum to prolapsed, non-reducible and painful anal masses. Therefore, hemorrhoidectomy is one of most frequently performed surgical procedures worldwide. AIM: In this study, we will compare between the conventional surgical method and between LigaSure™ hemorrhoidectomy. PATIENTS AND METHODS: All 120 patients underwent hemorrhoidectomy by conventional and LigaSure™ method between September 2015 and September 2018 in Al-Kafeel hospital in Karbala city in Iraq. All cases underwent surgery by the three authors under regional anesthesia or general anesthesia by anesthetic team. A thorough history taking and physical examination were done and an informed consent has been taken from each patient before the surgery. Conventional hemorrhoidectomy was done for 50 patients randomly selected. The operation was done in the open method (Milligan Morgan’s). LigaSure™ hemorrhoidectomy was done for 70 patients randomly selected as well. Quantification of intra-operative bleeding was done by counting the number of gauzes. Patients were evaluated 5 days and a month and 3 months after the operation for complications and improvement of symptoms. The data were analyzed using Statistical Package for Social Sciences version 22.0. RESULTS: There were significant differences regarding the operation time, number of gauzes soaked with blood, hospital stay, pain score, post-operative bleeding, wound infection, residual mass, fecal incontinence and anal stenosis in favor of the LigaSure™ method. There was no significant difference regarding urine retention and post-operative discharge between the two methods. CONCLUSION: LigaSure™ hemorrhoidectomy can be a good alternative to conventional methods to reduce pain and make a more rapid recovery after hemorrhoidal surgery.